Discitis and spinal infection

Spinal infection poses a diagnostic challenge and a low threshold for investigation should be maintained. Presentation is varied and non-specific symptoms mean that patients are investigated by many specialities. The majority of spinal infection is from haematogenous spread and therefore an origin of infection needs to be sought. Treatment of spondylodiscitis is routinely managed by non-surgical treatment with a prolonged period of antibiotics. Complications of spondylodiscitis can lead to morbidity and may be difficult to treat and often require surgery. It is essential to attempt to obtain microbiological diagnosis. Initial management and investigation does affect treatment strategies and it is important to understand this.     

Total removal of infected pacemaker lead with cardiopulmonary bypass; report of a case

The incidence of infection after pacemaker implant has been reported to occur rarely but it's one of the severe complication. Pacemaker lead sometimes imbedded in the right atrial and ventricular wall, and it seemed to be difficult to remove the pacemaker lead by closed techniques. The optimal treatment is total removal generator and pacing lead, therefore, it is necessary to remove with cardiopulmonary bypass. Septicemia caused by infections retained pacemaker lead developed in an 87-year-old man. Following antibiotic therapy, the lead was successfully removed by cardiotomy on cardiopulmonary bypass. Total removal with cardiopulmonary bypass would be recommended.     

Salvage of exposed implantable cardiac electrical devices and lead systems with pocket change and local flap coverage

Erosion and exposure of pacemaker (PPM) and implantable cardiac defibrillator (ICD) devices are potentially dire complications, which have classically required the removal of the entire generator and lead systems. This study evaluates a series of cases wherein debridement, irrigation, pocket change, and local flap coverage were used for the successful salvage of indwelling leads after exposure and infection of implantable cardiac defibrillator devices. Patients with skin erosion, infection, and/or exposure of prepectoral infraclavicular cardiac defibrillator devices were treated over a 23-month period between June 2004 and April 2006. The surgical technique involved wide excision of the exposure site with a rhombic incision pattern, followed by removal of the generator unit and complete debridement of the peridevice capsule. Subclavian atrioventricular (AV) leads were preserved. The pocket was irrigated with antibiotic solution. A new pocket plane was selected and developed, and a new generator unit was implanted. A rhombic flap was developed and transposed to achieve tension-free closure over closed suction drains. Data were reviewed retrospectively. Six patients were treated, all male, mean age 66 years (range, 50 to 83 years). All patients presented with "new" exposure of the implantable generator within 48 hours. None demonstrated gross purulence, sepsis, or endocarditis. Initial gram stain was negative for bacteria in all cases, 1 (17%) grew sensitive Staphylococcus epidermidis species. Mean follow-up is 22 months (range, 8 to 31 months). One patient (17%) developed a hematoma, successfully treated by aspiration. Five patients (83%) were treated successfully, with no wound dehiscence, generator or lead exposure, or recurrence of infection. One patient (17%) developed drainage and exposure at a separate site (AV lead) at 10 months postoperative and required generator and lead explantation and site change to the contralateral anterior chest wall. In conclusion, in the absence of sepsis or gross infection, skin excision, pocket change, generator change with lead preservation, closed-suction drainage, and flap coverage for tension-free closure should be considered in the treatment of early ICD and PPM exposure.     

Spontaneous ejection of a ring sequestrum in a 10-year-old: a case report

A case of a 10-year-old patient with a femur fracture treated with an external fixator who subsequently went on to develop a free-floating ring sequestrum is presented. The patient was largely asymptomatic throughout his course of treatment until seen emergently at 2 years postinjury with local and systemic signs of infection. He was successfully treated with intravenous and oral antibiotics as well as thorough irrigation and debridement. Ring sequestrum is the end point for pin tract infection that is left untreated. When it occurs, a course of antibiotics and thorough irrigation and debridement can lead to a successful outcome.     

Antimicrobial silver grafts for prevention and treatment of vascular graft infection

In vascular surgery, graft infection remains a serious limb-threatening and often life-threatening complication, despite progress in the last several decades. During the past 3 decades, prevention of surgical site infection predominantly relied on availability of effective perioperative antibiotic prophylaxis or the use of systemic antibiotics for treatment of infections after their clinical manifestation. However, evidence for the prophylactic effect of systemic antibiotics exists only for patients with vein grafts, who are at a lower risk of infection compared to patients receiving prosthetic material. Furthermore, because of the changed epidemiology of bacterial susceptibility against antibiotics today, reliance on the efficacy of systemic antibiotic prophylaxis must be done with caution. The outlook of current trends indicates that maximum effort is needed to maintain the current balance. Simply looking for new antibiotics will not lead to an additional decrease in the rate of infection in vascular surgery. Because of the consequences of infection in vascular surgery and the increasing resistance of causative micro-organisms, the future strategy to deal with infection needs to shift from reliance on systemic antibiotics and treatment of manifest infection to a strong focus on primary prevention of infection, particularly for surgical procedures involving prosthetic materials. This article summarizes current strategies for prevention of surgical site infection in vascular surgery and reviews current literature on antimicrobial vascular grafts using antiseptic agents instead of antibiotics to achieve antimicrobial efficacy. Specific emphasis is put on silver and its use in antimicrobial vascular grafts for prevention and treatment of vascular surgical infection.     

Single incision for implanting a vagal nerve stimulator system (VNSS): technical note

BACKGROUND: A technique for implanting the vagal nerve stimulator system through a single incision is described.METHOD: A transverse incision is made in the lower part of the neck. Subcutaneous (s.c.) dissection is then done over the clavicle into the infraclavicular area to create a pocket. The vagus nerve is exposed and the electrodes are wrapped around it through the neck incision. The distal ends of the lead are connected to the pulse generator, and latter is then placed in the infraclavicular pocket through the neck incision.RESULTS: Thirty-eight implants were conducted with this technique. The pulse generator could be implanted and anchored to the underlying tissue without any difficulty. Except for wound infections in two patients there was no other complication.CONCLUSION: A single incision is an alternate to the double incision procedure. This procedure can be performed safely.     

Acute bacterial sinusitis and diabetes mellitus

Diabetes mellitus has deleterious effects on the immune system which may lead to infection that is more serious and difficult to treat. Fifteen diabetic patients with acute bacterial sinusitis are reviewed. Diabetic pathophysiology and its relationship to infection are discussed. A protocol for treatment is outlined, with emphasis on the importance of intravenous antibiotics.     

Management of multidrug resistant Gram-negative bacilli infections in solid organ transplant recipients: SET/GESITRA-SEIMC/REIPI recommendations

Solid organ transplant (SOT) recipients are especially at risk of developing infections by multidrug resistant (MDR) Gram-negative bacilli (GNB), as they are frequently exposed to antibiotics and the healthcare setting, and are regulary subject to invasive procedures. Nevertheless, no recommendations concerning prevention and treatment are available. A panel of experts revised the available evidence; this document summarizes their recommendations: (1) it is important to characterize the isolate's phenotypic and genotypic resistance profile; (2) overall, donor colonization should not constitute a contraindication to transplantation, although active infected kidney and lung grafts should be avoided; (3) recipient colonization is associated with an increased risk of infection, but is not a contraindication to transplantation; (4) different surgical prophylaxis regimens are not recommended for patients colonized with carbapenem-resistant GNB; (5) timely detection of carriers, contact isolation precautions, hand hygiene compliance and antibiotic control policies are important preventive measures; (6) there is not sufficient data to recommend intestinal decolonization; (7) colonized lung transplant recipients could benefit from prophylactic inhaled antibiotics, specially for Pseudomonas aeruginosa; (8) colonized SOT recipients should receive an empirical treatment which includes active antibiotics, and directed therapy should be adjusted according to susceptibility study results and the severity of the infection.     

Infection of a retained permanent epicardial pacemaker lead

Infection of a retained permanent epicardial pacemaker lead rarely causes mediastinal infection. A 21-month-old boy who had undergone an arterial switch operation at day 6 of life presented with mediastinal infection 3 months after removal of the generator. Removal of the infected pacemaker leads with the inflammatory granuloma was performed under extracorporeal circulation. The mediastinal infection developed from the retained epicardial pacemaker lead infection.     

Breast cancer at the site of an implanted pacemaker]

We report here an 81-old-female patient who had a permanent pacemaker implanted in the right chest and who developed breast cancer near the site of the implanted generator. The cancer was diagnosed as stage I adenocarcinoma and radical mastectomy preserving pectoral muscles was indicated. During temporary pacing via the femoral approach, the pacemaker lead was transferred to the left subclavicular area crossing before the sternum and the generator was reimplanted in the left chest without use of lead extension kit. After reimplantation of the generator, radical mastectomy was performed. Clinical course was uneventful after the operation without infection or pacing failure. For the patient who needs surgical procedure in the site of implanted pacemaker generator, this technique of reimplantation is one of the useful choices.     

Surgical site infections

Surgical site infections are the second or third most common type of nosocomial infections in Germany. For hospitals an annual incidence of 130000-160000 cases is estimated. Microbiological findings basically depend on type of surgery and wound location. A variety of risk factors is known. Discrimination of avoidable and unavoidable risk factors is the key for prevention. Most important points in prevention are perioperative prophylaxis with antibiotics 30-60 minutes prior to incision and strict asepsis in the operation room. Clinical findings include a variety of symptoms. They can be assigned to an early course or a definitive infection. However, wound scores are better applicable when comparing clinical studies. The most important therapeutic procedure is clearing the source of infection. Subsequently the wound can be closed by secondary intention or lead to open wound healing. An accompanying therapy with antibiotics is recommendable in case of advanced local or systemic infection. To document wounds is an essential part of treating wounds.     

临床感染病原菌的变迁及其与抗菌药物应用的关系

目的:分析医院病原菌的结构和耐药的变迁趋势,探讨病原菌的变迁与临床抗菌药物使用的关系。方法:对解放军总医院第一附属医院1995年以来11年临床标本病原菌的分离鉴定结果进行统计分析,结合同期临床抗菌药物的使用强度,分析病原菌变迁与抗菌药物使用的相关性。结果:11年间从临床标本中共分离出病原菌15914株。①G 菌中金黄色葡萄球菌(金葡菌)和耐甲氧西林金葡菌(MRSA)的构成比上升趋势明显,凝固酶阴性葡萄球菌(CNS)和肠球菌属的构成比波动幅度较大,但变化趋势不明显。G-菌中,铜绿假单胞菌的构成比虽有波动,但始终维持在高水平;大肠杆菌和变形杆菌的构成比明显下降,不动杆菌的构成比明显上升。②1995年构成比最高的3种病原菌依次为大肠杆菌、铜绿假单胞菌和金葡菌,2005年变为铜绿假单胞菌、金葡菌和不动杆菌。③我院抗菌药物的使用强度在2005年达70DDD/100人天,使用最多的药物种类为喹诺酮类、二代头孢菌素和含酶抑制剂的三代头孢菌素;单一品种药物为左氧氟沙星、头孢呋辛和阿奇霉素。④大环内酯类、糖肽类、碳青霉烯类和3代头孢/抑制剂等药物的使用强度变化与多种病原菌构成比的变化呈显著正相关,MR-SA构成比的变化与多种药物使用强度变化呈显著正相关。结论:常见病原菌的耐药水平逐渐升高,将会增大抗感染治疗的难度;抗菌药物使用强度的变化有可能导致病原菌结构和耐药水平的变化。     

The exposed cardiac pacemaker. Treatment by subfascial pocket relocation

Ten patients were treated for skin erosion and exposure of chronically implanted pacemakers. The pulse generators had been implanted either subcutaneously or in the subpectoral, submammary location. All patients were treated either by primary or secondary relocation of the pulse generator to deeper subfascial planes. Pacemakers relocated primarily to subfacial planes healed without resurfacing. Those pacemakers relocated to other superficial planes resurfaced but healed in a second subfascial translocation. Bacteriologic studies on these patients revealed that the organisms cultured or antibiotics utilized did not influence the fate of the relocated pulse generator. The subfascial location was the only determinant of the ultimate healing of the exposed pacemaker. We conclude that subfascial relocation of well-functioning pacemaker generators should be considered as an alternative to complete replacement of the unit.     

Increased resistance of bacteria after adherence to polymethyl methacrylate. An in vitro study.

The pathobiology of total joint prosthesis infection was investigated in vitro. Discs of polymethylmethacrylate (PMMA) were exposed to a suspension containing cells of 10(8) per mL Staphylococcus epidermidis E-46. After 12 hours, exposed discs were rinsed with phosphate-buffered saline and placed in brain heart infusion broth containing antibiotics (2.5 mg per mL of Cephaloridine). After gentle shaking for 24 hours at 37 degrees C, the bacteria on the PMMA surface were detached and washed with phosphate-buffered saline to remove the antibiotics. Compared with the free bacteria which were detached from the PMMA by sonication immediately after exposure to the antibiotic solution, those allowed to remain adhered to the PMMA surface were more resistant to antibiotics. Scanning electron microscopy showed accumulation of bacteria surrounded by slime on PMMA discs exposed for 12 hours. Our results indicate that resistance of bacteria to antibiotics is increased after adherence to the biomaterial and formation of a slime layer.     

人工关节置换术后假体周围感染与术前贫血的研究进展

假体周围感染是人工关节置换术后最严重的并发症。流行病学调查发现,围术期贫血是造成假体周围感染的独立危险因素,其可通过影响细胞机制及自身免疫功能等多个方面发挥重要影响。既往国内外诸多学者对假体周围感染与术后贫血的关系进行研究,但对假体周围感染与术前贫血的相关性探讨较少。术前贫血可使红细胞表面的C3b受体减少,机体免疫功能降低,血源性感染增加,术后康复时间延长,进而诱发假体周围感染。故对于术前合并贫血的患者,除预防性使用抗生素外,术前应补充铁剂、配合促红细胞生成素积极纠正贫血、治疗影响血红蛋白生成的慢性并发症、提高患者自身的免疫状况、对符合输血指征的患者进行相应的输血治疗,从而更好地预防人工关节置换术后假体周围感染的发生,减少二次或多次翻修的概率。     

Pacemaker implanted in right inguinal region following removal of infected generator; report of a case

We treated a 62-year-old male who had previously undergone a mitral valve plasty and aorto-coronary bypass. One year after the operation, he underwent pacemaker implantation for atrial fibrillation. Two months following implantation, the pacemaker generator was exposed due to a methicillin-resistant Staphylococcus aureus (MRSA) infection. We selected a new catheter route from the right saphenous vein, and implanted a generator under the fascia of the external oblique abdominal muscle. Thereafter, the pacemaker is functioning without trouble and there is no evidence of infection.     

Treatment and outcome of human bites in the head and neck

OBJECTIVE: Our goal was to review head and neck human bite injuries for demographic, treatment, and outcome data to identify factors influencing infection.Study design Retrospective chart review of all human bite injuries (adult and pediatric) over 10 years. SETTING: Tertiary referral medical center. RESULTS: We reviewed 40 human bites (average follow-up, 139 days). Young males were the most common victims, altercation was the most common etiology, and auricular avulsion was the most common injury. Six wounds closed primarily became infected (40%) versus no wound infection with delayed closure. Primary wound closure (P <.01), exposed cartilage (P <.07), and less than 48 hours of intravenous antibiotics (P <.06) were associated with postoperative infection (P <.01). CONCLUSION: Human bites to the head and neck, especially those with exposed cartilage, are best treated with at least 48 hours of intravenous antibiotics and delayed surgical closure (>24 hours postinjury) to prevent infection. SIGNIFICANCE: This information enables the clinician who sees these bite wounds infrequently to understand the treatment associated with avoiding infection.     

Therapeutic principles of antimicrobial therapy and new antimicrobial agents

It is important that newly developed antibiotics be used so as to increase our ability to eradicate infection, rather than to complicate the treatment of infection by spawning the creation of organisms resistant to multiple antibiotics. One must peruse the literature with a very critical eye, as most new agents are touted as tremendous advances on past antibiotics. With rising medical costs becoming of ever-greater significance, proper choice of antimicrobial agent assumes more importance as well. The proper bacterial coverage in a given clinical setting, duration of treatment, and drug pharmacokinetics and the concept of the "total cost" of administering an antibiotic (taking into account fixed and variable hospital costs) all must be considered. Although it is virtually impossible to become experienced in using all of the currently available antibiotics, it is not necessary, either. Based on the literature and discussion with infectious disease colleagues, one can choose to use one or two antimicrobials in each broad class and gain the benefits of that class for his or her patients.     

上海地区膝关节置换术后深部感染的防治现状

目的了解上海地区有关全膝关节置换术后深部感染的预防、诊断和处理方法等方面的基本情况。方法就全膝关节置换术后的感染率、感染菌种、预防性抗生素应用情况、感染的诊断、翻修手术的方法等各方面的细节，用当面或电话咨询的方式，向上海市12间二、三级甲等医院的关节外科医师进行问卷调查。结果在感染的病原菌种类、预防性抗生素应用的必要性、感染的诊断手段、感染发生后做二期翻修手术等方面有比较一致的共识，但在预防性抗生素的具体用药选择、用药时间、抗生素骨水泥应用以及预防术后感染的其他手段、二期翻修间隔期抗生素的用法、二期翻修术后抗生素的用法等方面存在较大的差异。对照预防性抗生素的应用原则，上海地区应用的时机规范一致，但用药的品种偏于高级，用药的时问大多过长。在翻修手术的方法上，上海地区主流的做法都是二期（二步）延期翻修加抗生素骨水泥固定假体。结论上海地区关节外科医师普遍认为，预防性抗生素应用对控制全膝关节置换术后的感染是有效的，只要重视这一问题，感染的诊断并不困难。感染发生后的处理，以二步延期翻修法加抗生素骨水泥固定假体为主流方法，成功率高；但访治过程中的许多细节还有待进一步探索。     

Vacuum-assisted conservative treatment for the management and salvage of exposed prosthetic hemodialysis access.

Recurrent puncture of dialysis grafts can cause erosion and ulcer formation in the skin over the prosthetic material. Contamination of the wound can lead to infection of the graft, and the necessity to remove it. We describe four cases where agressive treatment with debridement, intravenous antibiotics and negative pressure therapy allowed prosthesis salvage without discontinuation of hemodialysis.