Experimental hematogenous infection of subcutaneously implanted foreign bodies

Is Antibiotic Prophylaxis Necessary before Dental Implant Procedures in Patients with Orthopaedic Prostheses? A Systematic Review

As the population ages, more and more patients with orthopaedic prostheses (OPs) require dental implant treatment. Surveys of dentists and orthopaedic surgeons show that prophylactic antibiotics (PAs) are routinely prescribed with a very high frequency in patients with OPs who are about to undergo dental procedures. The present study aims to determine the need to prescribe prophylactic antibiotic therapy in patients with OPs treated with dental implants to promote their responsible use and reduce the risk of antimicrobial resistance. An electronic search of the MEDLINE database (via PubMed), Web of Science, LILACS, Google Scholar, and OpenGrey was carried out. The criteria used were those described by the PRISMA® Statement. No study investigated the need to prescribe PAs in patients with OPs, so four studies were included on the risk of infections of OPs after dental treatments with varying degrees of invasiveness. There is no evidence to suggest a relationship between dental implant surgeries and an increased risk of OP infection; therefore, PAs in these patients are not justified. However, the recommended doses of PAs in dental implant procedures in healthy patients are the same as those recommended to avoid infections of OPs.

Contributions of animal studies to the understanding of infectious diseases

Experiments in animals have played an integral role in furthering basic understanding of the pathophysiology, host immune response, diagnosis, and treatment of infectious diseases. However, competing demands of modern-day clinical training and increasingly stringent requirements to perform animal research have reduced the exposure of infectious disease physicians to animal studies. For practitioners of infectious diseases and, especially, for contemporary trainees in infectious diseases, it is important to appreciate this historical body of work and its impact on current clinical practice. In this article, we provide an overview of some major contributions of animal studies to the field of infectious diseases. Areas covered include transmission of infection, elucidation of innate and adaptive host immune responses, testing of antimicrobials, pathogenesis and treatment of endocarditis, osteomyelitis, intraabdominal and urinary tract infection, treatment of infection associated with a foreign body or in the presence of neutropenia, and toxin-mediated disease.

Gross and Histopathology of Goats Feeding on Opuntia stricta in Laikipia County, Kenya

Various plant species such as Opuntia stricta have developed defensive measures, namely, spines, thorns, and other sharp pointed structures to protect themselves from herbivores and other animals feeding on them. Opuntia stricta has invaded the northern part of Laikipia County, Kenya, and its fruits are protected by small spines called glochids. This study determined the pathology in goats feeding on this plant in Laikipia County. Eighteen goats that had eaten the plant and six others that were raised in a ranch without O. stricta were purchased for the study. All study animals were clinically examined for lesions and euthanized for necropsy examination. Clinically, goats affected by O. stricta had poor body condition, wounds on various body parts, and diarrhea. Variable numbers of O. stricta spines occurred externally on the skin throughout the body and elicited pain, swelling, and ulcerative wounds on affected parts. Internal lesions were observed in subcutaneous tissues (100%), together with stomatitis, cheilitis, gingivitis, glossitis, abomasitis (100%), rumen, reticulum, omasum thinning and loss of papillae (72.2%), esophagitis, and duodenitis (5.6%). Carcasses had gelatinous fat and muscular atrophy. Other gross lesions were generalized viscera atrophy, edema, subcutaneous emphysema, lymphadenopathy, abscesses, ascites, hydrothorax, and hydropericardium. The abomasum wall and its mucosal folds were swollen with edema, haemorrhages, and scattered foci of abscesses. Histopathology confirmed the main lesions in all affected goats were foreign-body granulomas which were located in all organs with gross lesions. Goats from O. stricta-free ranches had no spines or lesions. The pathological effects caused by O. stricta resulted in emaciated goats due to pain, inability to masticate and assimilate food, and stress, resulting in poor carcass and organs quality and possible condemnation and death. This could affect the socioeconomics and livelihoods of communities in the study area, and therefore, the spread of this plant needs to be controlled.

Photosensitizer-Modified MnO2 Nanoparticles to Enhance Photodynamic Treatment of Abscesses and Boost Immune Protection for Treated Mice

The emergence of drug-resistant bacteria and easy recurrence has been challenging in the clinical treatment of skin abscesses resulting from bacterial infections (e.g., by Staphylococcus aureus (S. aureus)). Herein, an antibacterial nanoagent capable of modulating the abscess microenvironment is designed to enhance photodynamic treatment of skin abscesses, and subsequently activate the immune system to effectively prevent abscess recurrence. In the system, manganese dioxide nanoparticles (MnO₂ NPs) with high catalytic reactivity toward H₂ O₂ are modified with photosensitizer chlorine e6 (Ce6) and coated with polyethylene glycol (PEG). The obtained Ce6@MnO₂ -PEG NPs, by triggering the decomposition of lesion endogenous H₂ O₂ , are able to effectively relieve the hypoxic abscess microenvironment during S. aureus infection. The light-triggered photodynamic bacterial killing effect could thus be remarkably enhanced, resulting in effective in vivo therapy of S. aureus-induced skin abscesses. Interestingly, a notable pathogen-specific immunological memory effect against future infection by the same species of bacteria is elicited after such treatment, owing to the release of bacterial antigens post photodynamic therapy (PDT) together with the adjuvant-like function of manganese ions to activate the host immune system. This work thus presents a new type of photodynamic nanoagent particularly promising for highly effective light-triggered abscess treatment and prevention of abscess recurrence.

Prevalence and quantification of contamination of knitted cotton outer gloves during hip and knee arthroplasty surgery

INTRODUCTION

Knitted cotton outer gloves offer protection against surgical glove perforation and provide improved grip on instruments. These gloves absorb blood and other fluids during surgery, and may therefore also accumulate contaminating bacteria. To date, there is no published data on microbial contamination of such gloves during surgery.

METHODS

Knitted cotton outer gloves used in primary and revision hip and knee arthroplasty from two Swiss hospitals were analysed by quantitative bacteriology. Samples were subjected to sonication and vortexing, followed by membrane filtration of the sonicate. Membranes were incubated under aerobic and anaerobic culture conditions, respectively, for 21 days. Total microbial load for each pair of gloves was determined by colony-forming units (CFU) count. Strain identification was performed with MALDI-TOF.

RESULTS

A total of 43 pairs of gloves were collected from continuous series of surgeries. Under aerobic culture conditions, total CFU counts ranged 0-1103, 25 (58%) samples remaining sterile, and 4 (9%) yielding > 100 CFU. Under anaerobic culture conditions, total CFU counts ranged 0-3579, 22 (51%) samples remaining sterile, 6 (14%) yielding > 100 CFU. The only covariate significantly associated with the level of contamination was the provider hospital (p < 0.0001 for aerobic and p = 0.007 for anaerobic cultures). Strain identification revealed only skin commensals, mainly coagulase-negative staphylococci and Propionibacterium spp.

CONCLUSION

While contamination of surgical latex gloves is a well-known issue, no study has examined so far contamination of knitted cotton outer gloves. No or very low microbial contamination could be identified in the majority of the knitted cotton outer gloves assayed. However, a relevant proportion showed contamination far higher than estimated minimal thresholds for implant-associated infection. Clinical relevance of these findings remains to be established.

Role of Rifampin against Staphylococcal Biofilm Infections In Vitro, in Animal Models, and in Orthopedic-Device-Related Infections

Rifampin has been used as an agent in combination therapy in orthopedic device-related infections (ODRI) for almost three decades. The aim of this review is to provide data regarding the role of rifampin against biofilm infection in vitro, in animal models, and in clinical ODRI. Available data are gathered in order to present the rational use of rifampin combinations in patients with periprosthetic joint infection (PJI). The role of rifampin is well defined in patients with PJI and is indicated in those who fulfill the Infectious Diseases Society of America criteria for debridement and implant retention or one-stage exchange. It should be used with care because of the danger of rapid emergence of resistance. Potential drug interactions should be considered.

Molybdenum Disulfide Surface Modification of Ultrafine-Grained Titanium for Enhanced Cellular Growth and Antibacterial Effect

The commercially pure Ti (CP Ti) and equal-channel angular pressing (ECAP) processed Ti can contribute to the downsizing of medical devices with their superior mechanical properties and negligible toxicity. However, the ECAP-processed pure Ti has the risk of bacterial infection. Here, the coarse- and ultrafine-grained Ti substrates were surface-modified with molybdenum disulfide (MoS2) to improve the cell proliferation and growth with antibacterial effect for further dental applications. According to in vitro tests using the pre-osteoblast of MC3T3-E1 cell and a bacterial model of Escherichia coli (E. coli), MoS2 nanoflakes coated and ECAP-processed Ti substrates showed a significant increase in surface energy and singlet oxygen generation resulting in improved cell attachment and antibacterial effect. In addition, we confirmed the stability of the surface modified Ti substrates in a physiological solution and an artificial bone. Taken together, MoS2 modified and ECAP-processed Ti substrates might be successfully harnessed for various dental applications.

Antibiotic prophylaxis is not indicated prior to dental procedures for prevention of periprosthetic joint infections

Background and purpose - To minimize the risk of hematogenous periprosthetic joint infection (HPJI), international and Dutch guidelines recommended antibiotic prophylaxis prior to dental procedures. Unclear definitions and contradictory recommendations in these guidelines have led to unnecessary antibiotic prescriptions. To formulate new guidelines, a joint committee of the Dutch Orthopaedic and Dental Societies conducted a systematic literature review to answer the following question: can antibiotic prophylaxis be recommended for patients (with joint prostheses) undergoing dental procedures in order to prevent dental HPJI? Methods - The Medline, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs), reviews, and observational studies up to July 2015. Studies were included if they involved patients with joint implants undergoing dental procedures, and either considered HPJI as an outcome measure or described a correlation between HPJI and prophylactic antibiotics. A guideline was formulated using the GRADE method and AGREE II guidelines. Results - 9 studies were included in this systematic review. All were rated "very low quality of evidence". Additional literature was therefore consulted to address clinical questions that provide further insight into pathophysiology and risk factors. The 9 studies did not provide evidence that use of antibiotic prophylaxis reduces the incidence of dental HPJI, and the additional literature supported the conclusion that antibiotic prophylaxis should be discouraged in dental procedures. Interpretation - Prophylactic antibiotics in order to prevent dental HPJI should not be prescribed to patients with a normal or an impaired immune system function. Patients are recommended to maintain good oral hygiene and visit the dentist regularly.

Antibiotic Prophylaxis During Dental Procedures in Patients with Prosthetic Joints

In patients with artificial joints, the need for antimicrobial prophylaxis during dental procedures is often raised. The present document describes the pathogenic mechanisms and epidemiological data on the subject of periprosthetic joint infections (PJI) after dental procedures. The document reflects the opinion and recommendations of the expert group 'Infection' of Swiss Orthopaedics. Microorganisms belonging to oral flora can seed haematogenously to an artificial joint. The proof of a causative relation with dental procedures is not possible, because the responsible bacteraemia can originate from the oral cavity at any time, irrespective of when the dental procedure occurs. Good oral hygiene is associated with a lower risk for PJI. Transient bacteraemia occurs during daily oral hygiene activity (e.g., tooth brushing) and thus the cumulative risk for a haematogenous PJI from tooth brushing is higher than that from a dental procedure. PJI after a dental procedure are rarely reported. On the basis of an epidemiological model, several thousand patients with artificial joints must receive antimicrobial prophylaxis to prevent a single PJI. Considering this ratio, the number of adverse events due to the antimicrobial compound exceeds the benefit of administering it by a large magnitude. Therefore, as a rule for the vast majority of cases, antimicrobial prophylaxis during dental procedures is not recommended. It is important that a patient has a good oral health status before joint implantation and that good oral hygiene is continuously maintained in patients with artificial joints.

Clinical presentation and treatment of orthopaedic implant-associated infection

Orthopaedic implants are highly susceptible to infection. The aims of treatment of infection associated with internal fixation devices are fracture consolidation and prevention of chronic osteomyelitis. Complete biofilm eradication is not the primary goal, as remaining adherent microorganisms can be removed with the device after fracture consolidation. By contrast, in periprosthetic joint infection (PJI), biofilm elimination is required. Surgical treatment of PJI includes debridement with retention, one- or two-stage exchange and removal without reimplantation. In addition, prolonged antibiotic treatment, preferably with an agent that is effective against biofilm bacteria, is required. Rifampicin is an example of an antibiotic with these properties against staphylococci. However, to avoid the emergence of resistance, rifampicin must always be combined with another antimicrobial agent. With this novel treatment approach, orthopaedic implant-associated infection is likely to be eradicated in up to 80-90% of patients. Because most antibiotics have a limited effect against biofilm infections, novel prophylactic and therapeutic options are needed. Surface coating with antimicrobial peptides that reduce bacterial attachment and biofilm formation can potentially prevent implant-associated infection. In addition, quorum-sensing inhibitors are a novel therapeutic option against biofilm infections.

Pathogenesis and treatment concepts of orthopaedic biofilm infections

Implant-associated infection is caused by surface-adhering bacteria persisting as biofilm. Periprosthetic joint infection is difficult to diagnose and treat. The high susceptibility of implanted devices to infection is because of a locally acquired host defense defect, and persistence is mainly because of the rapid formation of a biofilm resistant to host defense and antimicrobial agents. Successful treatment of periprosthetic joint infection requires the optimal surgical procedure combined with long-term antimicrobial therapy directed against surface-adhering microorganisms. Surgical treatment according to an algorithm has been validated in several observational studies. The role of rifampin against device-associated staphylococcal infection has been evaluated in an animal model, in observational studies and in a controlled trial. Given the limited efficacy of traditional antibiotics in implant-associated infections, novel strategies such as coating of the device, vaccination against biofilms, and quorum-sensing inhibitors are promising future options for prevention and treatment.

New approaches for treating staphylococcal biofilm infections

Bacteria of the genus Staphylococcus are a prominent cause of acute and chronic infections. The ability of the staphylococci to establish biofilms has been linked to the persistence of chronic infections, which has drawn considerable interest from researchers over the past decade. Biofilms can be defined as sessile communities of surface-attached cells encased in an extracellular matrix, and treatment of bacteria in this mode of growth is challenging due to the resistance of biofilm structures to both antimicrobials and host defenses. In this review of the literature, we introduce Staphylococcus aureus and Staphylococcus epidermidis biofilms and summarize current antibiotic treatment approaches for staphylococcal biofilm infections. We also review recent studies on alternative strategies for preventing biofilm formation and dispersing established biofilms, including matrix-degrading enzymes, small-molecule approaches, and manipulation of natural staphylococcal disassembly mechanisms. While research on staphylococcal biofilm development is still in its early stages, new discoveries in the field hold promise for improved therapies that target staphylococcal biofilm infections.

Challenges in Periprosthetic Knee-Joint Infection

The number of knee arthroplasty procedures is growing and projected to further increase. The risk for periprosthetic joint infection (PJI) is estimated to be low (<1%). However, considering the increasing number of total knee arthroplasty, the increasing number of patients with multiple comorbidities, and the lifelong risk for acquiring hematogenous infection, the total number of PJI will further increase. Despite existing treatment concepts for PJI of the knee, there are still questions to solve, such as type of debridement surgery in case of implant retention, the role of a spacer from a microbiological perspective, and the optimal duration of antimicrobial therapy. In this review, these questions will be analyzed according to the available literature and the experience of the authors. Moreover, we review the most recent data on infection, risk factors, and microbiology of PJI.

Antimicrobial agents in orthopaedic surgery: Prophylaxis and treatment

The pathogenesis of implant-associated infection involves interaction between the microorganisms (biofilm formation), the implant and the host. Despite improvement of perioperative prophylaxis, orthopaedic implants still remain highly susceptible to bacterial or fungal contamination, generally resulting in persistent implant-associated infection. Therefore, perioperative and life-long prevention of infection is important. For perioperative prophylaxis, a first- or second-generation cephalosporin is recommended, which should be administered between 60 and 30 minutes before incision. The duration of prophylaxis should not exceed 1 day. In centres with a low incidence of infection, a single dose is sufficient. Treatment of infections associated with orthopaedic devices usually requires appropriate surgical intervention combined with prolonged antimicrobial therapy. The choice of the antimicrobial regimen depends on the duration and pathogenesis of infection, stability of the implant, antimicrobial susceptibility of the pathogen and condition of the surrounding soft tissue. The role of rifampicin (rifampin), which has excellent activity on adherent staphylococci, in combination with beta-lactams, glycopeptides, fluoroquinolones, minocycline, cotrimoxazole or fusidic acid, in the treatment of staphylococcal infections is outlined. Increasing antimicrobial resistance requires the use of alternative agents, such as quinupristin/dalfopristin, linezolid and daptomycin, but results of clinical trials with these agents are limited. Also reviewed are potential new antimicrobial agents currently undergoing investigation, such as the novel oxazolidinone RWJ-416457, the new glycopeptide dalbavancin, the glycylcycline compound tigecycline, the new carbacephem BP-102 and novel rifamycin derivatives. Vaccination against Staphylococcus aureus with StaphVAX induced specific antibodies potentially preventing bacteraemia; however, there are no studies on efficacy in the prophylaxis of device-associated infections with this vaccine.

Prediction of traumatic wound infection with a neural network-derived decision model

The objective of this study was to develop and validate a decision model, using an artificial neural network, that predicts infection in uncomplicated, traumatic, sutured wounds. The study was a prospective, cohort study of all patients presenting to the emergency department of a county teaching hospital with uncomplicated wounds that required suturing. In evaluating and treating wounds, emergency medicine (EM) faculty and residents, resident physicians in primary-care specialties, and supervised medical students on EM clerkships followed a standardized wound-management protocol. Clinicians estimated the likelihood of subsequent infection using a 5-point scale. Wound healing was followed until sutures were removed. Wound outcome data were collected by medical personnel blinded to the initial prediction. Student's t-tests and Pearson's chi-square statistic were used to identify independent predictors that served as input variables. Wound infection was the single output variable. Neural network analysis was used to assign weights to input variables and derive a decision equation. A total of 1,142 wounds were analyzed in the study. The overall infection rate was 7.2%. The most predictive factors for wound infection were wound location, wound age, depth, configuration, contamination, and patient age. To derive a decision equation for the model, the network was trained on data from half of the subjects and tested on the remainder. When used as a diagnostic test for wound infection, the decision model had a sensitivity of 70%, as compared to 54% for physicians, and a specificity of 76%, as compared to 78% for physicians. We conclude that through the use of combinations of 7 clinical variables available at the time of initial wound management, a neural network-derived decision model may be used to identify uncomplicated, traumatic wounds at higher risk for infection.

Transcription of clumping factor A in attached and unattached Staphylococcus aureus in vitro and during device-related infection

Staphylococcus aureus is one of the pathogens most frequently isolated in device-related infections. S. aureus is equipped with surface-associated proteins promoting specific binding to matrix molecules. Clumping factor A (ClfA, encoded by clfA) mediates adhesion to fibrinogen. Whereas the contribution of ClfA to pathogenicity is well documented, the influence of different growth and host parameters on gene activity is unclear. To elucidate this question, we investigated clfA transcript levels in an animal model of device-related infection and in planktonic and sessile bacteria grown in vitro. Specific mRNA from the S. aureus strains Newman, Reynolds, and RN6390 was quantified by LightCycler reverse transcription-PCR. In vitro, clfA transcript levels were low in the early logarithmic growth phase, but a clear increase was observed after the late logarithmic phase. Quantities of clfA transcripts were four to six times higher in the planktonic than in the sessile bacterial subpopulations grown to the stationary phase. During infection, in strains Newman and Reynolds levels of clfA transcripts in exudates accumulating in the infected devices were lower than those in the bacteria grown in vitro to stationary phase. clfA mRNA levels in the exudates increased during the initial phase of infection and remained constant after 96 h postinoculation. In contrast to the in vitro results, quantities of clfA transcripts in the unattached bacteria of the exudates never exceeded the level of clfA transcripts in the sessile bacteria attached to glass beads. However, a clear increase in clfA quantities in the sessile bacteria was observed late in infection after 144 h. In conclusion, maximal clfA transcript levels are reached late during growth in vitro and in vivo.

In vitro models of biological responses to implant microbiological models

To study the etiology and explore possibilities for the therapy of implant-associated infections, investigators have developed and utilized various in vitro models. Major contributions have come from the non-oral medical field, where device-related infections can create life-threatening situations. Microbiological models may include (i) models to study the reaction of micro-organisms to the presence of implants, (ii) models to study the reaction of implant-associated micro-organisms to antimicrobial agents, and (iii) models to study the reaction of the host tissues to the presence of implants contaminated with micro-organisms. In evaluating the potential usefulness of these models for research in oral implantology, one must consider common features as well as important differences between implanted medical devices and oral implants. Although infections associated with implantable medical devices and oral peri-implant infections share a remarkable number of common features, there are also important differences that need attention when findings from in vitro experiments are extrapolated to clinical relevance.

Differential effects of prednisolone and indomethacin on zymosan-induced inflammation in a modified murine tissue-chamber model

A tissue-chamber model of inflammation in mice has been modified and used to investigate the kinetics of zymosan-induced inflammatory mediators such as tumour necrosis factor alpha (TNF alpha), interleukin-1 beta (IL-1 beta) and prostaglandin E2 (PGE2). In addition, the influx of polymorphonuclear leukocytes (PMN) into the chamber fluid and the granuloma surrounding the chamber was measured by myeloperoxidase (MPO) activity using a new microtitre plate assay. TNF alpha and IL-1 beta reached a peak concentrations at 3 and 6 h respectively after zymosan injection. Intermediate high concentrations of IL-1 beta were observed until the end of the experiment at 72 h, but TNF alpha concentrations decreased from 24 h to biologically insignificant values. In contrast, exudate PGE2 and MPO activity increased up to 24 h after zymosan injection and remained high until 72 h. At 6 h after zymosan challenge, oral pre-treatment with prednisolone (3 to 30 mg/kg) dose-dependently reduced TNF alpha, IL-1 beta and PGE2 concentrations while indomethacin (0.3 to 3 mg/kg) significantly attenuated PGE2, slightly enhanced TNF alpha and had no effect on IL-1 beta concentrations in the exudate. Both drugs had similar potencies against exudate and tissue MPO activities. Prednisolone inhibited IL-1 beta at 72 h post-zymosan. Indomethacin was more potent than prednisolone against PGE2 (ID50 of< 0.3 versus 0.6 mg/kg). The data obtained confirm the usefulness and reliability of this model in evaluating the effects of anti-inflammatory agents on inflammatory mediators induced by zymosan.

Hydrogen peroxide as a potent bacteriostatic antibiotic: implications for host defense

Host defense against bacterial pathogens in higher organisms is mediated in part by the generation of reactive oxygen species (ROS) by PMN. In this study, we determined the following effects of exposure of constant concentrations of H2O2 on E. coli in a culture continuously monitored for H2O2 concentration, numbers, and viabilities of cells: (1) E. coli growth rates monitored for 1 h were profoundly affected by concentrations of H2O2, between 25-50 microM. (2) Complete bacteriostasis was observed at 100 microM. (3) Significant cell killing was not observed until the concentration of H2O2 was greater than 500 microM. (4) Bacteriostatic (25-50 microM) concentrations of H2O2 appeared not to be toxic to human skin fibroblasts for a 2-h exposure. (4) Bacteriostasis by H2O2 could not be explained by metabolic inhibition, because intracellular ATP levels were not compromised at bacteriostatic doses of H2O2. (5) Measurements of H2O2 concentrations in subcutaneous abscess fluid infected with both E. coli and S. aureus indicated prevailing concentrations of the oxidant consistent with a proposed role of H2O2 in host defense.

Interleukin-1 (IL-1) production in a mouse tissue chamber model of inflammation. I. Development and initial characterisation of the model

A simple and reliable animal model to quantify interleukin-1 (IL-1) production at a site of inflammation has been developed and characterised. This model involves the subcutaneous implantation of sterile Teflon chambers (30 mm x 10 mm diameter) into the backs of mice. After 14 days, a straw coloured transudate fluid was present in the lumen of the implanted chamber which was withdrawn for the determination of baseline measurements of various inflammatory parameters. A localised chronic inflammatory response was then induced in the chambers by injection of 1% zymosan or Bordetella pertussis vaccine (BPV) (in presensitised animals). The local inflammatory reaction in the chamber, over a 30 day time course, was characterised by leucocyte infiltration, and marked increases in protein, prostaglandin E2, IL-1 and IL-6 concentrations in the chamber fluid. A rapid increase in plasma concentrations of the acute-phase reactant serum amyloid P (SAP) also occurred. This model allows repeated samples to be obtained from the same animal for the assessment of inflammatory parameters and may be useful for investigating the mechanisms controlling the production of IL-1 during the inflammatory response in vivo.

Antibiotic prophylaxis with two doses of cephalosporin in patients managed with internal fixation for a fracture of the hip

A prospective, randomized, double-blind study was performed to evaluate the effects of antibiotic prophylaxis on the development of a wound infection in 239 patients who had immediate stabilization of a fracture of the proximal part of the femur with a dynamic hip screw. The effects of two perioperative doses of cefotiam, given twelve hours apart, were compared with those of two doses of a placebo. Sixteen perioperative risk factors were evaluated to determine whether it was possible to identify patients who were at risk for a wound infection. All patients were followed for a minimum of six weeks. Antibiotic prophylaxis significantly reduced the prevalence of wound infection (p < 0.05): the rate of major wound infection decreased from 5 to 1 per cent and the rate of minor wound infection, from 11 to 4 per cent. The most powerful predictors of major wound infection were the duration of the operation, the interval between the accident and admission to the hospital, and the duration of postoperative urinary catheterization. The preoperative level of serum albumin and the absolute lymphocyte count were significant predictors (p < 0.05) of minor wound infection and systemic infection, respectively.

Timing, dosing and duration of antimicrobial prophylaxis in urology: a study in guinea pigs with special reference to high-risk conditions

A study in guinea pigs was performed to investigate the importance of timing, dosage and duration of antimicrobial prophylaxis in urologic surgery. To simulate high-risk conditions, in one group a foreign body was implanted subcutaneously. The prostate and one kidney were cauterized and bacteremia was induced by intravenous injection of an Escherichia coli suspension. Various ciprofloxacin regimens were tested. The results indicate that antimicrobial prophylaxis is beneficial only if administered before or shortly after surgery. Full therapeutic dosage may not be necessary for prophylactic efficacy. Single-dose prophylaxis was as effective as multiple doses. Foreign body infection could be prevented by single-dose prophylaxis.

Successful single-dose prophylaxis of Staphylococcus aureus foreign body infections in guinea pigs by fleroxacin

Single-dose administration of fleroxacin was evaluated as a means of preventing foreign body infection due to staphylococci. Tissue cages were implanted into guinea pigs and subsequently infected (100% rate) with 10(2) or more CFU of Staphylococcus aureus Wood 46. When a single dose of 30 mg of fleroxacin or vancomycin per kg of body weight was administered intraperitoneally, bactericidal levels of the antimicrobial agent were found in the tissue cage fluid after 3 h (when guinea pigs were inoculated with S. aureus) and during the next 24 h. Either fleroxacin or vancomycin successfully prevented experimental infection in all tissue cages challenged by 10(2) CFU of S. aureus Wood 46. When tissue cages were challenged with 10(4) CFU of S. aureus Wood 46, however, fleroxacin was more effective than vancomycin (P less than 0.05) in reducing colony counts below the detection limit of 10 CFU/ml in the inflammatory fluid of all tissue cages during the initial 48 h. In contrast to their initially different actions, the effects of the antibiotics were similar after 7 days, mostly because bacterial regrowth occurred more frequently in the fleroxacin-treated than in the vancomycin-treated tissue cages. These data show that experimental infections of subcutaneous tissue cages are a useful model for studying the prophylaxis of foreign body infections with antimicrobial agents.

Salmonella infection in total hip replacement: tests to predict the outcome of antimicrobial therapy

We report a hematogenous implant infection with Salmonella dublin in a renal transplant patient with total hip replacement. A 16-month treatment with cotrimoxazole failed, as evidenced by culture and electron microscopy, despite persisting low MIC after therapy. Data from a foreign body animal model and in vitro tests, which take into account the properties of adhering and stationary-phase bacteria, explain the failure of a long-term treatment with cotrimoxazole. The patient was subsequently cured by ciprofloxacin which was successful in these tests. No relapse was noted after a follow-up of 1 year.