Suppressive antibiotic therapy in chronic prosthetic joint infections

Thirteen patients with chronic total joint infections (eight knees, five hips) were treated with suppressive antibiotic therapy and retention of the prosthesis following surgical debridement and 4 to 6 weeks of intravenous antibiotic therapy. These patients faced poor functional outcome after prosthesis removal. After a mean follow up of 37.6 months (range: 24 to 55), only three patients have retained their prostheses. Ten patients required prosthesis removal for recurrent infection a mean of 21.6 months (range: 6 to 48) after starting suppressive therapy. In addition, 38% of patients experienced adverse effects which led to changes in the antibiotic regimen. Suppressive antibiotic therapy in the treatment of chronic prosthesis infections has limited clinical efficacy and is associated with a substantial risk of adverse effects.     

Management of deep wound infection after posterior lumbar interbody fusion with cages

OBJECTIVES: To evaluate long-term treatment outcome of patients with infected posterior lumbar interbody fusion (PLIF) managed with surgical debridement and or prolonged antiobiotic treatment without removal of the interbody cages. METHODS: Between 1996 and 1999, 8 out of 111 patients who underwent PLIF were diagnosed with deep wound infection (7.2%). All infected patients were clinically followed for at least 2 years after completion of the antibiotic treatment. Longer follow-up of at least 6 years duration was performed by a telephone interview. RESULTS: Six patients were managed with surgical debridement, wound irrigation, and primary closure of the wound. None of the patients required removal of the instrumentation. In 2 patients, the PLIF cages were repositioned in the face of infection. All 8 patients received 4 to 6 weeks of intravenous antibiotic therapy followed by another 6 to 9 weeks of oral antibiotic administration. At 2-year follow-up, no clinical or laboratory signs of recurrent infection were evident. Four of the 8 patients reported improved clinical status compared with their prefusion status. At 6-year follow-up, 3 patients had minimal disability according to the Oswestry Disability Index and 2 patients had moderate disability with residual leg pain. CONCLUSIONS: In cases of postoperative deep wound infection after PLIF with cages, removal of the interbody implants is not necessary. Treatment is composed of prolonged antibiotic therapy guided by antimicrobial susceptibility of the isolated bacteria and supplemented with extensive surgical debridement if needed.     

腰椎后路椎间融合术后伤口深部感染的处理

目的 评估手术清创或保守治疗方法在腰椎后路椎间融合术后伤口深部感染治疗中的临床疗效.方法 收集从2001年1月至2005年1月收治的213例因腰椎退行性疾病而接受后路椎间融合内固定术患者的临床资料,发现7例确诊为伤口深部感染,占3.3%.采用手术清创或者延长抗生素使用时间等保守治疗,所有7例患者均得到有效治疗,康复出院.术后对其随访,时间2.5～6.4年,平均3.6年.结果 6例患者行手术清创,1例使用针对性较强的敏感抗生素治疗.手术清创者在术中分别使用体积分数为2%的过氧化氢、生理盐水反复浸泡、冲洗伤口,质量浓度为0.1%的苯扎溴铵和生理盐水冲洗后明胶海绵填塞消灭死腔,严密缝合伤口.无一例患者取出内固定,有2例患者椎间融合器位置重置.术后延长抗生素静滴和口服时间,直至红细胞沉降率和血常规白细胞计数达正常后3～4d,随访期内无再次感染的病例.Oswestry残障评分显示3例患者下肢功能轻度残碍,3例中度残障,1例患者重度残障.结论 腰椎椎间融合术后深部椎间隙感染没有必要取出椎间融合器,可以采用手术清创或保守治疗等方法处理.     

内置物保留治疗脊柱内固定术后细菌感染8例报告

目的探讨脊柱内固定术后细菌感染发生时在保留内固定物的情况下手术联合药物治疗的效果。方法对来自滨州医学院附属医院的458例脊柱疾患采用脊柱内固定治疗,8例（1．75％）确诊术后感染接受治疗。结果在保留内固定物的情况下,所有确诊感染的患者接受外科彻底清创、抗感染及VSD辅助治疗,感染均得以根治,平均随访时间2．1年（1-2．5年）。结论脊柱内固定术后发生的细菌感染通过积极的手术清创、应用抗生素并联合VSD辅助治疗均可得到控制。结果显示术后细菌感染在不取出内固定物的情况下,可以成功治愈。     

Actinomyces as a cause of recurrent perianal fistula in the immunocompromised patient.

Actinomycosis is an uncommon bacterial infection that has a characteristic chronic indolent course. Patients with this infection frequently undergo multiple surgical procedures before a correct diagnosis is made. Perianal actinomycosis should be suspected if a nontender perianal mass is found to contain thin purulent material and small yellow particles (sulfur granules). The diagnosis is confirmed by special stains and anaerobic cultures. Recognition of this infection is important because successful treatment requires combined surgical and antibiotic therapy. We report two patients, one with diabetes mellitus and one with human immunodeficiency virus III, who had recurrent perianal abscesses caused by Actinomyces and were treated successfully with surgical drainage and antimicrobial therapy.     

Eikenella corrodens infections in children

Techniques for obtaining, transporting, and culturing bacteriologic specimens have improved in recent years. The laboratory is now identifying rare fastidious organisms in surgical infections, which were previously unknown to clinicians. One of these organisms, Eikenella corrodens, was found in 28 children over 5 years. It was most commonly found in patients with perforated appendices or in wounds with oral contamination. Eikenella most often occurs in multibacterial infections but has also been grown in pure culture. When this bacteria is found in a patient with a serious surgical infection the wound must be widely opened and debrided of necrotic tissue. Prolonged antibiotic therapy based on culture and sensitivity is necessary to prevent prolonged or recurrent infection.     

Third-generation cephalosporins for polymicrobial surgical sepsis

During 31 months of study, 808 patients with polymicrobial surgical infection were randomized for antibiotic therapy between a third-generation cephalosporin (moxalactam disodium [149], cefotaxime sodium [125], and cefoperazone sodium [141]) and the combination of gentamicin sulfate plus clindamycin (393). Results based on antibiotic therapy included the following: cure in 83% given cephalosporin, 73% with antibiotic combination; control but recurrent sepsis in 7% and 15%; and failure in 4% and 8%, respectively. Such data support the tenet that third-generation cephalosporins are at least equal, if not superior, to the combination of gentamicin plus clindamycin for treatment of polymicrobial surgical sepsis.     

Pyogenic spondylitis in the cervicothoracic junction with high-positioned aortic arch. Case report and review of the literature

The authors report the case of an 87-year-old woman who suffered from T1-2 pyogenic spondylitis resulting in progressive and severe paraplegia. Debridement and anterior manubrium-splitting fusion were difficult because a high-positioned aortic arch was very close to the infectious lesion. Because adequate intravenous antibiotic agents had nearly resolved the inflammation, the authors undertook anterior debridement and posterior fusion that involved costotransversectomy and the placement of a posterior cervical pedicle screw fixation system. At 1.5 years postoperatively, there were no signs of recurrent infection. Solid osseous union was documented, and the patient's paraplegia had improved. A high-positioned aortic arch will likely interfere with an anterior approach to the cervicothoracic junction. If adequate antibiotic therapy has successfully controlled the spinal infection, anterior debridement and posterior fusion can be conducted in cases involving such anatomical limitations.     

Successful management of hepatic abscesses by percutaneous catheter drainage in chronic granulomatous disease

Chronic granulomatous disease (CGD) is a disorder of polymorphonuclear leukocytes that can cause multiple recurrent hepatic abscesses in 40% of those patients with the disorder. The mortality rate from this complication of CGD is estimated at 27%. Treatment has consisted of extensive surgical debridement and drainage and prolonged antibiotic therapy; however, this approach is accompanied by high morbidity and the frequent need for reoperation. Successful percutaneous drainage of multiple hepatic abscesses in a patient who had previously undergone 10 operative procedures to manage hepatic abscesses is reported. With the development of imaging and percutaneous drainage techniques, as well as the recurrent nature of this problem, percutaneous management should be given consideration in appropriate patients with CGD with hepatic abscesses.     

Role of prophylaxis in vesicoureteral reflux

PURPOSE OF REVIEW: Traditional management of vesicoureteral reflux focuses on preventing renal complications associated with ascending urinary tract infection by either providing continuous antibiotic prophylaxis to sterilize the urine and thus prevent recurrent infection, or abolishing reflux via surgical intervention. This review will consider the rationale for antibiotic prophylaxis in light of contemporary data regarding the natural history of vesicoureteral reflux, urinary tract infection and renal scarring, as well as the efficacy of various treatment strategies. RECENT FINDINGS: Recent studies have shown that in grades I-IV vesicoureteral reflux, open surgical intervention compared with antibiotic prophylaxis is no better at preventing renal complications. Endoscopic subureteral injection of biomaterials has been proposed as a cost-effective, minimally invasive alternative to surgical or medical intervention; however, given the variety of materials and techniques, the literature has yet to achieve consensus on its efficacy. The first study to compare antibiotic prophylaxis with increased surveillance and prompt treatment of urinary tract infection shows no difference between the two approaches in low-grade (grades I-II) vesicoureteral reflux. SUMMARY: Recent studies have challenged the traditional paradigm of aggressive vesicoureteral reflux management with surgery or antibiotic prophylaxis. In light of these findings, pediatric urologists will need to reexamine treatment modalities for vesicoureteral reflux.     

Reliability of criteria for predicting persistent or recurrent sepsis

We reviewed the charts of 2,567 patients from 11 prospective clinical trials of antibiotic therapy for surgical infection to identify reliable predictors of sepsis eradication. Particular attention was paid to temperature, blood cell counts, renal and hepatic function tests, arterial gases, and clotting factors, both at the termination of parenteral antibiotic administration as well as at patient discharge from the hospital. On the discontinuation of antibiotic therapy, sepsis recurred in 19% of the patients who had a normal rectal temperature, in 3% of the patients if the rectal temperature and WBC count were normal, but in no patient when both the temperature and WBC count were normal and the differential blood smear contained less than 73% granulocytes and less than 3% immature forms. Rates for recurrent sepsis, once antibiotic therapy was discontinued for more than 48 hours, were 8%, 2%, and 0%, respectively, for the same criteria at hospital discharge.     

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography for treatment of cholangitis in a patient with a Kasai portoenterostomy

Primary therapy for biliary atresia is a surgical hepatoportoenterostomy (Kasai procedure), which has been shown to reduce mortality, but is frequently complicated by ascending cholangitis and the development of biliary cirrhosis. Previously reported therapy for recurrent cholangitis caused by biliary obstruction has included surgical revision and percutaneous biliary drainage, but endoscopic retrograde cholangiopancreatography has not been previously described. Here, we report a patient with recurrent cholangitis after a Kasai procedure and an anastomotic stricture successfully treated with single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography. This novel technique could be considered in patients with this common complication of the Kasai procedure and may impact long-term outcomes in this patient population.     

Pathogenicity of the enterococcus in surgical infections.

The enterococcus has been relegated to a position of unimportance in the pathogenesis of surgical infections. However the increasing prevalence and virulence of these bacteria prompt reconsideration of this view, particularly because the surgical patient has become increasingly vulnerable to infectious morbidity due to debility, immunosuppression, and therapy with increasingly potent antibiotics. The enterococcus is a versatile opportunistic nosocomial pathogen, causing such diverse infections as wound, intra-abdominal, and urinary tract infections; catheter-associated infection; suppurative thrombophlebitis; endocarditis; and pneumonia. Although surgical drainage remains the cornerstone of therapy for enterococcal infections involving a discrete focus, in the circumstances typified by the compromised surgical patient, specific antibacterial therapy directed against the enterococcus is warranted. Recent evidence indicates that parenteral antibiotic therapy for enterococcal bacteremia is mandatory and that appropriate therapy clearly reduces the number of deaths.     

Necrotizing fasciitis with no mortality or limb loss

Necrotizing fasciitis is a potentially lethal invasive soft tissue infection. Early aggressive antibiotic therapy and surgical debridement have been the hallmark of successful therapy. It is commonly held that delays in surgical debridement significantly increase the mortality rate and rate of limb loss. A mortality rate of 20 per cent or greater has been reported throughout the last 80 years. We recently reviewed the cases of 20 consecutive patients admitted to our hospital in various stages of necrotizing fasciitis progression. Treatment of all 20 patients consisted of antibiotic therapy and surgical debridement, with frequent follow-up serial debridement. Topical negative pressure was achieved with the use of the Vacuum Assisted Closure system. An aggressive surgical approach, (including the frequency of debridement, appropriate antibiotic utilization, and use of the Vacuum Assisted Closure system), significantly impacted our results, despite delays in treatment and progression of the infection.     

Antibiotikatherapie bei operativen Intensivpatienten

The development of resistance by infective bacterial species is an incentive to reconsider the indications and administration of available antibiotics. Correct recognition of the indications and duration of therapy are particularly important for the use of highly potent substances in the intensive care situation. There has as yet been no clinical chemical parameter which is capable of specifically distinguishing a bacterial infection from a viral or non-infectious inflammatory reaction, but it now appears that procalcitonin (PCT) offers this possibility. The present study was intended to clarify whether PCT can be used to guide antibiotic therapy in surgical intensive care patients. A total of 110 patients in a surgical intensive care ward receiving antibiotic therapy after confirmed infection or a high grade suspicion of infection were enrolled in this study. In 57 of these patients a new decision was reached each day as to whether the antibiotic therapy should be continued after daily PCT determination and clinical assessment. The control group consisted of 53 patients with a standardized duration of antibiotic therapy over 8 days. Demographic and clinical data were comparable in both groups. However, in the PCT group the duration of antibiotic therapy was significantly shorter compared to controls (5.9+/-1.7 vs. 7.9+/-0.5 days, p<0.001) without unfavorable effects on clinical outcome.     

The cost-effectiveness of endoscopic injection of dextranomer/hyaluronic acid copolymer for vesicoureteral reflux

PURPOSE: Vesicoureteral reflux is a risk factor for progressive renal damage associated with urinary tract infection. Mild to moderate reflux is routinely treated with long-term antibiotic prophylaxis to prevent recurrent infections and open surgical reimplantation for breakthrough infections despite antibiotic therapy. Endoscopic subureteral injection of implant material is a therapeutic alternative to long-term prophylaxis and open surgery but its widespread use in the United States has been prevented by the lack of a stable implant material. Dextranomer/hyaluronic acid copolymer has been shown to be a safe, effective and durable implant material and was recently approved in the United States. We estimate the effect on costs and cure rates of introducing endoscopic injection with dextranomer/hyaluronic acid copolymer as a treatment alternative in the United States. MATERIALS AND METHODS: We constructed a model that mimics current clinical practice of vesicoureteral reflux treatment for 6 years, and incorporates spontaneous resolution and surgical intervention rates obtained from 2 long-term followup studies. The treatment algorithm was established using medical data from the literature, and clinical management practices from a Delphi survey of 27 pediatric urologists and nephrologists across the United States. Endoscopic injection was introduced into the model as replacement to surgery or alternative to long-term antibiotic prophylaxis. The effectiveness of dextranomer/hyaluronic acid copolymer was calculated from 140 patients (208 ureters) with grade III reflux treated in a clinical study of 221 children in Sweden. RESULTS: With current practice, the average cost per patient in 6 years was 6,640 US dollars and 23.5% of patients continued to have reflux. Replacing open surgery with endoscopic injection led to similar cure rates (22.2% failures) but costs were reduced to 5,522 US dollars. When injection was performed after 1 year of antibiotic therapy failure rates were reduced to 8.5% but costs increased to 7,644 US dollars. CONCLUSIONS: Our results show that a persistent approach to endoscopic surgery can be expected to result in overall success that equals or exceeds open surgery at a lower cost. This finding is particularly true if open reimplant is reserved for patients with high grade or persistent vesicoureteral reflux.     

Basic aspects of and general problems in surgical infections

Antibiotics are important in the prophylaxis and treatment of surgical infections as well as in the management of nosocomial infections acquired postoperatively in surgical patients. Surgeons encounter a range of infectious conditions, including established single-pathogen infections of soft tissues, polymicrobial intra-abdominal infections, and resistant gram-negative nosocomial infections such as ventilator-associated and aspiration pneumonia. Preoperative antibiotic administration has been shown to reduce the risk of surgical site infections and is now an accepted part of the standard care for most surgical patients. In patients with established single-pathogen or polymicrobial infections requiring surgery, studies have shown appropriate empiric antibiotic therapy to be an important adjunct to surgical intervention and general supportive measures in improving patient outcome. Antibiotics are also essential for those who develop postoperative nosocomial infections. Empiric coverage of the most likely causative organisms, especially in synergistic polymicrobial mixed infections, is one of the keys to successful prophylaxis and treatment of surgical infections.     

The use of intracatheter instillation of streptokinase in the treatment of recurrent bacterial peritonitis in continuous ambulatory peritoneal dialysis

Recurrent bacterial peritonitis resistant to therapy with antibiotics is seen in a small percentage of patients maintained on continuous ambulatory peritoneal dialysis. In these patients, removal of the Tenckhoff catheter is necessary to achieve a cure. Sequestration of bacteria within fibrin clots located on the catheter has been postulated to contribute to this resistance to standard therapy. We, therefore, examined the efficacy of intraperitoneal streptokinase in combination with antibiotic therapy in the treatment of two patients with recurrent bacterial peritonitis. After addition of streptokinase to the therapeutic regimen, no further episodes of peritonitis were observed after 6 to 8 weeks follow-up. These data suggest that intraperitoneal streptokinase may be useful as adjunctive therapy in the treatment of recurrent bacterial peritonitis.     

Persistent infection after successful arthrodesis for infected total knee arthroplasty. A report of two cases

Infection in total knee arthroplasty has been reported to range from 1.1% to 12.4%. The literature contains numerous articles on salvage procedures including antibiotic suppression, surgical debridement, resection arthroplasty, arthrodesis, reimplantation, and amputation. Of those knees not reimplantable, a successful arthrodesis is felt by many to give the most predictable long-term results. The majority of literature on arthrodesis for infected total knee arthroplasty concentrates on technical factors and techniques to facilitate fusion. A successful fusion is considered an end point of treatment.     

A functional treatment method for interphalangeal pyogenic arthritis

A treatment plan for pyogenic arthritis has been devised in which the accessory collateral ligaments are resected through radial and ulnar midaxial incisions. The surgical wound is debrided and copiously irrigated with an antibiotic solution, and intravenous antibiotics are instituted before operation and continued after operation. Physical therapy is begun within 24 hours of surgery and includes active range of motion (ROM) of all joints, dynamic splinting, and hand therapy to ensure both full flexion and extension. Forty patients were treated with this method within a 6-year period. Of five interphalangeal (IP) joints of the thumb, four regained 0 degree to 60 degrees full ROM and one gained 15 degrees to 65 degrees limited ROM. Of the two distal IP joints, one regained full ROM and the other became fused. Among the 33 proximal IP joints, 13 regained full ROM of 110 degrees and 13 regained limited ROM. Good functional results were obtained with this treatment plan in lieu of amputation, which previously was the most likely treatment.