Spinal epidural abscesses – The role for non-operative management: A systematic review

BackgroundSpinal Epidural Abscesses (SEAs) are traditionally seen as a surgical emergency. However, SEAs can be discovered in entirely asymptomatic patients. This presents a dilemma for the attending clinician as to whether to subject these patients to significant surgery. This systematic review updates the evidence surrounding the efficacy of non-operative SEA management by means of intravenous antibiotics ± radiologically-guided aspiration.Aims1. To assess failure rates of medical therapy for SEA. The absolute definition of ‘failure’ used by the study was recorded, and comparisons made. 2. To review of risk factors for success/failure of medical treatment for SEA.MethodsA database search with the MESH term ‘epidural abscess’ and keywords [‘treatment’ OR ‘management’] were used.Results14 studies were included. The number of SEA patients managed non-operatively ranged from 19 to 142. There was significant heterogeneity across the studies. Pooled Failure of Medical Therapy (FMT) (defined as any poor outcome) was 29.40%. When FMT = mortality the pooled rate was 11.49%. Commonly cited risk factors for FMT included acute neurological compromise, diabetes mellitus, increasing age and Staphylococcus aureus.ConclusionSEA will always be a condition mostly managed surgically. Despite this, there is growing evidence that non-operative management can be possible in the correct patients. The key is in patient selection – patients with any of the above-mentioned risk factors have the potential to deteriorate further on medical treatment and have a worse outcome than if they had undergone emergency surgery straight away. Ongoing research will hopefully further investigate this crucial step.     

Influence of very short patch mismatch repair on SOS inducing lesions after aminoglycoside treatment in Escherichia coli

Low concentrations of aminoglycosides induce the SOS response in Vibrio cholerae but not in Escherichia coli. In order to determine whether a specific factor present in E. coli prevents this induction, we developed a genetic screen where only SOS inducing mutants are viable. We identified the vsr gene coding for the Vsr protein of the very short patch mismatch repair (VSPR) pathway. The effect of mismatch repair (MMR) mutants was also studied. We propose that lesions formed upon aminoglycoside treatment are preferentially repaired by VSPR without SOS induction in E. coli and by MMR when VSPR is impaired.     

Effects of air tourniquet on the antibiotics concentration,in bone marrow,injected just before the start of operation

Abstract

Infection is one of the most serious complications after artificial arthroplasty. In order to establish the effective prevention for after operative infection, we measured the serum and bone marrow blood cefmetazole (CMZ) concentration time dependently (1?g CMZ, one shot). Furthermore, we studied the effect of air tourniquet on CMZ transmit into bone marrow blood. Thirteen knees with total knee arthroplasty (TKA) were included in the study. As a control group, 11 hips with total hip arthroplasty (THA) were also included. In TKA, air tourniquet was used during operation in all cases. Just before the start of the operation, 1?g CMZ was injected intravenously (one shot). Subsequently we sampled peripheral blood and bone marrow blood time dependently. Cefmetazole concentration was measured with HPLC. In the THA group, serum and bone marrow blood CMZ concentration showed almost the same time-dependent change. On the other hand, in the TKA group we could not detect CMZ in bone marrow blood in cases where CMZ was injected within 8?min before starting use of an air tourniquet. If CMZ was injected more than 10?min before starting use of the air tourniquet, CMZ concentration in bone marrow blood was much lower than minimum inhibitory concentration (MIC) for Staphylococcus aureus; but after releasing the air tourniquet, CMZ concentration in bone marrow blood was higher than MIC for S. aureus. These data suggested that our injection method is effective for prevention of infection both during and just after operation in the THA but in the TKA, CMZ should be injected more than 10?min before starting to use the air tourniquet.     

Efficacy of photodynamic therapy versus antibiotics as an adjunct to scaling and root planing in the treatment of periodontitis: A systematic review and meta-analysis

BackgroundTo determine whether treatment with antimicrobial photodynamic therapy (aPDT) as an adjunct to scaling and root planing (SRP) yield better clinical periodontal outcomes than antibiotics (AB) as adjunct to SRP in periodontitis.MethodsElectronic searches were conducted in databases (MEDLINE, PubMed, EMBASE, SCOPUS, Cochrane Central Register of Controlled Trials and Cochrane Oral Health Group Trials Register databases) up to and including April 2017.ResultsFive randomized trials were included. All studies used the combined approach aPDT + SRP and AB + SRP in the test and control group respectively. The follow up period ranged from 12 to 48 weeks. All studies used diode lasers. The wavelengths, power density and duration of irradiation used were 670 nanometre, 75 milliwatts per square centimeters and 60 s respectively. None of the studies showed additional benefits of aPDT at follow up. Considering the effects of adjunctive aPDT as compared to AB, a high degree of heterogeneity for periodontal probing depth (PPD) (p < 0.0001, I² = 87.47%) was noticed among both the groups. Meta-analysis showed significant clinical attachment level (CAL) gain (WMD = 0.60, 95% CI = 0.25 to 0.95, p = 0.001), and not PPD reduction (WMD = 0.67, 95% CI = –0.36 to 1.71, p = 0.204) for aPDT as compared to AB at follow up.ConclusionIt remains debatable whether aPDT is more effective as compared to adjunctive AB in the treatment of periodontitis, given that the scientific evidence is weak. Precautions must be exercised when interpreting the results of this study due to the small sample size and high heterogeneity among studies.     

A novel host-protein assay outperforms routine parameters for distinguishing between bacterial and viral lower respiratory tract infections

Bacterial and viral lower respiratory tract infections (LRTIs) are often clinically indistinguishable, leading to antibiotic overuse. We compared the diagnostic accuracy of a new assay that combines 3 host-biomarkers (TRAIL, IP-10, CRP) with parameters in routine use to distinguish bacterial from viral LRTIs. Study cohort included 184 potentially eligible pediatric and adult patients. Reference standard diagnosis was based on adjudication by an expert panel following comprehensive clinical and laboratory investigation (including respiratory PCRs). Experts were blinded to assay results and assay performers were blinded to reference standard outcomes. Evaluated cohort included 88 bacterial and 36 viral patients (23 did not fulfill inclusion criteria; 37 had indeterminate reference standard outcome). Assay distinguished bacterial from viral LRTI patients with sensitivity of 0.93 ± 0.06 and specificity of 0.91 ± 0.09, outperforming routine parameters, including WBC, CRP and chest x-ray signs. These findings support the assay's potential to help clinicians avoid missing bacterial LRTIs or overusing antibiotics.     

阑尾消炎片联合抗生素治疗急、慢性阑尾炎96例临床体会

目的观察阑尾消炎片联合抗生素治疗急性阑尾炎的效果。方法采取阑尾消炎片口服,同时给予抗生素静点。结果本文报道96例,以用药一周为疗效统计依据。痊愈64例(66.66%),有效13例(13.54%),无效19例(19.79%),治愈率66.66%。结论口服阑尾消炎片联合抗生素口服或静点治疗阑尾炎效果很好,此种治疗方法可以免除一些不必要的手术,减少患者痛苦及经济上负担。     

Treatment and prophylaxis of melioidosis

Melioidosis, infection with Burkholderia pseudomallei, is being recognised with increasing frequency and is probably more common than currently appreciated. Treatment recommendations are based on a series of clinical trials conducted in Thailand over the past 25 years. Treatment is usually divided into two phases: in the first, or acute phase, parenteral drugs are given for ≥10 days with the aim of preventing death from overwhelming sepsis; in the second, or eradication phase, oral drugs are given, usually to complete a total of 20 weeks, with the aim of preventing relapse. Specific treatment for individual patients needs to be tailored according to clinical manifestations and response, and there remain many unanswered questions. Some patients with very mild infections can probably be cured by oral agents alone. Ceftazidime is the mainstay of acute-phase treatment, with carbapenems reserved for severe infections or treatment failures and amoxicillin/clavulanic acid (co-amoxiclav) as second-line therapy. Trimethoprim/sulfamethoxazole (co-trimoxazole) is preferred for the eradication phase, with the alternative of co-amoxiclav. In addition, the best available supportive care is needed, along with drainage of abscesses whenever possible. Treatment for melioidosis is unaffordable for many in endemic areas of the developing world, but the relative costs have reduced over the past decade. Unfortunately there is no likelihood of any new or cheaper options becoming available in the immediate future. Recommendations for prophylaxis following exposure to B. pseudomallei have been made, but the evidence suggests that they would probably only delay rather than prevent the development of infection.     

临床肺部感染评分干预对VAP患者的疗效观察

目的 探讨临床肺部感染评分对VAP患者抗生素选择策略进行干预后对预后的影响.方法 采用随机、对照、临床研究.连续入选符合诊断标准的VAP患者56例,随机分为2组:A组(评分干预组,28例)临床肺部感染评分大于6分者抗生素选择策略采用降阶梯治疗方案,小于6分者采用常规升级治疗方案.B组(常规组,28例)按常规自然决定抗生素的选择和疗程.比较两组患者抗生素使用疗程、病死率及真菌定植发生率等.结果 A组抗生素使用疗程、病死率显著低于B组,B组真菌定植发生率高于A组.结论 临床肺部感染评分干预抗生素选择策略对改善VAP的疗效、预后具有良好效果.