Prosthetic-Joint Infections — NEJM
Role of Biofilm
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Source of Infection: The are in general low virulence pathogens, but like any commensal organisms, careful evaluation of skin and oral structures is necessary before VGS bacteremia is considered non-clinically significant. Some of the important species of viridans-group Streptococci include and . Transient bacteremias may occur following dental manipulation and frequently are of no consequence in patients without predisposing conditions. It has been estimated that only 21-50% of the positive blood cultures for VGS are clinically significant. Viridans-group Streptococci used to be the most common cause of native valve endocarditis and late onset prosthetic valve endocarditis but nowadays has taken over as the most common organism (). VGS have also been associated with serious pyogenic infections, bacteremia in neutropenic patients, neonatal , and septicemia/shock syndrome (also known as "α strep shock syndrome"). The risk factors for VGS bacteremia include: , oral mucositis, irradiation to the oral cavity, antibiotic prophylaxis with and fluoroquinolones, intravenous hyperalimentation, high dose chemotherapy and female sex ().
The duration of antibiotic therapy for bacteremia must be at least 2 weeks of an intravenous agent. If the bacteremia is secondary to a distant source of infection or in the context of septic embolization, recommended therapy would be at least 4-6weeks. Selected patients with bacteremia can be treated for 2 weeks if they meet the following criteria: (1) removal of intravascular catheters that were present during the bacteremia, (2) endocarditis is excluded with TEE, (3) absence of implanted prosthesis (prosthetic valves, cardiac devices or arthroplasties, (4) follow up cultures obtained 2-4 days after initiation of therapy are negative and (5) resolution of fever and absence of localizing symptoms or signs suggestive of metastatic staphylococcal infection (, ). Though lacking clinical evidence to suggest benefit, if the patient presents with a severe infection or , consideration for combination therapy which could include 2 antistaphylococcal agents (vancomycin, daptomycin or linezolid in combination) or the addition of for synergy during the initial 3-5 days.
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It is a common skin inhabitant, therefore a common blood culture contaminant. If a decision to treat is made, which would be unusual, the antibiotics that would be most effective include penicillins, and macrolides. has been associated with upper extremity prosthetic joint infections, therefore a musculoskeletal evaluation is in order in patient with bacteremia.
Opportunistic fungal infections such as mucormycosis usually occur in immunocompromised patients, but can infect healthy individuals as well. The predisposing factors for mucormycosis are uncontrolled diabetes (particularly in patients with ketoacidosis), malignancies such as lymphomas and leukemia's, renal failure, organ transplant, long-term corticosteroid and immunosuppressive therapy, cirrhosis, burns, protein energy malnutrition and acquired immune deficiency syndrome. Our patient had uncontrolled diabetes, which is a well-known predisposing factor for mucormycosis.[,,,,,,,]
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In conclusion, an immunocompromised or immunosuppressed patient having bone necrosis following tooth extraction should alert a clinician of possible mucormycotic infection.
utcomes: Although severe CA-MRSA can result, CA-MRSA infections tend to be less severe and less invasive than health-care associatedMRSA infections. But CA-MRSA is generally more aggressive and results in more adverse outcomes than MSSA (46% of CA-MRSA infected patients were hospitalized versus 18% of CA-MSSA infected patients in one study (). Recurrences of CA-MRSA infections may be more common than CA-MSSA infection recurrences. The most common manifestations are skin and soft tissue infections, including wound infections and necrotizing fasciitis. Other possible manifestations include otitis media, otitis externa, sinusitis, brain abscesses, myositis, osteomyelitis, prosthetic joint infection urinary tract infection, endocarditis, sepsis, and necrotizing pneumonia. CA-MRSA colonization appears to put individuals at greater risk for soft tissue infections. One study of soldiers showed that 38% of colonized subjects subsequently developed soft tissue infections ().
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Nephrotic syndrome patients are also very prone to infection, notably with gram-positive cocci ("cellulitis", "primary pneumococcal peritonitis", etc., etc.) Loss of complement factors B and D is cited as a cause, and of course there is also iatrogenic immunosuppression.
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are a number of alternatives for oral therapy for less serious infection or step-down therapy. In general, combination oral therapy with two active agents is recommended for haMRSA. Most experience has been gained with , fluoroquinolones, and (in countries where it is available) . Chloramphenicol was used in the past but has fallen into disfavour. is a suitable alternative as a single agent and has proven effective in the short and long term management of bone and joint (including prosthetic) infections (, , ). Pristinamycin has found a role in MRSA infections when patients are intolerant of other drugs ().
In only one patient was a relapsed Gram-negative infection ..
adening the spectrum of initial antimicrobial therapy for additional bacterial species may be indicated in specific clinical settings. These include, human or animal bites, for which initial therapy might include ampicillin/sulbactam intravenously (1.5-3g intravenously every 6 hours) (MN) or amoxicillin/clavulanate (500 mg orally every 8 hours in an adult). In the setting of cellulitis after an abrasion or laceration occurring with salt water exposure, where might be the pathogen, treatment with doxycycline (200 mg intravenously per day in two divided doses) might be preferred. Doxycycline also covers MSSA. In the setting of cellulitis after an abrasion or laceration occurring with fresh water exposure, where might be involved, treatment with (400 mg intravenously every 12 hours) might be preferred. Quinolones also cover MSSA, but are not the antibiotics of choice. A combination of plus gentamicin may be added to antistaphylococcal antibiotics for invasive infection in immunosuppressed patients.
Two patients were immunosuppressed, ..
ided Endocarditis: A minimum of 4 weeks of intravenous treatment is recommended for left-sided endocarditis (). This duration is also recommended for septicemia complicated by metastatic infection, on the presumption that endocarditis may well be present. Of 20 patients with endocarditis receiving at least 4 weeks of treatment, all were cured at 1 month follow-up (). For endocarditis occurring on prosthetic devices, a 6-week course of a with an aminoglycoside has been recommended ().
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