Three-decade trends in the distribution of organisms causing septic arthritis in native joints: Single-center study of 374 cases

ObjectiveA rise in the incidence of septic arthritis due to methicillin-resistant Staphylococcus aureus (MRSA) has been reported in several parts of the world. Here, our objective was to look for changes over the last 30 years in the distribution and antibiotic susceptibility profiles of organisms responsible for septic arthritis.MethodsWe conducted a single-center retrospective study of all cases of septic arthritis documented by joint specimens and/or blood cultures between 1979 and 2008. Prosthetic joint infections were excluded.ResultsWe enrolled 374 patients, of whom 127, 136, and 111 were included during each decade, respectively. We detected no significant time trends in the proportions of staphylococci (67%, 65%, and 64%), streptococci (14%, 21%, and 17%), or Gram-negative rods (7%, 10%, and 14%). Tuberculosis was more common during the earliest decade (1979–1988, n = 10, 4, 2%; P < 0.05). No significant changes occurred in the proportions of methicillin-resistant staphylococci or MRSA (13%, 11%, 15%). Age and prevalence of risk factors for infection increased over time.ConclusionThe distribution and susceptibility of organisms causing septic arthritis has changed little over time. Our findings do not support the use of broader-spectrum antibiotics when empirical treatment is deemed necessary at our center.     

Septic arthritis of the acromioclavicular joint

The acromioclavicular joint is rarely the site of septic arthritis. We conducted a retrospective review at our rheumatology department, which identified five cases within the last 6 years. All five patients were males, and their mean age was 63 years. Risk factors were consistently identified and included intravenous substance abuse, prior joint disease, a recent history of intraarticular injections, and a remote history of surgery. Joint aspiration was performed in all five patients and provided the organism in two patients. Blood cultures recovered Staphylococcus aureus in three patients, a coagulase-negative Staphylococcus in one patient, and no organism in one patient. Ultrasonography and/or magnetic resonance imaging established the early diagnosis in four patients and ruled out concomitant involvement of the glenohumeral joint. Only about 20 cases of septic arthritis of the acromioclavicular joint have been reported to date. This rare infection must be diagnosed rapidly to prevent joint destruction. The treatment is that usually recommended for septic arthritis.     

Clinical characteristics and outcomes in polyarticular septic arthritis

Objectives

Septic polyarthritis is rarer than septic monoarthritis, but associated with higher mortality. Septic polyarthritis may be difficult to distinguish clinically from noninfectious inflammatory arthritis. We describe one of the largest samples of septic polyarthritis with the aim of distinguishing septic monoarthritis from polyarthritis.

The evaluation of nasal mupirocin to prevent Staphylococcus aureus burn wound colonization in routine clinical practice

BackgroundStaphylococcus aureus wound colonization frequently occurs in patients with burns and can cause impaired wound healing. Nasal mupirocin application may contribute to the reduction of burn wound colonization of endogenous origin, whereas colonization by the exogenous route can be reduced by blocking cross-infection from other sources. In this study we evaluated whether the implementation of routine treatment of patients and burn center personnel using nasal mupirocin ointment reduces S. aureus burn wound colonization.MethodsWe composed three study groups, consisting of a control period (Control), a mupirocin period (MUP), in which patients with burns were all receiving nasal mupirocin at admission, and a mupirocin + personnel period (MUP + P), in which we also screened the burn center personnel and decolonized S. aureus carriers by nasal mupirocin.ResultsThe patients who carried S. aureus in their nose and did not have S. aureus burn wound colonization at admission were considered as patients susceptible for the use of nasal mupirocin. In these patients, the S. aureus burn wound colonization rate was the same in all study groups. S. aureus nasal carriage was a significant independent risk factor for burn wound colonization (OR: 3.3; 95% CI: 1.4–7.6) when analyzed within the three study groups.ConclusionAlthough S. aureus carriage is a significant risk factor for developing burn wound colonization, the routine use of nasal mupirocin did not contribute to a reduction of burn wound colonization.     

Efficacy of anakinra for refractory acute calcium pyrophosphate crystal arthritis

Acute synovitis induced by deposition of calcium pyrophosphate (CPP) and monosodium urate crystals involves interleukin-1β production and activation. The efficacy of blocking interleukin-1β activity (with an interleukin-1 receptor antagonist [anakinra] or interleukin-1β antibody) is well documented for gout attacks but has only been reported in two single-case reports of CPP crystal-induced acute arthritis. Here we report on five cases (four males, mean age 71 ± 27) of CPP crystal-induced inflammatory arthritis refractory and/or intolerant to usual drug therapy and efficiently treated with anakinra. Diagnosis of CPP crystal-induced arthritis was confirmed by identification of crystals in synovial fluid. CPP crystal-induced oligo-arthritis (n = 4) and polyarthritis (n = 1) were refractory to conventional treatments, including non-steroidal anti-inflammatory drugs, colchicine and steroids (systemic administration or intra-articular injection). After latent infection was ruled out, anakinra, 100 mg/day, was administered subcutaneously for 3 days. Four patients showed rapid clinical and biological responses at a mean of 3 days after treatment. Anakinra provided good joint pain relief (baseline 0–100 mm visual analog scale score 60 ± 17 mm, outcome 10 ± 10 mm) and decreased serum C-reactive protein level (58 ± 43 to 5 ± 2 mg/L). Anakinra was well tolerated. One injection-site skin reaction was observed but no infection. Anakinra was effective and safe in this small series of patients with refractory arthritis due to acute CPP crystal deposition.     

Septic arthritis with negative bacteriological findings in adult native joints: a retrospective study of 74 cases

BackgroundNo microorganism is identified in 7–35% of cases of septic arthritis. The diagnosis is, therefore, only presumptive. We reviewed our cases of septic arthritis in adult native joints to determine the frequency of negative cultures, disease characteristics and the frequency of misdiagnosis of septic arthritis.MethodsThis retrospective study included all patients admitted to our department from 1979–2005 with arthritis, diagnosed and treated as septic.ResultsNo microorganism was isolated from synovial fluid or blood samples from 74 out of 398 (19%) patients with presumed septic arthritis. Patients without microorganisms were younger (54 vs 62 years), less likely to have risk factors for septic arthritis (31% vs 41%) and had lower mortality (0 vs 5%) than patients with positive cultures. Long-term outcome was known for 48 patients. A retrospective analysis of all data and long-term outcome concluded that septic arthritis was probable in 18 patients and improbable in 13. Ten of the latter developed rheumatic disease after a mean time of 6 months: rheumatoid arthritis (n = 3), spondyloarthropathies (n = 3), unclassified rheumatic disease (n = 2), Wegener granulomatosis (n = 1) and cytosteatonecrosis (n = 1). Fever and signs of inflammation were more frequent and synovial fluid cell counts were higher in patients with improbable septic arthritis. Conversely, radiological signs were more common in patients with probable septic arthritis.ConclusionAt least 14% of patients diagnosed with septic arthritis with negative bacteriological results subsequently develop rheumatic disease. This pseudoseptic arthritis is indistinguishable from true septic arthritis. When no microorganism is identified, the diagnosis remains presumptive and follow-up is necessary to screen for other diseases, especially rheumatic diseases.     

The effect of presence of facultative bacteria species on semen and sperm quality of men seeking fertility care

IntroductionInfections of male urogenital tracts may contribute to male infertility. However, the effects of bacterial presence on sperm quality and fertility are controversial.ObjectivesWe investigated the occurrence of non-specific bacteria and quality/quantity of semen of infertile and fertile control groups in Nigeria.Subjects and methodsWe investigated 162 infertile and 54 fertile men. Spermiogram, culture, bacterial isolation and characterization were conducted.ResultsWe report 114/162(70.4%) occurrence of bacteria species, 49.4% of such were Gram positive and 21% Gram negative: Staphylococcus aureus (29.6%) and Escherichia coli (10.5%) had the highest occurrence for each group respectively. On semen quality/quantity, we report 14.2% azoospermia, 52.5% oligozoospermia and 33.3% of normozoospermia. The mean sperm concentrations were 10 × 7/ml and 41 × 10 6/ml for oligo and normozoospermia respectively. Majority (52%) of azoospermic group had no bacterial growth. S. aureus was the most implicated among the bacterial positive group. Within the ologozoospermic category, 28% had no bacterial growth, 28% had S. aureus and 11.8% E. coli. The normozoospermic patients had 18.5% no bacteria contamination, 33.3% had S. aureus, 13% had E. coli. From the analysis, the normozoospermic group with bacterial contamination had lower sperm concentrations compared with those without contamination. It was apparent that factors other than bacterial contamination may contribute more to oligozoospermia (compare: “no bacteria” group mean sperm concentration 8.97 × 106/ml, Gram positive bacteria contaminated group 17.74 × 106/ml and Gram negative bacteria contaminated group 13.66 × 106/ml). The mean progressive motility ratios were lower (15.6 [a]% + 18.3 [b]%) = 33.9%) against WHO standard (a + b = >50%) and control RPM (a) = 55.3%. Generally, the semen quality (vol., rapid progressive motility, sperm concentration and immotility) were significantly lower than the fertile group, P = 0.0005, <0.0001, <0001 and 0.0335, respectively.ConclusionsAlthough bacterial presence in semen reduced mean sperm concentration and viability, thereby contributed to oligozoospermia and by extension the chances of siring a child, however, factors other than bacterial presence may contribute more. Improved interpretative approaches of semen analyses are highlighted.     

Factores pronósticos en pielonefritis enfisematosa

ObjectivesThe purpose of this study is to analyze our experience with 18 cases of Emphysematous pyelonephritis (EPN) in a tertiary care center and describe our treatment strategy.Material and methodsOf 262 patients admitted with acute pyelonephritis, 18 had CT findings of EPN. The Wan and Huang classifications were used. We assessed the clinical, radiological, and therapeutic characteristics of these patients and investigated potential prognostic factors of mortality.ResultsBetween 2005 and 2010, 17 women and 1 man with EPN were treated. Mean age was 52.4 years. Diabetes was found in 66% and hypertension in 72%. The most common clinical findings were tachycardia (11), fever (11) and flank pain (9); 66% (12) presented with severe sepsis and 2 had septic shock. Acute renal injury developed in 61%. Nine patients were treated exclusively with conservative management; 5 had double J stenting, 3 had CT-guided PCD and 1 required nephrectomy after unsuccessful medical management. Mortality was 11%. Altered consciousness (P = .0001), multiple organ failure (P = .0004), hyperglycemia (P = .003) and elevated leukocyte count (> 20 000 K) (P = .01) were more frequent among patients dying from EPN. No difference in mortality was found between patients managed conservatively and those undergoing invasive therapy.ConclusionsAlthough rare, EPN should be suspected in patients with multiple comorbidities presenting with severe sepsis. Altered consciousness, multiple organ failure, hyperglycemia and elevated leukocyte count are poor prognosis indicators. Invasive management should be used judiciously and medical treatment can be a safe strategy in selected cases.     

Safety and vasopressor effect of rosuvastatin in septic patients

BackgroundStatins anti-inflammatory and antioxidant properties improve vascular function in septic patients. The aim of this prospective study was to assess vasopressor effect and safety of rosuvastatin therapy in septic patient.MethodsOne hundred and eight patients admitted to intensive care unit (ICU) with suspected or confirmed infection plus at least 2 systemic inflammatory response syndrome criteria were included in this prospective double-blinded randomized two groups’ parallel study. Group R received standard therapy and rosuvastatin 20 mg/day and Group C received standard therapy with placebo/day for 14 days.The primary endpoint was number of acceptable blood pressure and systemic perfusion days (ABPSPD). Secondary outcome included time to initial ABPSPD, vasopressor dose and duration, arterial lactate, organ dysfunction or failure free days, ICU and hospital stay, 28 ICU and hospital mortality, CPK and transaminases level.ResultsThe number of ABPSPD was significantly increased 11(3) vs. 8 (3) (p = 0.0001), with a shorter time to initial ABPSPD 18(21) vs. 41(37) h (p = 0.0001) in Group R than Group C. Norepinephrine dose 0.8 (0.5) vs. 1.6 (0.6) and duration 3(2) vs. 6(3) were significantly reduced in Group R with no significant elevation in transaminases or CPK.ConclusionsRosuvastatin 20 mg/day in septic patients increased number ABPSPD, decreased time to initial ABPSPD, norepinephrine dose and duration, with no significant elevation in transaminases or CPK.     

Prevalence of calcium pyrophosphate and monosodium urate crystals in synovial fluid of patients with previously diagnosed joint diseases

ObjectiveThe main aim of this study was to investigate the frequency of monosodium urate (MSU) and calcium pyrophosphate (CPP) crystals in synovial fluid (SF) obtained from patients with previously diagnosed joint diseases.MethodsWe reviewed the results of SF analysis of 5020 samples identifying those collected from patients with a previously definite diagnosis (2370 samples). SF analysis results, age, sex, diagnosis and disease duration were recorded from computerized records of patients’ archives.ResultsThe prevalence of CPP crystals in SF was 22.28% in osteoarthritis (OA), 8.28% in rheumatoid arthritis (RA), 3.82% in psoriatic arthritis (PsA), 2.79% in other spondyloarthropathies (SpA), 10% in septic arthritis (SeA), 0.66% in gout and 9.18% in the miscellanea of joint diseases, respectively. The prevalence of MSU crystals in SF was 0.30% in RA, 3.34% in PsA, 0.70% in other SpA, 0.80% in acute CPP crystal arthritis (CPP-CA), 0% in OA, reactive arthritis (ReA), SeA, juvenile idiopathic arthritis (JIA) and miscellanea.In OA group, we observed that age and SF inflammatory indices were higher in SF positive to CPP crystals with respect to those without crystals (P < 0.0001). In RA, we found that the group of patients with CPP crystals was significantly older (P = 0.001) and had a SF less inflammatory (P = 0.022) with respect to that without crystals but with a higher disease duration than those without crystals.ConclusionCrystals can be detected more frequently than expected in SF from joint diseases with a previous established diagnosis. This highlights the importance of SF analysis for the diagnosis of possible comorbidities linked to the presence of crystals.     

Levosimendan does not provide mortality benefit over dobutamine in adult patients with septic shock: A meta-analysis of randomized controlled trials

ObjectivesDespite of advancement in intensive care medicine, sepsis and septic shock carry a high mortality. Levosimendan, an inodilator, may be promising for septic shock patients with myocardial dysfunction; however, firm evidence is lacking. In this meta- analysis of randomized controlled trials, levosimendan has been compared with dobutamine in adult patients with sepsis and septic shock.DesignMeta-analysis of randomized controlled trial.SettingIntensive-care unit.ParticipantsAdult septic shock patients.InterventionAdult septic shock patients received dobutamine or levosimendan.Main outcome measureMortality at longest follow-up, blood lactate level, cardiac index and noradrenaline requirement.ResultsData from 7 randomized trials have been included in this meta-analysis. Levosimendan has no benefit in terms of mortality at longest follow up in comparison to dobutamine (Odds ratio 0.77, 95% CI 0.45, 132; p = 0.34) and length of ICU stay (MD − 4.7 days, 95% CI − 10.3, 0.9 days, p = 0.10). Patients received levosimendan had less blood lactate level (standardized mean difference − 0.95; 95% CI − 1.64, − 0.27; p = 0.006) and higher cardiac index (mean difference 0.44; 95% CI 0.17, 0.71; p = 0.001). Noradrenaline requirements are similar in both the groups.ConclusionThere is no evidence that levosimendan is superior to dobutamine in adult patients with sepsis and septic shock. Further large randomized trials are necessary in this area.     

Combining cytology and microcrystal detection in nonpurulent joint fluid benefits the diagnosis of septic arthritis

Objective

To evaluate the performance of combined cytology and microcrystal detection in joint fluid for diagnosing septic arthritis.

Safety of rituximab in rheumatoid arthritis patients with a history of severe or recurrent bacterial infection: Observational study of 30 cases in everyday practice

ObjectivesTo report our experience with rituximab therapy in patients with rheumatoid arthritis (RA) and a history of severe or recurrent bacterial infections.Patients and methodsRetrospective observational study in five rheumatology departments experienced in the use of biotherapies. Patients were included if they had RA and a history of severe or recurrent bacterial infection (requiring admission and/or intravenous antimicrobial therapy) that contraindicated the introduction or continuation of TNFα antagonist therapy.ResultsOf 161 RA patients given rituximab in the five study centers, 30 met the inclusion criteria, 23 females and seven males with a mean age of 58.4 ± 11.8 years and a mean disease duration of 11.4 ± 13.9 years. Among them, 22 had rheumatoid factors and 21 had received TNFα antagonist therapy (one agent in 15 patients, two in five patients and three in one patient). Prior infections were as follows: septicemia, n = 2; lower respiratory tract infection or lung abscess, n = 12; prosthesis infection, n = 3; septic arthritis, n = 3; endocarditis, n = 1; pyelonephritis, n = 2; osteitis, n = 4; and various skin infections (erysipelas, cellulitis or skin abscess), n = 6. Of these 33 infections, 21 occurred during TNFα antagonist therapy. During rituximab therapy, all patients received concomitant glucocorticoid therapy (mean dosage, 12 ± 7.9 mg/day). The number of rituximab cycles was one in 13 patients, two in seven patients and three or more in 10 patients. Mean time from the single or last serious infection and the first rituximab infusion was 20.1 ± 18.7 months. Mean follow-up since the first rituximab infusion was 19.3 ± 7.4 months. During follow-up, six (20%) patients experienced one infection each. Immunoglobulin levels after rituximab therapy were within the normal range.ConclusionRituximab therapy was well tolerated in 24 (80%) of 30 patients with RA and a history of severe or recurrent bacterial infection. In everyday practice, rituximab therapy seems safe with regard to the recurrence of infectious episodes. However, longer follow-ups are needed.     

Pre-operative labs: Wasted dollars or predictors of post-operative cardiac and septic events in orthopaedic trauma patients?

PurposeAs US healthcare expenditures continue to rise, there is significant pressure to reduce the cost of inpatient medical services. Studies have estimated that over 70% of routine labs may not yield clinical benefits while adding over $300 in costs per day for every inpatient. Although orthopaedic trauma patients tend to have longer inpatient stays and hip fractures have been associated with significant morbidity, there is a dearth of data examining pre-operative labs in predicting post-operative adverse events in these populations. The purpose of this study was to assess whether pre-operative labs significantly predict post-operative cardiac and septic complications in orthopaedic trauma and hip fracture patients.MethodsBetween 2006 and 2013, 56,336 (15.6%) orthopaedic trauma patients were identified and 27,441 patients (7.6%) were diagnosed with hip fractures. Pre-operative labs included sodium, BUN, creatinine, albumin, bilirubin, SGOT, alkaline phosphatase, white count, hematocrit, platelet count, prothrombin time, INR, and partial thromboplastin time. For each of these labs, patients were deemed to have normal or abnormal values. Patients were noted to have developed cardiac or septic complications if they sustained (1) myocardial infarction (MI), (2) cardiac arrest, or (3) septic shock within 30 days after surgery. Separate regressions incorporating over 40 patient characteristics including age, gender, pre-operative comorbidities, and labs were performed for orthopaedic trauma patients in order to determine whether pre-operative labs predicted adverse cardiac or septic outcomes.Results749 (1.3%) orthopaedic trauma patients developed cardiac complications and 311 (0.6%) developed septic shock. Multivariate regression demonstrated that abnormal pre-operative platelet values were significantly predictive of post-operative cardiac arrest (OR: 11.107, p = 0.036), and abnormal bilirubin levels were predictive (OR: 8.487, p = 0.008) of the development of septic shock in trauma patients. In the hip fracture cohort, abnormal partial thromboplastin time was significantly associated with post-operative myocardial infarction (OR: 15.083, p = 0.046), and abnormal bilirubin (OR: 58.674, p = 0.002) significantly predicted the onset of septic shock.ConclusionsThis is the first study to demonstrate the utility of pre-operative labs in predicting perioperative cardiac and septic adverse events in orthopaedic trauma and hip fracture patients. Particular attention should be paid to haematologic/coagulation labs (platelets, PTT) and bilirubin values.Level of evidencePrognostic Level II.     

Association between respiratory and herpes viruses on pulmonary exacerbations in cystic fibrosis patients

Respiratory viruses discovered in the 21st century and human herpes viruses (N = 13) were seldom (4/50) detected in our cystic fibrosis patients although exacerbation frequency (7.75 ± 2.9/a versus 4.45 ± 2.1/a; p = 0.03) and colonization with Aspergillus fumigatus (RR: 2.6; CI95: 1.8–3.7), Pseudomonas aeruginosa (RR: 1.84; CI95: 1.4–2.4), and Staphylococcus aureus (RR: 1.5; CI95: 1.2–1.9) including MRSA (RR: 4.6; CI95: 1.3–16.6) were associated with virus positivity. Further studies should clarify whether this finding reflects non-specific colonization (human Bocavirus) or reactivation (Epstein-Barr virus) or rather an acceleration of lung tissue inflammation.     

Insuffisance rénale aiguë dans les formes graves du paludisme chez les enfants vivant à Kinshasa

BackgroundData on acute renal failure in complicated malaria in children in the Democratic Republic of Congo are sparse. The objective of this study was to document the profile of acute renal failure in severe malaria in admitted patients in pediatric hospitals from Kinshasa.MethodsA prospective cohort study was conducted from January 2008 to December 2008 in children admitted in emergency units of five hospitals in Kinshasa for severe malaria.ResultsIn our series, 378 children with severe malaria were included. There were 226 boys and 152 girls (sex ratio 1.49). One hundred and ninety four (194) of these patients were under 5 years old. Acute renal failure was observed in 89 children (23.6%) and 87 of them had blackwater fever (BWF). This form of severe malaria was predominant in children older than 5 years. Quinine was the commonest antimalarial drug involved in the genesis of BWF. Dialysis was indicated in 23 children (24.0%) and was effective (acute peritoneal dialysis) in 21 patients. The death rate in children with ARF was 12.6% (n = 87). Recovery of renal function was obtained by conservative treatment in the remained group.ConclusionThis study confirmed the emergence of BWF in seemed protected autochthon children older than 5 years. BWF remained the leading cause of acute renal failure in complicated malaria among Congolese children in Kinshasa.     

Myocardial deformation assessment in patients with precapillary pulmonary hypertension: A cardiac magnetic resonance study

PurposeThe purpose of this study was to investigate right atrial and ventricular strain parameters on cardiac magnetic resonance (CMR) in patients with precapillary pulmonary hypertension (PPH) and whether they can aid in the assessment of PPH prognosis.Materials and methodsAdult patients with groups 1 and 4 PPH were invited to participate in the study. Age- and sex-matched healthy volunteers were also recruited as controls. At baseline, patients underwent clinical examination, N-terminal pro-B-type natriuretic peptide measurement and CMR with feature tracking post-processing (CMR-FT). Healthy controls underwent only CMR-FT. The study's primary endpoint was clinical failure, defined as death, hospitalization or demonstrable clinical deterioration during follow-up. Patients who were unable to perform 6-minute walking test due to musculoskeletal disorders were excluded from the study.ResultsThirty-six patients (8 men, 28 women; mean age, 50.6 ± 13.8 [SD] years [range: 18.6–78.5 years]) and 12 healthy control subjects (5 mean, 7 women; mean age, 40.6 ± 13.5 [SD] years [range: 23.1–64.4 years]) were recruited. Right ventricular global longitudinal strain (GLS) was significantly impaired in PPH patients (?20.2 ± 5.3 [SD] % [range: ?28.8 to ?9.1%] vs. ?28.4 ± 3.1% [?33.7 to ?22.7%] respectively, P < 0.001). The right atrial GLS was significantly impaired in PPH compared to healthy controls (?19.9 ± 4.5% [range: ?28.6 to ?3.6%] vs. ?26.5 ± 4.2% [range: ?32.8 to ?15.8%] respectively) (P < 0.001). Clinical failure occurred in 19 (19/36, 53%) of patients. Right ventricular GLS predicted clinical failure most reliably among CMR parameters (?22.6 ± 3.8 [SD] % [range: ?27.6 to ?12.7%] for patients without clinical failure vs. ?18 ± 5.6 [SD] % [range: ?28.8 to ?9.1%] for patients with clinical failure; hazard ratio [HR] = 1.85; P = 0.007; area under the AUC curve = 0.75). Lower absolute right atrial GLS was significantly associated with clinical failure (?22.7 ± 3.0 [SD] % [range: ?28.6 to ?17.7%] for patients without clinical failure vs. ?16.9 ± 5.8 [SD] % [range: ?24.2 to ?3.6%] for patients with clinical failure) (HR = 1.53; P = 0.035).ConclusionCMR feature tracking-derived myocardial strain parameters of both the right atrium and ventricle can assist clinicians in the prognosis of PPH.     

Impact of prophylactic CpG Oligodeoxynucleotide application on implant-associated Staphylococcus aureus bone infection

TLR-9 ligand CpG oligodeoxynucleotide type B (CpG ODN) induces a proinflammatory environment. We evaluated the effects of a preoperative CpG ODN application in an implant-associated Staphylococcus aureus bone infection model by monitoring bacterial loads and cytokine and chemokine levels.A total of 95 rats were used in four different groups: CpG ODN group (group 1; n = 25), non-CpG-ODN group (group 2; n = 25); saline pretreatment (group 3; n = 25), and one uninfected group (group 4; n = 20). A single dose of CpG-ODN was administered to the left tibialis anterior muscle 3 days prior to surgery and the tibia midshaft was osteotomized, stabilized by an intramedullary implant and subsequently contaminated with 10³ colony forming units (CFUs) of S. aureus in groups 1–3. The osteotomy gap in animals of group 4 was not contaminated with S. aureus and those animals did not receive any pretreatment.CpG ODN administration resulted in significant reduction of the bacterial load in tibia tissue homogenate and on the implant surface on day 1 post-infection compared to non-CpG-ODN pretreatment (p < 0.05; p < 0.05). Reductions in bacterial CFUs, compared to non-treated (saline) controls, were approximately 67% and 77% for bone tissue homogenates and implants. No bacteria were detected in uninfected rats. Early reduction of bacterial CFUs in the tibia was accompanied by increased levels of proinflammatory mediators MIP-2, IL-1β and RANTES in bone tissue milieu of the CpG ODN treated group compared to controls.At day 42 post-infection, bone marrow tissue of rats pretreated with CpG ODN had comparable high bacterial CFU numbers as the non-CpG ODN or saline treated groups. Microbiological analysis of implants removed from CpG ODN treated rats showed high bacterial growth densities on their surfaces which were not different from those observed in controls. In histology, all animals of groups 1–3 showed established infected non-unions. Additionally, inflammatory mediator profiles in bone marrow homogenates of CpG ODN treated rats resembled those seen in infected controls.In this rat model, prophylactic administration of a single dose of CpG ODN, resulted in marked reduction of S. aureus load in the infected tibia during the initial stage of infection but failed to prevent development of chronic infection over time.     

Role of Computed tomography in predicting prognosis of Hepatic portal venous gas

BackgroundThe aim of this study was to report through 13 cases the particularities of abdominal computed tomography (CT) aspects of hepatic portal venous gas (HPVG) and its correlation with patient prognosis.MethodsWe analyzed abundance of HPVG and its association with pneumatosis intestinalis (PI) in correlation with fatal outcome using chi-square tests.ResultsEtiologies were mesenteric infarction (n = 5), sigmoid diverticulitis (n =  1), septic shock (n = 1), postoperative peritonitis (n = 1), acute pancreatitis (n = 1), iatrogenic cause (n = 3) and idiopathic after a laparotomy (n = 1). The outcome was fatal in for 6 patients. Abundance of HPV was expressed in total number of hepatic segments involved. The involvement of 3 or more segments was a sensitive sign for lethal outcome with high sensitivity (100%) but it was not specific (50%). Negative predictive value of this sign was 100% (p ≤ 0.005). Positive predictive value of PI for death was 100% (p ≤ 0.001).DiscussionAbundance of HPVG is correlated with prognosis. The presence of PI announces poor outcome Negative predictive value of presence of HPVG in 3 or more segments is interesting. Predicting prognosis with CT can help surgeons to assess the most adequate treatment. Iatrogenic causes are increasingly described after interventional radiology procedures with favorable course.ConclusionThe first etiology radiologists should look for in front of HPVG involving more than 3 hepatic segments and associated with PI is intestinal necrosis which announces a poor prognosis. This study shows that outside of shock situations, HPVG involving 2 or less hepatic segments without PI predicts a good outcome.