Eradication of Acinetobacter baumannii/Enterobacter cloacae complex in an open proximal tibial fracture and closed drop foot correction with a multidisciplinary approach using the Taylor Spatial Frame®

Background Multi-drug-resistant bacteria (e.g. Carbapenem-resistant Acinetobacter baumannii, extended-spectrum betalactamase or carbapenemase-producing enterobacteriaceae) are emerging in early-onset infections. So far, there is no report describing the eradication of these bacteria in a osseous infection of an open proximal tibial fracture in combination with the hexapod technology to address both osseous consolidation and closed drop foot correction. Case presentation After sustaining a proximal tibial fracture (Gustilo 3B), a 41-year-old man was primarily treated with open reduction and internal fixation by a locking plate and split-thickness skin graft in the home country. At the time of admission to our hospital there was a significant anterolateral soft tissue defect covered with an already-necrotic split-thickness graft and suspicious secretion. CAT and MRI scans revealed no signs of osseous healing, intramedullary distinctive osteomyelitis, as well as a large abscess zone in the dorsal compartment. Multiple wound smears showed multi-drug-resistant bacteria: Acinetobacter baumannii (Carbapenem resistant) as well as Enterobacter cloacae complex (AmpC overexpression). After implant removal, excessive osseous and intramedullary debridements using the Reamer Irrigator Aspirator (RIA®) as well as initial negative pressure wound therapy were performed. Colistin hand-modelled chains and sticks were applied topically as well as an adjusted systemic antibiotic scheme was applied. After repetitive surgical interventions, the smears showed bacterial eradication and the patient underwent soft tissue reconstruction with a free vascularized latissimus dorsi muscle flap. External fixation was converted to a hexapod fixator (TSF®) to correct primary varus displacement, axial assignment and secure osseous healing. A second ring was mounted to address the fixed drop foot in a closed fashion without further intervention. At final follow-up, 12 months after trauma, the patient showed good functional recovery with osseous healing, intact soft tissue with satisfactory cosmetics and no signs of reinfection. Conclusions A multidisciplinary approach with orthopaedic surgeons for debridement, planning and establishing osseous and joint correction and consolidation, plastic surgeons for microvascular muscle flaps for soft tissue defect coverage as well as clinical microbiologists for the optimized anti-infective treatment is essential in these challenging rare cases

Calculated parenteral initial treatment of bacterial infections: Microbiology

This is the second chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience.Preliminary microbiological findings regarding the patient and their immediate environment are crucial for the calculation of treatment with antibiotics in each case, as well as the resistance situation of the ward on which the patient is being cared for. If such data is not available, regional or supra-regional data can be used as a fallback. This chapter describes the methods of susceptibility testing, informs about the resistance situation in Germany and describes the main resistance mechanisms of bacterial pathogens against antibiotics. Further, the chapter informs about collateral damage of antibiotics as well as medical measures against increasing resistance.Dies ist das zweite Kapitel der von der Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) herausgegebenen S2k Leitlinie "Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen - Update 2018" in der 2. aktualisierten Fassung.Entscheidend für die Kalkulation einer Therapie mit Antibiotika im Einzelfall sind vorausgehende mikrobiologische Befunde des Patienten selbst und seiner unmittelbaren Umgebung sowie die Resistenzsituation der Abteilung, in der der Patient versorgt wird. Sind solche Daten nicht verfügbar, kann auf regionale oder überregionale Daten zurückgegriffen werden. Dieses Kapitel beschreibt die Methoden der Empfindlichkeitsprüfung, informiert über die überregionale Resistenzsituation in Deutschland und beschreibt die wichtigsten Resistenzmechanismen bakterieller Krankheitserreger gegen Antibiotika. Ferner informiert das Kapitel über Kollateralschäden von Antibiotika sowie medizinische Maßnahmen gegen die zunehmende Resistenz

Patientenanzahl und Jahrestherapiekosten in der frühen Nutzenbewertung - Kann der Beschluss des G-BA vorhergesagt werden?

Roll 369b. Homecoming Parade. Image 20 of 36. (8 February, 1958) [PHO 1.369b.21] Some images from this roll are restricted.The Boleslaus Lukaszewski (Father Luke) Photographs contain more than 28,000 images of Saint Louis University people, activities, and events between 1951 and 1970. The photographs were taken by Boleslaus Lukaszewski (Father Luke), a Jesuit priest and member of the University's Philosophy Department faculty

Intravenous fosfomycin—back to the future. Systematic review and meta-analysis of the clinical literature

[Objectives] We conducted a systematic review and meta-analysis to summarize the clinical evidence and usage patterns of intravenous fosfomycin from its development to the present time.[Methods] PubMed, the Cochrane Library and local journals were searched for relevant studies reporting aggregated data of intravenous fosfomycin use in adults and children, with no restrictions regarding study design. Single case reports were excluded. Data were systematically abstracted for all included studies. Clinical and microbiological efficacy from randomized controlled and comparative observational studies were synthesized using meta-analysis to calculate pooled effect sizes.[Results] In all, 128 studies on intravenous fosfomycin in 5527 patients were evaluated. Fosfomycin was predominantly used for sepsis/bacteraemia, urinary tract, respiratory tract, bone and joint, and central nervous system infections. No difference in clinical (OR 1.44, 95% CI 0.96–2.15) or microbiological (OR 1.28, 95% CI 0.82–2.01) efficacy between fosfomycin and other antibiotics was observed in comparative trials. The pooled estimate for resistance development during fosfomycin monotherapy was 3.4% (95% CI 1.8%–5.1%). Fosfomycin showed a favourable safety profile, with generally mild adverse events not requiring discontinuation of treatment. Included studies explored intravenous fosfomycin as an anti-staphylococcal agent in monotherapy and combination therapy, whereas studies from 1990 focused on combination therapy (fosfoymcin + β-lactams or aminoglycosides) for challenging infections frequently caused by multidrug-resistant organisms.[Conclusion] Intravenous fosfomycin can play a vital role in the antibiotic armamentarium, given its long history of effective and safe use. However, well-designed randomized controlled trials are still desired.All authors approved the final version of the manuscript. JRB receives funding for research from the Ministerio de Economía y Competitividad, Instituto de Salud Carlos III—co-financed by European Development Regional Fund “A way to achieve Europe” ERDF, Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015), FIS (PI 13/01282), and the Innovative Medicines Initiative (European Union and EFPIA partners in kind; agreements 115523 COMBACTE-NET, 115620 COMBACTE-CARE and 115737 COMBACTE-MAGNET projects)

Calculated initial parenteral treatment of bacterial infections: Sepsis

This is the eleventh chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience.Sepsis, defined as a life threatening organ dysfunction caused by a misregulated host response to an infection, is the third leading cause of death in Germany with a lethality rate of 30% to over 50%. An early, effective antimicrobial therapy is, next to infectious source control, the most important causal treatment option. It should be complemented by the mainly supportive measures of general intensive care therapy. Prior antimicrobial therapy, the patient's medical history (e.g. risk factors for multiresistant agents) and small-scale epidemiology are to be considered as part of the therapeutic and practical decisions. A modification of the often needed broad initial calculated combination therapy is desirable. In the future, prompt measurements of plasma concentrations of antiinfectives, especially for the sepsis patient with diverse and partly conflicting pathophysiological changes, will have great importance regarding efficacy, toxicity and resistance development. In order to apply those complex strategies in clinical routine, there is a requirement for a strong interdisciplinary collaboration between the intensive care unit, clinical infectiology, microbiology, and clinical pharmacology, ideally in the framework of a functional antimicrobial stewardship program.Dies ist das elfte Kapitel der von der Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) herausgegebenen S2k Leitlinie "Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen - Update 2018" in der 2. aktualisierten Fassung.Sepsis als die dritthäufigste Todesursache in Deutschland mit einer Letalität von 30 bis über 50% ist definiert als lebensbedrohliche Organdysfunktion, die durch eine fehlregulierte Wirtsantwort auf eine Infektion hervorgerufen wird. Die frühe, wirksame antimikrobielle Therapie stellt neben der Fokussanierung/-kontrolle die wichtigste kausale Behandlungsoption dar, ergänzt durch die allgemeine Intensivtherapie mit ihren vor allem supportiven Maßnahmen. Eine antimikrobielle Vortherapie, die Vorgeschichte des Patienten (z.B. Risikofaktoren für multiresistente Erreger) und die Kleinraumepidemiologie sollten unbedingt in die therapeutischen und praktischen Erwägungen einbezogen werden. Eine Modifizierung der zunächst oft breit notwendigen kalkulierten Kombinationstherapie ist anzustreben. In Zukunft wird der zeitnahen Plasmakonzentrationsbestimmung von Antiinfektiva gerade beim Sepsis-Patienten mit seinen vielfältigen, teils gegenläufigen pathophysiologischen Veränderungen eine herausragende Bedeutung im Hinblick auf Wirksamkeit, Toxizität und Resistenzentwicklung zukommen. Um diese komplexen Strategien im klinischen Alltag erfolgreich umsetzen zu können, bedarf es der engen Zusammenarbeit des Intensivmediziners/Klinikers mit der klinischen Infektiologie, der Mikrobiologie und der klinischen Pharmakologie, idealerweise im Rahmen eines funktionierenden Antimicrobial Stewardship Programmes