Prosthetic Joint Infection Update Beam, Elena; Osmon, Douglas
Infectious disease clinics of North America,
12/2018, Letnik:
32, Številka:
4
Journal Article
Recenzirano
Prosthetic joint infection occurs in a minority of arthroplasties performed; however, it brings a large burden to both the individual and society in terms of morbidity, mortality, and health care ...expenditure. Although prevention of prosthetic joint infection is becoming more effective, the number of total arthroplasties in patients with increasing comorbidities continues to rise, and the total number of diagnosed and managed prosthetic joint infections is expected to rise accordingly. Management is complex and involves a multispecialty approach.
Cytomegalovirus (CMV) is one of the most important pathogens that infect solid organ transplant recipients. CMV is associated with increased morbidity and mortality in this population as a result of ...its numerous direct and indirect effects. Prevention strategies consist of preemptive therapy and antiviral prophylaxis, and the choice of which preventive approach to implement should be guided by advantages and drawbacks related to the population being managed. There are differences in the approaches to the laboratory diagnosis and treatment of CMV infection and disease depending on assay availability, clinical presentation, disease severity, and specific transplant populations. In this article, the authors aim to summarize recent publications and updates in the epidemiology, diagnosis, prevention, and treatment of CMV infection in solid organ transplant recipients during the past year, including a brief review of future directions in the field.
Abstract
Background
Fluoroquinolones (FQs) are known to be accompanied by significant risks. However, the incidence of adverse events (ADEs) resulting in unplanned drug discontinuation when used for ...periprosthetic joint infections (PJIs) is currently unknown.
Methods
This study included 156 patients over the age of 18 treated for staphylococcal PJI with debridement, antibiotics, and implant retention between 1 January 2007 and 21 November 2019. Of the 156 patients, 64 had total hip arthroplasty (THA) and 92 had total knee arthroplasty (TKA) infections. The primary outcome was rate of unplanned drug discontinuation. Secondary outcomes included incidence of severe ADEs, unplanned rifamycin discontinuation, mean time to unplanned regimen discontinuation, and all-cause mortality.
Results
Overall, unplanned drug discontinuation occurred in 35.6% of patients in the FQ group and 3% of patients in the non-FQ group. The rate of unplanned discontinuation of FQ regimens as compared with non-FQ regimens was 27.5% vs 4.2% (P = .021) in THA infections and 42% vs 2.4% (P < .001) in TKA infections. There was no significant difference in severe ADEs between FQ and non-FQ regimens in both THA and TKA infections. The overall rate of nonsevere ADEs in FQ compared with non-FQ regimens was 43.3% vs 6.1% (P < .001). FQs were associated with tendinopathy, myalgia, arthralgia, and nausea.
Conclusions
A significantly higher rate of unplanned drug discontinuation was associated with FQ as compared with non-FQ regimens. This provides a real-world view of the implications of FQ-related ADEs on unplanned discontinuation when used in prolonged durations for the management of staphylococcal PJIs.
Fluoroquinolones are recommended in the management of staphylococcal periprosthetic joint infections. This study identifies that fluoroquinolone use is associated with a significantly higher unplanned drug discontinuation rate compared with non-fluoroquinolones when administered for a duration of 3 to 6 months.
Cytomegalovirus(CMV) infection is a common complication after liver transplantation, and it is associated with multiple direct and indirect effects. Management of CMV infection and disease has ...evolved over the years,and clinical guidelines have been recently updated.Universal antiviral prophylaxis and a pre-emptive treatment strategy are options for prevention. A currentlyrecruiting randomized clinical trial is comparing the efficacy and safety of the two prevention strategies in the highest risk D+R- liver recipients. Drug-resistant CMV infection remains uncommon but is now increasing in incidence. This highlights the currently limited therapeutic options, and the need for novel drug discoveries.Immunotherapy and antiviral drugs with novel mechanisms of action are being investigated, including letermovir(AIC246) and brincidofovir(CMX001). This article reviews the current state of CMV management after liver transplantation, including the updated practice guidelines, and summarizes the data on investigational drugs and vaccines in clinical development.
Objectives
Urinary tract infection (UTI) is the most common infectious complication after kidney transplantation. We aim to determine its impact on allograft function as indicated by several measures ...such as iothalamate glomerular filtration rate (iGFR), estimated glomerular filtration rate (eGFR), and creatinine value.
Methods
We performed a single‐center retrospective cohort study to determine the impact of UTI on kidney allograft outcome.
Results
The study population consisted of 301 kidney transplant recipients; 84% were living donor transplants. One hundred and one patients (34%) developed at least one episode of UTI and the incidence of UTI during the first year after transplantation was 25%. At the end of the follow‐up, the iGFR was lower among patients who had developed at least one UTI (p = 0.044). However, eGFR and creatinine values were not significantly different between UTI and non‐UTI groups.
Conclusion
When kidney function was measured by eGFR and creatinine, there was no significant difference in allograft function between kidney recipients with or without UTI. However, when kidney function was measured by nuclear studies, there was a tendency toward impairment in allograft function among patients who developed atleast one UTI after transplantation.
Optimal management of infection with mycobacterial species requires accurate identification down to complex/species level due to variations in outcomes. Over the last few decades, there have been ...significant advances in laboratory diagnostics with development of newer and rapid molecular methods. Here we describe a case of Mycobacterium smegmatis that was misidentified as Mycobacterium fortuitum by DNA line probe assay.
Despite the use of antiviral prophylaxis, cytomegalovirus (CMV) remains a common opportunistic infection following heart transplantation. This study analyzes the rates, risk factors, and outcomes of ...CMV among heart transplant recipients.
A retrospective cohort study was conducted of adults who underwent heart transplantation between January 1, 2011, and March 31, 2019. The primary outcome was clinically significant CMV infection (csCMVi), defined as CMV disease or asymptomatic infection requiring pre-emptive therapy. The secondary outcome was all-cause mortality. Patients received valganciclovir prophylaxis up to 6 months, depending on CMV donor/recipient serostatus. Kaplan-Meier curve and multivariable Cox regression were used for outcome analysis.
Among 553 heart transplant recipients, 101 (18.3%) experienced csCMVi, including 35 (6.3%) with CMV disease. csCMVi was uncommon during prophylaxis. In multivariable analysis, CMV D+/R– status hazard ratio (HR 12.88, 95% CI 6.76-24.56; p < 0.001) and lower absolute lymphocyte counts in seropositive recipients (HR 1.48, 95% CI 1.23-1.79; p < 0.001), but not CMV D+/R– patients (HR 1.18, 95% CI 0.94-1.47; p = 0.162), were significantly associated with csCMVi. Sixty patients died during follow-up, and csCMVi was associated with increased mortality (HR 2.84, 95% CI 1.62-4.98; p < 0.001).
In this large cohort of heart transplant recipients, csCMVi was linked to higher mortality. CMV D+/R– serostatus was associated with an increased risk of csCMVi, with lower absolute lymphocyte counts increasing risk only in CMV seropositive recipients. Strategies for optimizing CMV prevention in serodiscordant heart recipients are warranted.
Background. Solid organ transplant (SOT) candidates should be screened and treated for latent tuberculosis infection (LTBI) to prevent tuberculosis (TB) reactivation after transplantation. We aimed ...to assess the steps from positive QuantiFERON (QFT) through LTBI treatment (cascade of care) in the SOT population. Methods. We conducted a retrospective study of SOT recipients older than 18 y with a positive QFT during pretransplant evaluation at the Mayo Clinic from January 2010 to June 2023. We analyzed each cascade step to determine associated drop-out factors for LTBI management. Results. Of 629 patients who had positive QFT results, 587 (93%) were evaluated by an infectious disease (ID) specialist, 478 (76%) were recommended to start LTBI treatment, 473 (75%) initiated LTBI treatment, and 457 (73%) completed LTBI treatment. LTBI treatment was not recommended in 109 patients evaluated by infectious disease, most of whom had previously received either LTBI (n = 72) or TB (n = 14) treatment. LTBI treatment was initiated before or after transplantation for 45% and 55% of patients, respectively. Isoniazid monotherapy was the most common regimen (92%), and adverse events were rare (7%). Seven patients developed active TB infection posttransplantation under various circumstances (3 without LTBI treatment, 1 during LTBI treatment, and 3 after completing LTBI treatment). Conclusions. Our findings demonstrate the variability of LTBI management in SOT recipients with positive QFT. When recommended, most patients completed LTBI treatment successfully. Nonetheless, active TB was noted regardless of whether patients received LTBI treatment. This study highlights the importance of optimizing LTBI management in this population.
Urinary tract infections (UTI), the most common infectious complications after kidney transplantation, are associated with poor allograft survival. Identifying its predisposing factors is therefore ...remarkably important in order to optimize prevention strategies.
A retrospective study was performed in a cohort of patients who received kidney transplantation between June 2007 and June 2009. Factors associated with development of UTI were assessed.
The population consisted of 301 patients, with majority receiving allograft from living donors (85%). A total of 101 patients (34%) developed at least one episode of UTI, and 25% of the episodes occurred during the first year after transplantation. Risk factors associated with increased risk of UTI were female gender, recurrent UTI prior to transplant, and presence of urological abnormalities. Trimethoprim-sulfamethoxazole (TMP-SMZ) use was associated with a lower risk of UTI, including a lower risk of recurrent UTI.
In this cohort of predominantly living donor kidney transplant recipients, we report a high incidence of UTI, despite our practice of early ureteral and Foley catheter removal. Female gender and prior recurrent UTI or urological abnormalities were predisposing factors, while TMP-SMZ use had a protective role. These clinical relevant findings should guide clinicians in optimizing prevention strategies against UTI in kidney transplant recipients.
PDF
