Posts filed under ‘Profilaxis Antibiótica en Cirugía – PAC’
Chlorhexidine plus alcohol versus povidone iodine plus alcohol, combined or not with innovative devices, for prevention of short-term peripheral venous catheter infection and failure (CLEAN 3 study): an investigator-initiated, open-label, single centre, randomised-controlled, two-by-two factorial trial – Randomized Controlled Trial
Lancet Infect Dis. July 2021 V.21 N.7 P.1038-1048.
doi: 10.1016/S1473-3099(20)30738-6
Service des Urgences et SAMU 86 Centre 15, CHU de Poitiers, France; Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France; INSERM U1070, Pharmacologie des Agents Anti-Infectieux, Poitiers, France.
Service des Urgences et SAMU 86 Centre 15, CHU de Poitiers, France; Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France.
Service des Urgences et SAMU 86 Centre 15, CHU de Poitiers, France.
Service de Gériatrie, CHU de Poitiers, France.
Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France; INSERM U1070, Pharmacologie des Agents Anti-Infectieux, Poitiers, France; Service des Maladies Infectieuses et Tropicales, CHU de Poitiers, France.
Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France; Service de Neurologie, CHU de Poitiers, France.
Service de Pneumologie, CHU de Poitiers, France.
Service d’Hépato-Gastro Entérologie, CHU de Poitiers, France.
Plateforme Méthodologie-Data-Management, CHU de Poitiers, France.
Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France; INSERM U1070, Pharmacologie des Agents Anti-Infectieux, Poitiers, France; Département des agents infectieux, Laboratoire de Bactériologie-Hygiène, Chu de Poitiers, France.
Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France; INSERM U1070, Pharmacologie des Agents Anti-Infectieux, Poitiers, France; Service d’Anesthésie, Réanimation et Médecine Péri-Opératoire, CHU de Poitiers, France.
Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France; Service d’Anesthésie, Réanimation et Médecine Péri-Opératoire, CHU de Poitiers, France; INSERM U1246, Methods in Patients-centered outcomes and Health Research – SPHERE, Nantes, France.
Service des Urgences et SAMU 86 Centre 15, CHU de Poitiers, France; Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France; INSERM U1070, Pharmacologie des Agents Anti-Infectieux, Poitiers, France. Electronic address: olivier.mimoz@chu-poitiers.fr
Cada año se venden dos mil millones de catéteres venosos periféricos en todo el mundo, pero la desinfección óptima de la piel y los tipos de dispositivos no están bien establecidos.
El objetivo fue mostrar la superioridad de la desinfección con clorhexidina al 2% más alcohol versus 5% de yodo de povidona más alcohol para prevenir complicaciones infecciosas, y de los catéteres integrados cerrados, los conectores sin aguja de desplazamiento positivo, los tapones desinfectantes y las jeringas de lavado precargadas de un solo uso utilizadas en combinación (grupo de innovación) sobre catéteres abiertos y llaves de paso de tres vías para la administración del tratamiento (grupo estándar) para prevenir la falla del catéter.
Métodos
Hicimos un ensayo abierto, controlado, aleatorizado con un diseño factorial de dos por dos, para el cual inscribimos a adultos (edad ≥ 18 años) que visitaban el departamento de emergencias del Hospital Universitario de Poitiers, Francia, y necesitaban un catéter venoso periférico. antes de la admisión a las salas médicas.
Antes de la inserción del catéter, los pacientes se asignaron al azar (1: 1: 1: 1) mediante un generador de números aleatorios seguro basado en la web a uno de los cuatro grupos de tratamiento según la preparación de la piel y el tipo de dispositivos (dispositivos innovadores o dispositivos estándar; 2% clorhexidina más alcohol o povidona yodada al 5% más alcohol).
Los resultados primarios fueron la incidencia de complicaciones infecciosas (infección local, colonización del catéter o infecciones del torrente sanguíneo) y el tiempo entre la inserción del catéter y su falla (oclusión, desplazamiento, infiltración, flebitis o infección).
Este estudio está registrado en ClinicalTrials.gov, NCT03757143.
Recomendaciones
Se reclutaron 1000 pacientes entre el 7/01/19 y el 6/09/19, de los cuales 500 fueron asignados al grupo de clorhexidina más alcohol y 500 al grupo de povidona yodada más alcohol (250 con soluciones innovadoras y 250 con dispositivos estándar en cada grupo antiséptico).
No se encontró interacción significativa entre las dos intervenciones del estudio.
Las infecciones locales se produjeron con menos frecuencia con clorhexidina más alcohol que con povidona yodada más alcohol (0 [0%] de 496 pacientes frente a seis [1%] de 493 pacientes) y lo mismo se observó para la colonización del catéter (4/431 [1%] vs 70/415 [17%] catéteres entre los catéteres cultivados; índice de riesgo de subdistribución ajustado 0 · 08 [95% CI 0 · 02-0 · 18]).
La mediana del tiempo entre la inserción del catéter y la falla del catéter fue mayor en el grupo de innovación en comparación con el grupo estándar (50 · 4 [IQR 29 · 6-69 · 4] h vs 30 · 0 [16 · 6-52 · 6] h; p = 0 · 0017).
Se produjeron reacciones cutáneas menores en nueve (2%) pacientes en el grupo de clorhexidina más alcohol y en siete (1%) pacientes en el grupo de povidona yodada más alcohol.
Interpretación
Para la antisepsia cutánea, la clorhexidina más alcohol proporciona una mayor protección de las complicaciones infecciosas relacionadas con el catéter venoso periférico que la povidona yodada más el alcohol.
El uso de dispositivos innovadores amplía el tiempo de permanencia del catéter sin complicaciones.
Background
Two billion peripheral venous catheters are sold globally each year, but the optimal skin disinfection and types of devices are not well established. We aimed to show the superiority of disinfection with 2% chlorhexidine plus alcohol over 5% povidone iodine plus alcohol in preventing infectious complications, and of closed integrated catheters, positive displacement needleless-connectors, disinfecting caps, and single-use prefilled flush syringes used in combination (innovation group) over open catheters and three-way stopcocks for treatment administration (standard group) in preventing catheter failure.
Methods
We did an open-label, randomised-controlled trial with a two-by-two factorial design, for which we enrolled adults (age ≥18 years) visiting the emergency department at the Poitiers University Hospital, France, and requiring one peripheral venous catheter before admission to the medical wards. Before catheter insertion, patients were randomly assigned (1:1:1:1) using a secure web-based random-number generator to one of four treatment groups based on skin preparation and type of devices (innovative devices or standard devices; 2% chlorhexidine plus alcohol or 5% povidone iodine plus alcohol). Primary outcomes were the incidence of infectious complications (local infection, catheter colonisation, or bloodstream infections) and time between catheter insertion and catheter failure (occlusion, dislodgment, infiltration, phlebitis, or infection). This study is registered with ClinicalTrials.gov, NCT03757143.
Findings
1000 patients were recruited between Jan 7, and Sept 6, 2019, of whom 500 were assigned to the chlorhexidine plus alcohol group and 500 to the povidone iodine plus alcohol group (250 with innovative solutions and 250 with standard devices in each antiseptic group). No significant interaction was found between the two study interventions. Local infections occurred less frequently with chlorhexidine plus alcohol than with povidone iodine plus alcohol (0 [0%] of 496 patients vs six [1%] of 493 patients) and the same was observed for catheter colonisation (4/431 [1%] vs 70/415 [17%] catheters among the catheters cultured; adjusted subdistribution hazard ratio 0·08 [95% CI 0·02-0·18]). Median time between catheter insertion and catheter failure was longer in the innovation group compared with the standard group (50·4 [IQR 29·6-69·4] h vs 30·0 [16·6-52·6] h; p=0·0017). Minor skin reactions occurred in nine (2%) patients in the chlorhexidine plus alcohol group and seven (1%) patients in the povidone iodine plus alcohol group.
Interpretation
For skin antisepsis, chlorhexidine plus alcohol provides greater protection of peripheral venous catheter-related infectious complications than does povidone iodine plus alcohol. Use of innovative devices extends the catheter complication-free dwell time.
Funding: Becton Dickinson.
ABSTRACT
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30738-6/fulltext
Unfortunately I do not have access to the original article that I recommend reading.
Sincerely
Jorge O. Calabrese – Tres Arroyos, province of Buenos Aires (ARGENTINA)
Lamentablemente no tengo acceso al artículo original que recomiendo su lectura.
Atentamente
Jorge O. Calabrese – Tres Arroyos, provincia de Buenos Aires (ARGENTINA)
Comparison of Diagnostic Accuracy of Periprosthetic Tissue Culture in Blood Culture Bottles to That of Prosthesis Sonication Fluid Culture for Diagnosis of Prosthetic Joint Infection (PJI) by Use of Bayesian Latent Class Modeling and IDSA PJI Criteria for Classification.
Journal of Clinical Microbiology May 25, 2018 V.56 N.6 P.e00319-18.
doi: 10.1128/JCM.00319-18
Qun Yan, Melissa J Karau, Kerryl E Greenwood-Quaintance, Jayawant N Mandrekar, Douglas R Osmon, Matthew P Abdel, Robin Patel
Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
Department of Clinical Laboratory, Xiangya Hospital of Central South University, Changsha, Hunan, China.
Divison of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.
Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA patel.robin@mayo.edu.
Anteriormente habían demostrado que el cultivo de tejido periprotésico en frascos de hemocultivo (BCB = blood culture bottles) mejora la sensibilidad en comparación con los métodos convencionales de cultivo en caldo y agar para el diagnóstico de infección de prótesis articular (PJI).
También habían demostrado que el cultivo de sonicación de prótesis mejora la sensibilidad en comparación con el cultivo de tejido periprotésico utilizando métodos convencionales de agar y caldo.
El propósito de este estudio fue comparar la precisión diagnóstica del cultivo de tejidos en BCB (posteriormente denominado cultivo de tejido) con el cultivo de sonicación de prótesis (posteriormente denominado cultivo de fluido por ultrasonidos).
Estudiaron a 229 sujetos que se sometieron a una cirugía de revisión o resección de artroplastia entre marzo 2016 y octubre 2017 en la Mayo Clinic en Rochester, Minnesota.
Utilizando los criterios de diagnóstico PJI de la Infectious Diseases Society of America (IDSA) (omitiendo los criterios de cultivo) como el estándar de oro, la sensibilidad del cultivo de tejidos fue similar a la del cultivo de fluido sonicado (66,4% vs 73,1%, P = 0,07) pero fue significativamente más bajo que el de las dos pruebas combinadas (66,4% vs 76,9%, P <0,001).
Utilizando el modelo de clase latente bayesiana, que asume que no hay un estándar de oro para el diagnóstico de PJI, la sensibilidad del cultivo de tejidos fue ligeramente más baja que la del cultivo de fluido sonicado (86,3% vs 88,7%) y mucho más baja que la de las dos pruebas combinadas (86,3% vs 99,1%).
En conclusión, el cultivo de tejidos en BCB alcanzó una sensibilidad similar a la del cultivo de fluido sonicado de prótesis para el diagnóstico de PJI, pero las dos pruebas combinadas tuvieron la mayor sensibilidad sin comprometer la especificidad.
Recomendamos la combinación de cultivo de tejidos en BCB y cultivo de líquido sonicado para lograr el más alto nivel de diagnóstico microbiológico de PJI.
We have previously demonstrated that culturing periprosthetic tissue in blood culture bottles (BCBs) improves sensitivity compared to conventional agar and broth culture methods for diagnosis of prosthetic joint infection (PJI).
We have also shown that prosthesis sonication culture improves sensitivity compared to periprosthetic tissue culture using conventional agar and broth methods.
The purpose of this study was to compare the diagnostic accuracy of tissue culture in BCBs (subsequently referred to as tissue culture) to prosthesis sonication culture (subsequently referred to as sonicate fluid culture).
We studied 229 subjects who underwent arthroplasty revision or resection surgery between March 2016 and October 2017 at Mayo Clinic in Rochester, Minnesota. Using the Infectious Diseases Society of America (IDSA) PJI diagnostic criteria (omitting culture criteria) as the gold standard, the sensitivity of tissue culture was similar to that of the sonicate fluid culture (66.4% versus 73.1%, P = 0.07) but was significantly lower than that of the two tests combined (66.4% versus 76.9%, P < 0.001).
Using Bayesian latent class modeling, which assumes no gold standard for PJI diagnosis, the sensitivity of tissue culture was slightly lower than that of sonicate fluid culture (86.3% versus 88.7%) and much lower than that of the two tests combined (86.3% versus 99.1%).
In conclusion, tissue culture in BCBs reached sensitivity similar to that of prosthesis sonicate fluid culture for diagnosis of PJI, but the two tests combined had the highest sensitivity without compromising specificity.
The combination of tissue culture in BCBs and sonicate fluid culture is recommended to achieve the highest level of microbiological diagnosis of PJI.
Treatment of Periprosthetic Joint Infection Using Antimicrobials: Dilute Povidone-Iodine Lavage.
J Bone Jt Infect. 2017 Jan 1;2(1):10-14. doi: 10.7150/jbji.16448. eCollection 2017.
Ruder JA1, Springer BD2.
Author information
1 Carolinas Medical Center, Department of Orthopaedics.
2 OrthoCarolina Hip and Knee Center, Charlotte, NC 28207.
Abstract
Periprosthetic joint infections (PJI) remain a challenge for the orthopaedic surgeon to treat and remain a leading cause of failure of both primary and revision total joint arthroplasty. Once a PJI develops, surgical treatment is generally indicated and includes an aggressive irrigation and debridement. One component of the irrigation and debridement involves the use of an antiseptic irrigating solution. In primary and revision TJA, dilute povidone-iodine lavage can be performed prior to wound closure. Approximately 17.5mL of 10% povidone-iodine is diluted with 500-1000cc of normal saline. The wound is then irrigated with the dilute povidone-iodine for 3 minutes. The dilute povidone-iodine is then thoroughly irrigated and washed out of the wound with normal saline prior to wound closure. The use of dilute povidone-iodine lavage prior to wound closure has been shown to reduce the risk of deep surgical site infection in multiple surgical specialties. In primary TJA, it has been demonstrated to reduce the risk of infection, without any associated adverse effects. It is also included in multiple protocols for the surgical treatment of PJI. Dilute povidone-iodine lavage provides a safe and inexpensive method to reduce the rate of PJI in TJA.
Use of Chlorhexidine Preparations in Total Joint Arthroplasty.
J Bone Jt Infect. 2017 Jan 1;2(1):15-22. doi: 10.7150/jbji.16934. eCollection 2017.
George J1, Klika AK1, Higuera CA1.
Author information
1 Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA.
Abstract
Prosthetic joint infection (PJI) is a serious complication after total joint arthroplasty (TJA). Chlorhexidine is a widely used antiseptic because of its rapid and persistent action. It is well tolerated and available in different formulations at various concentrations. Chlorhexidine can be used for pre-operative skin cleansing, surgical site preparation, hand antisepsis of the surgical team and intra-articular irrigation of infected joints. The optimal intra-articular concentration of chlorhexidine gluconate in irrigation solution is 2%, to provide a persistent decrease in biofilm formation, though cytotoxicity might be an issue. Although chlorhexidine is relatively cheap, routine use of chlorhexidine without evidence of clear benefits can lead to unnecessary costs, adverse effects and even emergence of resistance. This review focuses on the current applications of various chlorhexidine formulations in TJA. As the treatment of PJI is challenging and expensive, effective preparations of chlorhexidine could help in the prevention and control of PJI.
Clinical and Microbiological Characteristics of Bacteroides Prosthetic Joint Infections.
J Bone Jt Infect. 2017 Mar 19;2(3):122-126. doi: 10.7150/jbji.17129. eCollection 2017.
Shah N1, Osmon D1, Tande AJ1, Steckelberg J1, Sierra R2, Walker R1, Berbari EF1.
Author information
1 Division of Infectious Disease, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
2 Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
Abstract
Clinical and microbiological characteristics of patients with Bacteroides prosthetic joint infection (PJI) have not been well described in the literature. The aim of this retrospective cohort study was to assess the outcome of patients with Bacteroides PJI and to review risk factors associated with failure of therapy. Between 1/1969 and 12/2012, 20 episodes of Bacteroides PJI in 17 patients were identified at our institution. The mean age of the patients in this cohort at the time of diagnosis was 55.6 years; 59% (n=10) had knee involvement. Twenty four percent (n=4) had diabetes mellitus, and 24% had a history of either gastrointestinal (GI) or genitourinary (GU) pathology prior to the diagnosis of PJI. Thirty five percent (n=6) were immunosuppressed. The initial medical/surgical strategy was resection arthroplasty (n=9, 50%) or debridement and implant retention (n=5, 28%). Thirty seven percent (n=7) were treated with metronidazole. Eighty percent (n=4) of patients that failed therapy had undergone debridement and retention of their prosthesis, as compared to none of those treated with resection arthroplasty. Seventy percent (n=14) of patient episodes were infection free at their last date of follow up. In conclusion, a significant proportion of patients with Bacteroides PJI are immunosuppressed and have an underlying GI or GU tract pathology. Retention and debridement of the prosthesis is associated with a higher risk of treatment failure.
Brucella melitensis prosthetic joint infection.
J Bone Jt Infect. 2017 Apr 5;2(3):136-142.
doi: 10.7150/jbji.18408. eCollection 2017.
Flury D1, Behrend H2, Sendi P3, von Kietzell M1, Strahm C1.
Author information
1 Department of Infectious Diseases, Cantonal Hospital of St. Gallen, St. Gallen.
2 Department of Orthopaedics and Traumatology, Cantonal Hospital of St. Gallen, St. Gallen.
3 Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland.
Abstract
Periprosthetic joint infection (PJI) due to Brucella spp. is rare. We report a case in a 75-year-old man and review 29 additional cases identified in a literature search. The diagnosis of Brucella PJI is challenging, in particular in non-endemic countries. Serological tests prior to joint aspiration or surgical intervention are reasonable. Involvement of infection control and timely information to laboratory personnel is mandatory upon diagnosis. There is no uniform treatment concept, neither with respect to surgical intervention nor for the duration of antimicrobials. Most cases have a successful outcome, irrespective of surgical modality, and with an antimicrobial combination regimen for 12 or more weeks.
Distribution characteristics of Staphylococcus spp. in different phases of periprosthetic joint infection: A review.
Exp Ther Med. 2017 Jun;13(6):2599-2608.
doi: 10.3892/etm.2017.4300. Epub 2017 Apr 4.
Guo G1, Wang J1, You Y2, Tan J1, Shen H1.
Author information
1 Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai 200233, P.R. China.
2 Department of Obstetrics, Fudan University Affiliated Obstetrics and Gynecology Hospital, Shanghai 200233, P.R. China.
Abstract
Periprosthetic joint infection (PJI) is a devastating condition and Staphylococcus spp. are the predominant pathogens responsible, particularly coagulase-negative staphylococci (CoNS) and Staphylococcus aureus. The aim of the present systematic review was to evaluate the distribution characteristics of specific Staphylococcus spp. in different PJI phases, reveal the effect of pathogens’ feature on their distribution and suggest recommendations for antibiotic treatment of Staphylococcal PJI. The present systematic review was performed using PubMed and EMBASE databases with the aim to identify existing literature that presented the spectrum of Staphylococcus spp. that occur in PJI. Once inclusion and exclusion criteria were applied, 20 cohort studies involving 3,344 cases in 3,199 patients were included. The predominant pathogen involved in PJI was indicated to be CoNS (31.2%), followed by S. aureus (28.8%). This trend was more apparent in hip replacement procedures. In addition, almost equal proportions of CoNS and S. aureus (28.6 and 30.0%, respectively) were indicated in the delayed phase. CoNS (36.6%) were the predominant identified organism in the early phase, whereas S. aureus (38.3%) occurred primarily in the late phase. In PJI caused by S. aureus, the number of cases of methicillin-sensitive Staphylococcus aureus (MSSA) was ~2.5-fold greater than that of methicillin-resistant Staphylococcus aureus (MRSA). MRSA occurred predominantly in the early phase, whereas MSSA was largely observed in the delayed and late phases. With regards to antibiotic treatment, the feature of various pathogens and the phases of PJI were the primary considerations. The present review provides useful information for clinical practice and scientific research of PJI.
Dosificación de cefazolina prequirúrgica en pacientes obesos y no obesos. Importa el peso
Revista Española de Quimioterapia Junio 2020
Direct Detection and Identification of Prosthetic Joint Infection Pathogens in Synovial Fluid by Metagenomic Shotgun Sequencing
Journal of Clinical Microbiology September 2018 V.56 N.9
Morgan I. Ivy, Matthew J. Thoendel, Patricio R. Jeraldo, Kerryl E. Greenwood-Quaintance, Arlen D. Hanssen, Matthew P. Abdel, Nicholas Chia, Janet Z. Yao, Aaron J. Tande, Jayawant N. Mandrekar and Robin Patel
Metagenomic shotgun sequencing has the potential to transform how serious infections are diagnosed by offering universal, culture-free pathogen detection. This may be especially advantageous for microbial diagnosis of prosthetic joint infection (PJI) by synovial fluid analysis since synovial fluid cultures are not universally positive and since synovial fluid is easily obtained preoperatively. We applied a metagenomics-based approach to synovial fluid in an attempt to detect microorganisms in 168 failed total knee arthroplasties. Genus- and species-level analyses of metagenomic sequencing yielded the known pathogen in 74 (90%) and 68 (83%) of the 82 culture-positive PJIs analyzed, respectively, with testing of two (2%) and three (4%) samples, respectively, yielding additional pathogens not detected by culture. For the 25 culture-negative PJIs tested, genus- and species-level analyses yielded 19 (76%) and 21 (84%) samples with insignificant findings, respectively, and 6 (24%) and 4 (16%) with potential pathogens detected, respectively. Genus- and species-level analyses of the 60 culture-negative aseptic failure cases yielded 53 (88%) and 56 (93%) cases with insignificant findings and 7 (12%) and 4 (7%) with potential clinically significant organisms detected, respectively. There was one case of aseptic failure with synovial fluid culture growth; metagenomic analysis showed insignificant findings, suggesting possible synovial fluid culture contamination. Metagenomic shotgun sequencing can detect pathogens involved in PJI when applied to synovial fluid and may be particularly useful for culture-negative cases.
FULL TEXT
https://jcm.asm.org/content/56/9/e00402-18?etoc=
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