Posts filed under ‘Infecciones sitio quirurgico’

Managing an Elusive Pathogen: Treatment of Methicillin-Resistant Staphylococcus aureus Infections in a Variety of Care Settings

Infectious Diseases in Clinical Practice May 2011 V.19 N.3 P.150-155

NFID Clinical Updates

Poretz, Donald M.; Rehm, Susan J.

Methicillin-resistant Staphylococcus aureus (MRSA) infections continue to be a major problem both within hospitals (hospital-acquired MRSA) and increasingly in community settings (community-acquired MRSA), leading to well-publicized media reports and, as a result, greater public awareness of this problem.

Clinically, it is difficult to distinguish between a MRSA and a methicillin-sensitive S. aureus skin and soft tissue infection, and this should be taken into consideration when initiating empiric therapy.

There are several oral and intravenous antibiotics available to treat MRSA infections, some of which are inexpensive, whereas others are extremely costly; all have potential adverse effects and possible drug-drug interactions with which the prescriber should be familiar.

Careful monitoring of patients who receive outpatient intravenous antibiotics and an understanding of various intravenous devices and their associated possible complications in addition to knowledge of the economics involved are essential to make cost-effective decisions.

FULL TEXT

https://journals.lww.com/infectdis/Fulltext/2011/05000/Managing_an_Elusive_Pathogen__Treatment_of.2.aspx

PDF (CLIC en PDF)

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December 7, 2018 at 9:24 am

High-risk Staphylococcus aureus transmission in the operating room: A call for widespread improvements in perioperative hand hygiene and patient decolonization practices

American Journal of Infection Control October 2018 V.46 N.10 P.1134–1141

Randy W. Loftus, Franklin Dexter, Alysha D.M. Robinson

Highlights

  • Intraoperative Staphylococcus aureus multilocus sequence type 5 is hypertransmissible and pathogenic.
  • Intraoperative provider hands and patient skin surfaces are confirmed sources of sequence type 5 transmission.

Background

Increased awareness of the epidemiology of transmission of pathogenic bacterial strain characteristics may help to improve compliance with intraoperative infection control measures. Our aim was to characterize the epidemiology of intraoperative transmission of high-risk Staphylococcus aureus sequence types (STs).

Methods

S aureus isolates collected from 3 academic medical centers underwent whole cell genome analysis, analytical profile indexing, and biofilm absorbance. Transmission dynamics for hypertransmissible, strong biofilm-forming, antibiotic-resistant, and virulent STs were assessed.

Results

S aureus ST 5 was associated with increased risk of transmission (adjusted incidence risk ratio, 6.67; 95% confidence interval [CI], 1.82-24.41; P?=?.0008), greater biofilm absorbance (ST 5 median absorbance ± SD, 3.08 ± 0.642 vs other ST median absorbance ± SD, 2.38 ± 1.01; corrected P?=?.021), multidrug resistance (odds ratio, 7.82; 95% CI, 2.19-27.95; P?=?.002), and infection (6/38 ST 5 vs 6/140 STs; relative risk, 3.68; 95% CI, 1.26-10.78; P?=?.022). Provider hands (n?=?3) and patients (n?=?4) were confirmed sources of ST 5 transmission. Transmission locations included provider hands (n?=?3), patient skin sites (n?=?4), and environmental surfaces (n?=?2). All observed transmission stories involved the within-case mode of transmission. Two of the ST 5 transmission events were directly linked to infection.

Conclusions

Intraoperative S aureus ST 5 isolates are hypertransmissible and pathogenic. Improved compliance with hand hygiene and patient decolonization may help to control the spread of these dangerous pathogens.

FULL TEXT

https://www.ajicjournal.org/article/S0196-6553(18)30464-4/fulltext

PDF

https://www.ajicjournal.org/article/S0196-6553(18)30464-4/pdf

December 3, 2018 at 7:40 am

Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis

N Engl J Med January 7, 2010 V.362 N.1 P.18-26

Rabih O. Darouiche, M.D., Matthew J. Wall, Jr., M.D., Kamal M.F. Itani, M.D., Mary F. Otterson, M.D., Alexandra L. Webb, M.D., Matthew M. Carrick, M.D., Harold J. Miller, M.D., Samir S. Awad, M.D., Cynthia T. Crosby, B.S., Michael C. Mosier, Ph.D., Atef AlSharif, M.D., and David H. Berger, M.D.

BACKGROUND

Since the patient’s skin is a major source of pathogens that cause surgical-site infection, optimization of preoperative skin antisepsis may decrease postoperative infections. We hypothesized that preoperative skin cleansing with chlorhexidine–alcohol is more protective against infection than is povidone–iodine.

METHODS

We randomly assigned adults undergoing clean-contaminated surgery in six hospitals to preoperative skin preparation with either chlorhexidine–alcohol scrub or povidone–iodine scrub and paint. The primary outcome was any surgical-site infection within 30 days after surgery. Secondary outcomes included individual types of surgical-site infections.

RESULTS

A total of 849 subjects (409 in the chlorhexidine–alcohol group and 440 in the povidone–iodine group) qualified for the intention-to-treat analysis. The overall rate of surgical-site infection was significantly lower in the chlorhexidine–alcohol group than in the povidone–iodine group (9.5% vs. 16.1%; P=0.004; relative risk, 0.59; 95% confidence interval, 0.41 to 0.85). Chlorhexidine–alcohol was significantly more protective than povidone–iodine against both superficial incisional infections (4.2% vs. 8.6%, P=0.008) and deep incisional infections (1% vs. 3%, P=0.05) but not against organ-space infections (4.4% vs. 4.5%). Similar results were observed in the per-protocol analysis of the 813 patients who remained in the study during the 30-day follow-up period. Adverse events were similar in the two study groups.

CONCLUSIONS

Preoperative cleansing of the patient’s skin with chlorhexidine–alcohol is superior to cleansing with povidone–iodine for preventing surgical-site infection after clean-contaminated surgery. (ClinicalTrials.gov number, NCT00290290.)

FULL TEXT

https://www.nejm.org/doi/full/10.1056/NEJMoa0810988

PDF

https://www.nejm.org/doi/pdf/10.1056/NEJMoa0810988

October 3, 2018 at 3:02 pm

The Leukocyte Esterase Test Strip Is a Poor Rule-Out Test for Periprosthetic Joint Infection

Journal of Arthroplasty August 2018 V.33 N.8 P.2571–2574

Carl A. Deirmengian, Lihua Liang, John P. Rosenberger, Tony R. Joaquim, Martin R. Gould, Patrick A. Citrano, Keith W. Kardos

Background

The urinary leukocyte esterase (LE) test strip has been suggested as a good screening test for periprosthetic joint infection (PJI). The purpose of this study is to compare the diagnostic profile of LE assays from different manufacturers and determine whether the LE test strip is a good rule-out test.

Methods

Synovial fluid samples (N = 344), sent to 1 laboratory for PJI testing, were used in this prospective study. Four different tests for synovial fluid LE were simultaneously evaluated for their performance in detecting white blood cell (WBC) positive samples (>3000 cells/µL).

Results

Both neutrophil elastase immunoassays demonstrated greater sensitivity than urinary LE test strips (92.0% and 90.8% vs 72.4% and 80.3%; all P < 0.011). Fifty-three percent of false-negative urinary LE test strip results clearly missed the presence of elevated levels of synovial fluid LE. Invalid urinary LE test strip results were 4-fold more likely among WBC (+) compared with WBC (−) samples (27.0% vs 6.8%; P < 0.0001). The combined failure to detect an elevated WBC count, because of either false-negative or invalid results, was 47.1% and 41.4% for the Roche and Siemens test strips, respectively.

Conclusions

This study agrees with the existing literature demonstrating that the LE test strips are among the lowest sensitivity tests for PJI. The urinary LE tests strips should not be used to rule-out PJI, as they often fail to detect abundant levels of LE in synovial fluid. Instead, it is more appropriate to use the (++) LE test strip result as a secondary confirmatory rule-in test for PJI because of its high specificity.

FULL TEXT

https://www.arthroplastyjournal.org/article/S0883-5403(18)30243-2/fulltext

PDF

https://www.arthroplastyjournal.org/article/S0883-5403(18)30243-2/pdf

September 29, 2018 at 10:36 am

Predicting lower limb periprosthetic joint infections: A review of risk factors and their classification.

World J Orthop. May 18, 2017 V.8 N.5 P.400-411.

George DA1, Drago L1, Scarponi S1, Gallazzi E1, Haddad FS1, Romano CL1.

Author information

1 David A George, Fares S Haddad, Department of Trauma and Orthopaedics, University College London Hospitals, London NW1 2BU, United Kingdom.

Abstract

AIM:

To undertook a systematic review to determine factors that increase a patient’s risk of developing lower limb periprosthetic joint infections (PJI).

METHODS:

This systematic review included full-text studies that reviewed risk factors of developing either a hip or knee PJI following a primary arthroplasty published from January 1998 to November 2016. A variety of keywords were used to identify studies through international databases referencing hip arthroplasty, knee arthroplasty, infection, and risk factors. Studies were only included if they included greater than 20 patients in their study cohort, and there was clear documentation of the statistical parameter used; specifically P-value, hazard ratio, relative risk, or/and odds ratio (OR). Furthermore a quality assessment criteria for the individual studies was undertaken to evaluate the presence of record and reporting bias.

RESULTS:

Twenty-seven original studies reviewing risk factors relating to primary total hip and knee arthroplasty infections were included. Four studies (14.8%) reviewed PJI of the hip, 3 (11.21%) of the knee, and 20 (74.1%) reviewed both joints. Nineteen studies (70.4%) were retrospective and 8 (29.6%) prospective. Record bias was identified in the majority of studies (66.7%). The definition of PJI varied amongst the studies but there was a general consensus to define infection by previously validated methods. The most significant risks were the use of preoperative high dose steroids (OR = 21.0, 95%CI: 3.5-127.2, P < 0.001), a BMI above 50 (OR = 18.3, P < 0.001), tobacco use (OR = 12.76, 95%CI: 2.47-66.16, P = 0.017), body mass index below 20 (OR = 6.00, 95%CI: 1.2-30.9, P = 0.033), diabetes (OR = 5.47, 95%CI: 1.77-16.97, P = 0.003), and coronary artery disease (OR = 5.10, 95%CI: 1.3-19.8, P = 0.017).

CONCLUSION:

We have highlighted the need for the provider to optimise modifiable risk factors, and develop strategies to limit the impact of non-modifiable factors.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5434347/pdf/WJO-8-400.pdf

 

September 2, 2018 at 7:00 pm

How Reliable Is the Alpha-defensin Immunoassay Test for Diagnosing Periprosthetic Joint Infection? A Prospective Study.

Clin Orthop Relat Res. February 2017 V.475 N.2 P.408-415.

Bonanzinga T1, Zahar A2, Dütsch M1, Lausmann C1, Kendoff D3, Gehrke T1.

Author information

1 HELIOS ENDO Klinik, Holstenstrasse 2, 22767, Hamburg, Germany.

2 HELIOS ENDO Klinik, Holstenstrasse 2, 22767, Hamburg, Germany. akos.zahar@helios-kliniken.de.

3 HELIOS Klinik Berlin-Buch, Berlin, Germany.

Abstract

BACKGROUND:

A key issue in the treatment of periprosthetic joint infection (PJI) is the correct diagnosis. The main problem is lack of diagnostic tools able to diagnose a PJI with high accuracy. Alpha-defensin has been proposed as a possible solution, but in the current literature, there is a lack of independent validation.

QUESTIONS/PURPOSES:

We performed a prospective study to determine (1) what is the sensitivity, specificity, and positive and the negative predictive values of the alpha-defensin immunoassay test in diagnosing PJI; and (2) which clinical features may be responsible for false-positive and false-negative results?

METHODS:

Preoperative aspiration was performed in all patients presenting with a painful hip/knee arthroplasty, including both primary and revision implants. Metallosis, other inflammatory comorbidities, and previous/concomitant antibiotic therapy were not considered as exclusion criteria. An inadequate amount of synovial fluid for culture was an exclusion criterion. A total of 156 patients (65 knees, 91 hips) were included in this prospective study. At the time of revision, synovial fluid samples were taken to perform the alpha-defensin assay. During surgical débridement of tissue, samples for cultures and histologic evaluation were taken, and samples were cultured until positive or until negative at 14 days. A diagnosis of PJI was confirmed in 29 patients according to the International Consensus Group on PJI.

RESULTS:

The sensitivity of the alpha-defensin immunoassay was 97% (95% confidence interval [CI], 92%-99%), the specificity was 97% (95% CI, 92%-99%), the positive predictive value was 88% (95% CI, 81%-92%), and the negative predictive value was 99% (95% CI, 96%-99%). Among four false-positive patients, two had metallosis and one had polyethylene wear. The false-negative case presented with a draining sinus, and intraoperative cultures were also negative.

CONCLUSIONS:

Alpha-defensin assay appears to be a reliable test, but followup evaluation is needed to estimate longer term performance of the test. The authors believe that alpha-defensin has demonstrated itself to be sufficiently robust that PJI diagnostic criteria now should include this test. Future studies are needed to compare the differences among the diagnostic capability of the available tests, in particular when metallosis is present, because metallosis may predispose the test to a false-positive result.

LEVEL OF EVIDENCE:

Level I, diagnostic study.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5213924/pdf/11999_2016_Article_4906.pdf

September 2, 2018 at 6:58 pm

Current Recommendations for the Diagnosis of Acute and Chronic PJI for Hip and Knee-Cell Counts, Alpha-Defensin, Leukocyte Esterase, Next-generation Sequencing.

Curr Rev Musculoskelet Med. September 2018 V.11 N.3 P.428-438.

Goswami K1, Parvizi J1, Maxwell Courtney P2.

Author information

1 The Rothman Institute at Thomas Jefferson University, 125 S 9th St. Ste 1000, Philadelphia, PA, 19107, USA.

2 The Rothman Institute at Thomas Jefferson University, 125 S 9th St. Ste 1000, Philadelphia, PA, 19107, USA. Max.Courtney@rothmaninstitute.com .

Abstract

PURPOSE OF REVIEW:

Despite significant progress in recent years, the diagnosis of periprosthetic joint infection (PJI) remains a challenge and no gold standard test exists. A combination of serological, synovial, microbiological, histological, and radiological investigations is performed that are expensive, often invasive, and imperfect. Novel biomarkers and molecular methods have shown promise in recent years. The purpose of this review is to provide an update about the diagnostic recommendations for PJI and cover a selection of emerging diagnostic tools.

RECENT FINDINGS:

Recent literature highlights a new evidence-based definition for diagnosing hip and knee PJI that shows excellent performance on formal external multi-institutional validation. There is also increasing evidence to support the measurement of selected biomarkers in serum and synovial fluid, such as alpha-defensin, D-dimer, and interleukin-6. Finally, the emerging utility of next-generation sequencing for pathogen identification is discussed. In summary, we describe current recommendations and emerging tests for the diagnosis of PJI. Residual limitations and directions for future research are also discussed.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105482/pdf/12178_2018_Article_9513.pdf

 

 

 

September 1, 2018 at 7:18 pm

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