The efficacy of suppressive antibiotic treatment in patients managed non-operatively for periprosthetic joint infection and a draining sinus

Objectives: Patients with prosthetic joint infections (PJIs) not suitable for curative surgery may benefit from suppressive antibiotic therapy (SAT). However, the usefulness of SAT in cases with a draining sinus has never been investigated. Methods: A multicentre, retrospective observational cohort study was performed in which patients with a PJI and a sinus tract were eligible for inclusion if managed conservatively and if sufficient follow-up data were available (i.e. at least 2 years). SAT was defined as a period of > 6 months of oral antibiotic therapy. Results: SAT was initiated in 63 of 72 (87.5 %) included patients. Implant retention during follow-up was the same in patients receiving SAT vs. no SAT (79.4 % vs. 88.9 %; pCombining double low line0.68). In total, 27 % of patients using SAT experienced side effects. In addition, the occurrence of prosthetic loosening in initially fixed implants, the need for surgical debridement, or the occurrence of bacteremia during follow-up could not be fully prevented with the use of SAT, which still occurred in 42 %, 6.3 %, and 3.2 % of cases, respectively. However, the sinus tract tended to close more often (42 % vs. 13 %; pCombining double low line0.14), and a higher resolution of pain was observed (35 % vs. 14 %; pCombining double low line0.22) in patients receiving SAT. Conclusions: SAT is not able to fully prevent complications in patients with a draining sinus. However, it may be beneficial in a subset of patients, particularly in those with pain or the hindrance of a draining sinus. A future prospective study, including a higher number of patients not receiving SAT, is needed

Diretriz da Sociedade Brasileira de Cardiologia sobre Diagnóstico e Tratamento de Pacientes com Cardiomiopatia da Doença de Chagas

This guideline aimed to update the concepts and formulate the standards of conduct and scientific evidence that support them, regarding the diagnosis and treatment of the Cardiomyopathy of Chagas disease, with special emphasis on the rationality base that supported it.  Chagas disease in the 21st century maintains an epidemiological pattern of endemicity in 21 Latin American countries. Researchers and managers from endemic and non-endemic countries point to the need to adopt comprehensive public health policies to effectively control the interhuman transmission of T. cruzi infection, and to obtain an optimized level of care for already infected individuals, focusing on diagnostic and therapeutic opportunistic opportunities.   Pathogenic and pathophysiological mechanisms of the Cardiomyopathy of Chagas disease were revisited after in-depth updating and the notion that necrosis and fibrosis are stimulated by tissue parasitic persistence and adverse immune reaction, as fundamental mechanisms, assisted by autonomic and microvascular disorders, was well established. Some of them have recently formed potential targets of therapies.  The natural history of the acute and chronic phases was reviewed, with enhancement for oral transmission, indeterminate form and chronic syndromes. Recent meta-analyses of observational studies have estimated the risk of evolution from acute and indeterminate forms and mortality after chronic cardiomyopathy. Therapeutic approaches applicable to individuals with Indeterminate form of Chagas disease were specifically addressed. All methods to detect structural and/or functional alterations with various cardiac imaging techniques were also reviewed, with recommendations for use in various clinical scenarios. Mortality risk stratification based on the Rassi score, with recent studies of its application, was complemented by methods that detect myocardial fibrosis.  The current methodology for etiological diagnosis and the consequent implications of trypanonomic treatment deserved a comprehensive and in-depth approach. Also the treatment of patients at risk or with heart failure, arrhythmias and thromboembolic events, based on pharmacological and complementary resources, received special attention. Additional chapters supported the conducts applicable to several special contexts, including t. cruzi/HIV co-infection, risk during surgeries, in pregnant women, in the reactivation of infection after heart transplantation, and others.     Finally, two chapters of great social significance, addressing the structuring of specialized services to care for individuals with the Cardiomyopathy of Chagas disease, and reviewing the concepts of severe heart disease and its medical-labor implications completed this guideline.Esta diretriz teve como objetivo principal atualizar os conceitos e formular as normas de conduta e evidências científicas que as suportam, quanto ao diagnóstico e tratamento da CDC, com especial ênfase na base de racionalidade que a embasou. A DC no século XXI mantém padrão epidemiológico de endemicidade em 21 países da América Latina. Investigadores e gestores de países endêmicos e não endêmicos indigitam a necessidade de se adotarem políticas abrangentes, de saúde pública, para controle eficaz da transmissão inter-humanos da infecção pelo T. cruzi, e obter-se nível otimizado de atendimento aos indivíduos já infectados, com foco em oportunização diagnóstica e terapêutica. Mecanismos patogênicos e fisiopatológicos da CDC foram revisitados após atualização aprofundada e ficou bem consolidada a noção de que necrose e fibrose sejam estimuladas pela persistência parasitária tissular e reação imune adversa, como mecanismos fundamentais, coadjuvados por distúrbios autonômicos e microvasculares. Alguns deles recentemente constituíram alvos potenciais de terapêuticas. A história natural das fases aguda e crônica foi revista, com realce para a transmissão oral, a forma indeterminada e as síndromes crônicas. Metanálises recentes de estudos observacionais estimaram o risco de evolução a partir das formas aguda e indeterminada e de mortalidade após instalação da cardiomiopatia crônica. Condutas terapêuticas aplicáveis aos indivíduos com a FIDC foram abordadas especificamente. Todos os métodos para detectar alterações estruturais e/ou funcionais com variadas técnicas de imageamento cardíaco também foram revisados, com recomendações de uso nos vários cenários clínicos. Estratificação de risco de mortalidade fundamentada no escore de Rassi, com estudos recentes de sua aplicação, foi complementada por métodos que detectam fibrose miocárdica. A metodologia atual para diagnóstico etiológico e as consequentes implicações do tratamento tripanossomicida mereceram enfoque abrangente e aprofundado. Também o tratamento de pacientes em risco ou com insuficiência cardíaca, arritmias e eventos tromboembólicos, baseado em recursos farmacológicos e complementares, recebeu especial atenção. Capítulos suplementares subsidiaram as condutas aplicáveis a diversos contextos especiais, entre eles o da co-infecção por T. cruzi/HIV, risco durante cirurgias, em grávidas, na reativação da infecção após transplante cardíacos, e outros.    Por fim, dois capítulos de grande significado social, abordando a estruturação de serviços especializados para atendimento aos indivíduos com a CDC, e revisando os conceitos de cardiopatia grave e suas implicações médico-trabalhistas completaram esta diretriz.&nbsp

Pulmonary thromboembolism: retrospective study of necropsies performed over 24 years in a university hospital in Brazil

CONTEXT: Pulmonary thromboembolism is the third most frequent cause of morbidity and mortality among acute cardiovascular diseases. The incidence of pulmonary embolism in necropsies has remained unchanged over the last few decades. Cardiac diseases, neoplasia, trauma, recent surgery and systemic diseases are important predisposing clinical conditions. The relationship between male and female sexes is estimated at 1.24. Various studies have shown an increase in morbidity in spring and autumn. There is great difficulty in precise anatomopathological diagnosis in relation to the localization of the emboli in the pulmonary vessels, although they are preferentially located in the right lung and lower lobes. OBJECTIVE: To study the incidence of lethal and non-lethal pulmonary thromboembolism in relation to epidemiological and anatomical variables. DESIGN: Retrospective study performed via reports on the necropsy findings. SETTING: University hospital providing tertiary-level attendance. SAMPLE: 16,466 consecutive necropsies performed from January 1972 to December 1995. MAIN MEASUREMENTS: Frequency of lethal and non-lethal pulmonary thromboembolism, predisposing diseases, occurrence in relation to the seasons of the year, and location where the embolus is lodged. RESULTS: Pulmonary thromboembolism was found in 4.7% of all the necropsies performed. There was a predominance of lethal cases (68.2%). There was no difference in relation to sex or seasons of the year for the occurrence of this disease. Cardiovascular diseases were more frequently associated with thromboembolic phenomena. With regard to the location where the embolus was lodged, various lung segments showed greater incidence of being bilaterally compromised. CONCLUSION: Over the period of this study, it was observed that there was a reduction in the incidence of pulmonary thromboembolism, which was probably due to the increase in prophylactic measures over the last few decades. Nonetheless, lethal thromboembolism predominated in frequency, probably because of the abrupt onset of a condition of attack across a large area of the lung, lack of clinical suspicions and consequently a lack of early diagnosis, and delay in instituting fibrinolytic therapy in the cases with hemodynamic repercussions or a large number of lung segments affected

TRATAMENTO DE OSTEOMIELITE CRÔNICA DE ACETÁBULO COM USO DE ANTIBIÓTICO LOCAL COMO ALTERNATIVA PARA AUSÊNCIA DE DROGAS TERMOESTÁVEIS EM UM HOSPITAL PÚBLICO NO BRASIL: UM RELATO DE CASO

Introdução: O tratamento da osteomielite crônica inclui a terapia antimicrobiana sistêmica e desbridamento cirúrgico adequado, com gerenciamento do espaço morto. A associação de antimicrobianos locais tem se mostrado benéfica. Contudo, o polimetilmetacrilato (PMMA), veículo mais utilizado, exige a presença de antibióticos termoestáveis para eluição. Objetivo: O objetivo do estudo é a descrição do tratamento de uma paciente com anemia falciforme e osteonecrose da cabeça do fêmur, com osteomielite crônica de acetábulo bilateral, internada em um hospital terciário da cidade de São Paulo – Brasil, com quadro grave de sepse. O tratamento indicado foi de cirurgia associada a antibioticoterapia local e sistêmica. Métodos: Uma paciente de 36 anos, com diagnostico prévio de anemia falciforme, osteonecrose da cabeça do fêmur e osteomielite bilateral do acetábulo deu entrada no pronto atendimento de um hospital público terciário no Brasil com quadro de choque séptico. Na admissão, ela se apresentava desorientada, febril, sem sinais de pioartrite, fazendo uso de droga vasoativa, com 34920 leucócitos/mL e 569,83 mg/L de proteína C reativa (PCR), em uso de ciprofloxacino e meropenem. A paciente apresentava fistula em região glútea com saída de secreção purulenta, devido à osteomielite da crista ilíaca. Foi realizado um primeiro procedimento com limpeza e desbridamento cirúrgico. A análise da coleta de cultura identificou Pseudomonas aeruginosa multisensível e Staphylococcus coagulase negativo oxa-R e sensível a linezolida e vancomicina. A partir desses resultados, foi complementado o esquema antimicrobiano com o acréscimo de linezolida. Apesar de se manter clinicamente estável, a paciente ainda mantinha dor e fistulização com leucocitose e aumento de provas inflamatórias. Devido à ausência de gentamicina em pó, por meio de doação de sulfato de cálcio, foi realizado um novo desbridamento e limpeza cirúrgica com colocação de gentamicina 240 mg líquida + 2 g de vancomicina pó eluido em sulfato de cálcio. A paciente evoluiu com queda dos leucócitos e provas inflamatórias, ausência de fístula e melhora da dor, com deambulação sem auxílio de dispositivos. Resultados: Foi visto que, na ausência de antibióticos termoestáveis para o tratamento de osteomielites resistentes e recidivantes, o uso de biocerâmicas pode ser uma alternativa

Interferon-γ release assay as a sensitive diagnostic tool of latent tuberculosis infection in patients with HIV: a cross-sectional study

Abstract Background In developing countries, tuberculosis (TB) is a major public health problem and the leading cause of death among patients with HIV (Human Immunodeficiency Virus). Until 2001, the tuberculin skin test (TST) was the only available tool for the diagnosis of latent tuberculosis infection (LTBI), but false-negative TST results are frequently reported. Recently, the interferon-γ (IFN-γ) release assay (IGRA) has gained ground because it can detect the IFN-γ secreted by circulating lymphocytes T cells when stimulated by specific TB antigens. However, the role of IGRA in the diagnosis of LTBI in HIV-infected patients has not been well established. Methods This cross-sectional study compared the accuracy of TST (performed by the Mantoux method) and IGRA (QuantiFERON-TB Gold In-Tube, Cellestis, Carnegie, Australia) on the diagnosis of LTBI among patients with HIV. LTBI is defined by LTBI risk and at least one positive test (TST or IGRA), without clinical evidence of active TB. We also assessed the accuracy of TST and IGRA among HIV patients with high and low risk for LTBI. Results Among 90 HIV patients, 80 met the study criteria for LTBI, fifty-nine (73.7%) patients were TST positive, 21 (26.2%) were negative, whereas 75 patients (93.7%) were IGRA positive, and five (6.2%) were negative. TST showed poor agreement with the diagnosis of LTBI (Kappa: 0.384), while IGRA demonstrated good agreement (Kappa: 0.769). Among 69 patients with high risk and 21 with low risk for LTBI, TST was positive in 48 (69.5%) and 11 (52.4%), while IGRA was positive in 68 (98.5%) and 7 (33.3%) patients, respectively. There were no association between TST and the level of risk (P = 0,191). Conversely, we observed a strong association between the IGRA and risk for LTBI (p < 0.001). Conclusions Compared to TST, IGRA positivity is consistent with the risk of TB infection and seems to be a better diagnostic tool for LTBI in HIV-infected patients

Comparison of bacterial profile of gallbladder with gallstones from patients undergoing cholecystectomy due to complicated and uncomplicated cholelithiasis: changes in the epidemiological scenario

ABSTRACT Introduction: cholelithiasis is a highly prevalent disease of the digestive system in the world. In Brazil, it is a routine condition, whose studies suggest a prevalence of around 10% of adults. Colonization of bile and gallstone pathogens can occur when there is bacterial stasis and proliferation. This proliferation is facilitated by the adhesion and biofilm formation capacity of some bacteria. There are also lithogenic processes that involve bacterial participation. Studies have shown changes in the microbiota of the gallbladder of patients undergoing cholecystectomy, which may impact empirical treatment with antibiotics. Methodology: microbiological analyzes of the sonication fluid of the gallstones and of two samples with bile were performed. Identification and antimicrobial susceptibility testing were performed according to a standard routine. Results: of the 34 patients, 76.4% were female. The age group was 48 years +/- 16.61. Acute cholecystitis occurred in 50% of cases. Bactobilia was evidenced in 32.1% of the cases. Klebisiella pneumoniae was noted as the most prevalent pathogen in acute cholecystitis; and Enterobacter sp, in cases of uncomplicated cholelithiasis. Greater sensitivity was obtained in the search for microorganisms in the sonication fluid samples of the stones in relation to the bile samples (p=0.0058). Conclusion: there was a higher prevalence of bactobilia in patients with acute cholecystitis compared to those with uncomplicated cholelithiasis. The use of sonication in bacterial investigation proved to be superior to the conventional method and can be considered