Update on infections in articular prosthesis

O implante de próteses articulares, principalmente de quadril e joelho, vem se tornando cada vez mais frequente, representando significante redução no desconforto e imensurável melhora na mobilidade dos pacientes. As revisões da literatura mundial revelam que 1 a 5% destas próteses tornam-se infectadas, sendo importante lembrar que, conforme cresce o número de cirurgias para implantação destas próteses, cresce também o número de casos deste tipo de infecção. As bactérias gram-positivas são predominantes nas contaminações das próteses articulares, em especial o Staphylococcus aureus e o Staphylococcus epidermidis. As infecções causadas por bacilos gram-negativos e fungos como Candida sp vêm sendo relatadas com maior frequência em todo o mundo. As infecções de próteses articulares apresentam sinais característicos que podem ser divididos em manifestações agudas (dor severa, febre alta, toxemia, calor, rubor e secreção na ferida operatória) e crônicas (dor progressiva, formação de fístulas cutâneas, com drenagem de secreção purulenta, sem febre). O diagnóstico definitivo da infecção deve ser realizado através do isolamento em cultura do micro-organismo obtido a partir da punção do líquido articular, secreção da ferida cirúrgica e materiais colhidos durante desbridamento cirúrgico. É fundamental a cobertura de S.aureus meticilino-resistente, visto a importância epidemiológica deste agente nessas infecções. O tempo total da antibioticoterapia varia de seis semanas a seis meses, sendo que o tratamento deve ser readequado quando necessário, com base nos resultados das culturas colhidas.The implantation of artificial joints, especially the hip and knee, is becoming increasingly common, representing a significant reduction in discomfort and an immeasurable improvement in patient mobility. Reviews of the global literature indicate that 1-5% of these grafts become infected, though it is important to remember that, as the number of surgeries for implantation of these prosthesis grows, so will the number of cases of this type of infection. Gram-positive bacteria predominate in the contamination of joint prosthesis, in particular Staphylococcus aureus and Staphylococcus epidermidis. Infections caused by gram-negative bacilli and fungi such as Candida sp have been reported with increased frequency throughout the world. Infections of joint prosthesis have characteristic signals that can be divided into acute (severe pain, high fever, toxemia, heat, redness, and wound secretion) and chronic (progressive pain, cutaneous fistula formation, with pus drainage, no fever) manifestations. The definitive diagnosis of the infection should be made through the isolation in culture of the micro-organism obtained from the puncture of the joint fluid, surgical wound secretion, and material collected during surgical debridement. It is essential to cover methicillin-resistant Staphylococcus aureus, given the epidemiological importance of this agent in these infections. The total time of antibiotic therapy varies from six weeks to six months, and that treatment should be adjusted as needed, based on the results of culturing

Dor em afecções reumatológicas

Muscle skeletal pains are very common. The authors present a very simplified description of the most commonrheumatologic conditions resulting in pain. The occurrence of osthoarthritis, arthritis periarticular conditions is emphasized.Dores músculo-esqueléticas são comuns. Os autores apresentam descrições simples e objetivos das mais prevalentes condições reumatológicas associadas à dor. Destacam a importância epidemiológica das osteoartroses, artrites e das condições periarticulares

Carbapenem stewardship: positive impact on hospital ecology

INTRODUCTION: Excessive group 2 carbapenem use may result in decreased bacterial susceptibility. OBJECTIVE: We evaluated the impact of a carbapenem stewardship program, restricting imipenem and meropenem use. METHODS: Ertapenem was mandated for ESBL-producing Enterobacteriaceae infections in the absence of non-fermenting Gram-negative bacilli (GNB) from April 2006 to March 2008. Group 2 carbapenems were restricted for use against GNB infections susceptible only to carbapenems and suspected GNB infections in unstable patients. Cumulative susceptibility tests were done for nosocomial pathogens before and after restriction using Clinical and Laboratory Standards Institute (CLSI) guide-lines.Vitek System or conventional identification methods were performed and susceptibility testing done by disk diffusion according to CLSI.Antibiotic consumption (t-test) and susceptibilities (McNemar's test) were determined. RESULTS: The defined daily doses (DDD) of group 2 carbapenems declined from 61.1 to 48.7 DDD/1,000 patient-days two years after ertapenem introduction (p = 0.027). Mean ertapenem consumption after restriction was 31.5 DDD/1,000 patient-days. Following ertapenem introduction no significant susceptibility changes were noticed among Gram-positive cocci. The most prevalent GNB were P. aeruginosa, Klebsiella pneumoniae, and Acinetobacter spp. There was no change in P. aeruginosa susceptibility to carbapenems. Significantly improved P. aeruginosa and K. pneumoniae ciprofloxacin susceptibilities were observed, perhaps due to decreased group 2 carbapenem use. K. pneumoniae susceptibility to trimethoprim-sulfamethoxazole improved. CONCLUSION: Preferential use of ertapenem resulted in reduced group 2 carbapenem use, with a positive impact on P. aeruginosa and K. pneumoniae susceptibility

Septic arthritis of the knee: clinical and laboratory comparison of groups with different etiologies

OBJECTIVES: To clinically and epidemiologically characterize a population diagnosed with and treated for septic arthritis of the knee, to evaluate the treatment results and to analyze the differences between patients with positive and negative culture results, patients with Gram-positive and Gram-negative bacterial isolates and patients with S. aureus- and non-S. aureus-related infections. METHODS: One hundred and five patients with septic knee arthritis were included in this study. The clinical and epidemiological data were evaluated. Statistical analysis was performed to compare patients with and without an isolated causative agent, patients with Gram-positive and Gram-negative pathogens and patients with S. aureus-related and non S. aureus-related infections. RESULTS: Causative agents were isolated in 81 patients. Gram-positive bacteria were isolated in 65 patients and Gram-negative bacteria were isolated in 16 patients. The most commonly isolated bacterium was S. aureus. Comparing cases with an isolated pathogen to cases without an isolated pathogen, no differences between the studied variables were found except for the longer hospital stays of patients in whom an etiological agent was identified. When comparing Gram-positive bacteria with Gram-negative bacteria, patients with Gram-positive-related infections exhibited higher leukocyte counts. Patients with S. aureus-related infections were more frequently associated with healthcare-related environmental encounters. CONCLUSION: S. aureus is the most common pathogen of septic knee arthritis. Major differences were not observed between infections with isolated and non-isolated pathogens and between infections with Gram-positive and Gram-negative bacteria. S. aureus infections were more likely to be associated with a prior healthcare environment exposure

Orthopedic complications in HIV patients

O aumento considerável da expectativa de vida dos pacientes infectados pelo HIV na era do tratamento antirretroviral de alta potência, resulta em importantes alterações metabólicas e osteoarticulares decorrentes do prolongado tempo de infecção viral e desse tratamento. As complicações ortopédicas mais frequentes são as alterações da mineralização óssea, a osteonecrose, síndrome do túnel do carpo e capsulite adesiva glenoumeral, com padrão de apresentação clínica, evolução natural da doença e resposta terapêutica diferentes daqueles da população geral. Os relatos da literatura são iniciais e a experiência do serviço multidisciplinar do Instituto de Ortopedia e Traumatologia da USP permite avanço no conhecimento das diversas patologias envolvidas e o desenvolvimento de protocolos de tratamento adequados a esses diagnósticos.The considerable increase of the life expectancy of HIV-infected patients in the age of highly-powerful antiretroviral treatment results in important metabolic and bone-joint changes resulting from a long-lasting viral infection time and from this treatment. The most common orthopaedic complications are bone mineralization changes, osteonecrosis, carpal tunnel syndrome and gleno-humeral adhesive capsulitis, with different clinical presentation features, natural disease progression and therapeutic response compared to the overall population. Literature reports are initial, and the experience of the multidisciplinary service of the University of São Paulo's Institute of Orthopaedics and Traumatology enables us a more in-depth knowledge about the various pathologies involved and the development of treatment protocols that are appropriate to these diagnoses

Clinical and epidemiological differences between septic arthritis of the knee and hip caused by oxacillin-sensitive and -resistant s. aureus

OBJECTIVE: To establish the risk factors for joint infection by oxacillin-resistant Staphylococcus aureus (MRSA) using clinical and epidemiological data. METHODS: All septic arthritis cases of the knee and hip diagnosed and treated in our institution from 2006 to 2012 were evaluated retrospectively. Only patients with cultures identified as microbial agents were included in the study. The clinical and epidemiological characteristics of the patients were analyzed, seeking the differences between populations affected by MRSA and oxacillin-sensitive Staphylococcus aureus (MSSA). RESULTS: S. aureus was isolated in thirty-five patients (46.0%) in our total sample, 25 in the knee and 10 in the hip. Of these 35 patients, 22 presented with MSSA and 13 presented with MRSA. Provenance from a health service-related environment, as described by the Centers for Disease Control and Prevention, was the only variable associated with oxacillin-resistant strains of this bacterium (p = 0.001). CONCLUSION: Provenance from a health service-related environment was associated with a higher incidence of MRSA-related septic arthritis, suggesting that this agent should be considered in the initial choice of antibiotic treatment. Previous surgeries of the knee or affected limb and the absence of leukocytes might also be related to infection with this agent

Osteopenia and osteoporosis in people living with HIV: multiprofessional approach

Increasing bone mineralization abnormalities observed among people living with HIV (PLWHIV) result from various factors relating to the host, the virus, and the antiretrovirals used. Today, HIV infection is considered to be a risk factor for bone mineralization disorders. The test most recommended for diagnosing osteoporosis is measurement of bone mineral density by means of dual energy X-ray absorptiometry at two sites. Osteoporosis treatment has the aims of bone mass improvement and fracture control. A combination of calcium and vitamin D supplementation may reduce the risk of fractures. Antiresorptive drugs act by blocking osteoclastic activity and reducing bone remodeling. On the other hand, bone-forming drugs stimulate osteoblastogenesis, thereby stimulating the formation of bone matrix. Mixed-action medications are those that are capable of both stimulating bone formation and inhibiting reabsorption. Antiresorptive drugs form the group of medications with the greatest quantity of scientific evidence confirming their efficacy in osteoporosis treatment. Physical activity is a health promotion strategy for the general population, but only preliminary data on its real value and benefit among PLWHIV are available, especially in relation to osteoporosis

Gram-negative osteomyelitis: clinical and microbiological profile

Introduction: Despite the growing interest in the study of Gram-negative bacilli (GNB) infections, very little information on osteomyelitis caused by GNB is available in the medical literature. Objectives and methods: To assess clinical and microbiological features of 101 cases of osteomyelitis caused by GNB alone, between January 2007 and January 2009, in a reference center for the treatment of high complexity traumas in the city of Sao Paulo. Results: Most patients were men (63%), with median age of 42 years, affected by chronic osteomyelitis (43%) or acute osteomyelitis associated to open fractures (32%), the majority on the lower limbs (71%). The patients were treated with antibiotics as inpatients for 40 days (median) and for 99 days (median) in outpatient settings. After 6 months follow-up, the clinical remission rate was around 60%, relapse 19%, amputation 7%, and death 5%. Nine percent of cases were lost to follow-up. A total of 121 GNB was isolated from 101 clinical samples. The most frequently isolated pathogens were Enterobacter sp. (25%), Acinetobacter baumannii (21%) e Pseudomonas aeruginosa (20%). Susceptibility to carbapenems was about 100% for Enterobacter sp., 75% for Pseudomonas aeruginosa and 60% for Acinetobacter baumannii. Conclusion: Osteomyelitis caused by GNB remains a serious therapeutic challenge, especially when associated to nonfermenting bacteria. We emphasize the need to consider these agents in diagnosed cases of osteomyelitis, so that an ideal antimicrobial treatment can be administered since the very beginning of the therapy. (C) 2012 Elsevier Editora Ltda. All rights reserved.Merck Sharp and DohmeMerck Sharp and Dohm

LESÃO NA REGIÃO METACARPIANA DO MEMBRO TORÁCICO ESQUERDO DE BEZERRA GIR DECORRENTE DE CONTENÇÃO PARA PESAGEM

Bone fractures and dislocations are more common in young animals and mostly occur due to incorrect handling of these animals, which can lead to a short or long-term drop in production, generating economic and productive losses of animals of high genetic standard. This study aimed to report the occurrence of a fracture in the metacarpal region of the left thoracic limb of a 12-day-old Gir heifer, caused by an ineffective restraint during weighing. The animal from a farm in Umirim/CE was sent to the Veterinary Hospital of Large Animals of the University Center INTA in Sobral/CE. The radiographic examination found a fracture in the metacarpal region of the left thoracic limb. The animal was manually immobilized following semiological methods to minimize stress. For the limb immobilization, a modified Thomas crutch and bandages associated with pain control with the drugs Flunixin meglumine (1.1mg/kg) and Phenylbutazone (4.4mg/kg) were used. After immobilization, the animal remained hospitalized at HOVET-GA and after 18 days a new radiograph was performed to evaluate the progress achieved with the treatment adopted. It was found the formation of a bone callus with the ossification of the fracture, not requiring the surgical referral of the animal. Thus, the treatment with the modified Thomas crutch was effective for the recovery of the fractured limb, in addition to being a low-cost and easy-to-apply treatment. The animal showed a good response to the therapeutic treatment for pain control.Fraturas ósseas e luxações são mais comuns em animais jovens e, na maioria das vezes, essas fraturas ocorrem devido ao manejo incorreto desses animais, podendo levar a uma queda de produção a curto ou longo prazo, gerando perdas econômicas e produtivas de animais de alto padrão genético. Nesse contexto, o objetivo deste trabalho foi relatar a ocorrência de uma fratura na região metacarpiana do membro torácico esquerdo de uma bezerra Gir de 12 dias de idade, causada por uma contenção ineficaz durante a pesagem. O animal proveniente de uma fazenda em Umirim/CE foi encaminhado ao Hospital Veterinário de Grandes Animais do Centro Universitário INTA em Sobral/CE. Ao passar pelo exame radiográfico, foi constatada a fratura na região metacarpiana do membro torácico esquerdo. O animal foi imobilizado de forma manual, seguindo-se métodos semiológicos para minimizar o estresse. Para a imobilização do membro, foi utilizada a muleta de Thomas modificada e bandagens, associadas ao controle da dor com as drogas Flunixin meglumine (1,1mg/kg) e Fenilbutazona (4,4mg/kg). Depois da imobilização, o animal seguiu internado no HOVET-GA e, após 18 dias, foi realizada uma nova radiografia para ver o progresso a partir do tratamento adotado. Constatou-se a formação de um calo ósseo, com a ossificação da fratura, não sendo necessário o encaminhamento cirúrgico do animal. Assim, o tratamento com muleta de Thomas modificada foi efetivo para a recuperação do membro fraturado, além de ser um tratamento de baixo custo e fácil aplicação, tendo o animal apresentado uma boa resposta ao tratamento terapêutico para controle da dor

Avascular necrosis of the femoral head in HIV-infected patients: preliminary results from surgical treatment for ceramic-ceramic joint replacement

OBJETIVOS: Avaliar os resultados funcionais iniciais e o índice de complicações precoces das artroplastias totais do quadril cerâmica-cerâmica em pacientes que convivem com o HIV e apresentam osteonecrose da cabeça femoral. MÉTODO: Doze pacientes HIV+ com diagnóstico de osteonecrose da cabeça do fêmur incongruente foram avaliados através de critérios clínicos, laboratoriais, pela escala funcional WOMAC antes e após o tratamento com substituição articular. RESULTADOS: Observamos que 83,3% dos indivíduos faziam uso de inibidores de protease, 75% apresentavam dislipidemia e 66,6% síndrome lipodistrófica, a melhora na evolução no escore WOMAC foi estatisticamente significativa para seis e 12 meses de pós-operatório em comparação com o escore pré-operatório e não observamos complicações secundárias a esse procedimento. CONCLUSÃO: A artroplastia total do quadril com implante de cerâmica-cerâmica para o tratamento da necrose avascular do quadril nessa parcela da população é opção cirúrgica adequada, apresenta melhora funcional inicial significativa e baixo índice de complicação precoce