Silver-containing hydroxyapatite (Ag/HAp) layer on a bioinert material provides both bioactive and antibacterial properties; however, the Ag release duration needs to be customized to a patient's age and metabolism for minimizing the toxic effects. Herein, we present a facile chemical process to produce an ultrathin Ag/HAp layer on a Ti implant with a customized Ag-releasing profile. The process involves the following steps: preparation of a slurry-type reagent by mixing calcium phosphate powder with an aqueous AgNO₃ solution, burying a Ti substrate in the slurry, and heating the slurry in air. An HAp layer, approximately 50 nm thick, with Ag particle deposits was obtained using this process. The Ag-particle content can be varied by adjusting the concentration of AgNO₃ solution used for slurry preparation, resulting in different Ag-release profiles in a physiological solution. For instance, Ag release was retained for up to 30 days when 100 mM AgNO₃ was used, whereas the release lasted 15 days when 10 mM AgNO₃ was used. The duration of the antibacterial activity varied accordingly, but Ag-release-derived cytotoxicity was not observed irrespective of the AgNO₃ concentration. In addition, differentiation of osteoblast-like cells was facilitated owing to the formation of the HAp layer. Thus, the chemical process presented in this study allows the production-at a clinical site-of an Ag/HAp layer customized to the patient's needs.

Although empiric treatment of urinary tract colonized patients remains a frequent practice in neurosurgery, the value of this practice remains debatable.

To analyze the effect of screening and treatment of bacteriuria on surgical site infections, incidence of Clostridium difficile, and mortality in neurosurgical trauma patients.

Database queries and direct patient chart reviews were used to gather patient chart data. T-tests, chi-square tests, binary logistic regressions, and propensity matched cohorts comparisons were performed.

A total of 3563 admitted neurosurgical trauma patients were identified over an 8 yr period (1524 cranial, 1778 spinal, and 261 combined craniospinal diagnoses). Nine hundred ninety-one patients underwent an operative neurosurgical procedure. Urinalysis was significantly associated with antibiotics exposure in both operative and nonoperative patients (P < .001). Operative patients treated with empiric antibiotics did not have a reduced risk of wound infection (P = .21), including in a propensity matched cohort (P = .52). Patients treated with empiric antibiotics had significantly increased rates of C. difficile infection (P < .001). At last follow-up, neurosurgical trauma patients that developed C. difficile had an increased risk of death (P < .005); antibiotic exposure and death were also significantly associated (P = .018). The association of C. difficile with empiric antibiotics remained significant in a propensity-matched cohort (P = .0024).

The routine use of urinalysis and empiric urinary antibiotics for bacteriuria in neurosurgical trauma patients without urinary symptoms increases risk of exposure to antibiotics does not decrease rates of wound infection, and is associated with increased rates of C. difficile infection and death.

This meta-analysis aims to assess the incidences of surgical site infection of patients who applied preadmission chlorhexidine skin preparation, versus those who applied the traditional skin preparation before undergoing total knee and hip arthroplasty.

A systematic search is carried out through Medline (1966-2016.11), PubMed (1966-2016.11), Embase (1980-2016.11), ScienceDirect (1985-2016.11) and the Cochrane Library. Only high quality studies are identified. Meta-analysis is conducted with the use of Stata 11.0 software.

One RCT and five retrospective studies, published between 2010 and 2016, are included in the present meta-analysis. The present meta-analysis indicates that there are significant differences in surgical site infection rate (RD = -0.02, 95% CI: -0.02 to -0.01, P < 0.00001), revision surgery rate (RD = -0.01, 95% CI: -0.01 to -0.01, P < 0.00001) and length of stay (MD = -0.29, 95% CI: -0.48 to -0.11, P = 0.002) between groups.

Preoperative chlorhexidine skin preparation appears to reduce the risk of infection, the incidence of revision surgery, and the length of stay for patients undergoing total knee and hip arthroplasty. No adverse effects, such as DVT or PE, appear to be related to chlorhexidine preparation. Due to the limited quality of the evidence currently available, high quality RCTs with better study designs, larger sample sizes and longer follow-ups are needed.

Many preventive methodologies seek to reduce the risk of surgical site infections after total knee arthroplasty (TKA), including the use of preoperative chlorhexidine baths and cloths. Although we have demonstrated in previous studies that this may be an efficacious method for infection prevention, our study was underpowered and we therefore set out to evaluate this with a larger sample size.

(1) Does a preadmission chlorhexidine cloth skin preparation protocol decrease the risk of surgical site infection in patients undergoing TKA? (2) When stratified using the National Healthcare Safety Network (NHSN) risk categories, which categories are associated with risk reduction from the preadmission chlorhexidine preparation protocol?

In our study, all patients (3717 total) who had undergone primary or revision TKA at a single institution between January 1, 2007, and December 31, 2013, were identified, of whom 991 patients used the chlorhexidine cloths before surgery and 2726 patients did not. All patients were provided cloths with instructions before surgery; however, as a result of a lack of compliance, we were able to substratify patients into treatment and control cohorts. Additionally, we substratified patients by NHSN risk category to determine differences in infection between the two cohorts (cloth versus no cloth). Patient medical records and an infection-tracking database were reviewed to determine the development of periprosthetic infection (patients who had superficial infections were excluded from our study) in both groups after 1 year surveillance. We then calculated relative risk reductions with use of chlorhexidine gluconate and stratified results based on NHSN risk category.

Use of a preoperative chlorhexidine cloth skin preparation protocol is associated with reduced relative risk of periprosthetic infection after TKA (infections with protocol: three of 991 [0.3%]; infections in control: 52 of 2726 [1.9%]; relative risk [RR]: 6.3 [95% confidence interval [CI], 1.9-20.1]; p = 0.002). When stratified by NHSN risk category, periprosthetic infection risk reduction was seen in the medium-risk category (protocol: one of 402 [0.3%]; control: 25 of 1218 [2.0%]; RR, 8.3 [CI, 1.1-60.7]; p = 0.038), but no significant difference was detected in the low- and medium-risk groups (RR, 2.1 [CI, 0.5-9.6; p = 0.33] and RR, 11.3 [CI, 0.7-186.7; p = 0.09]).

A prehospital chlorhexidine gluconate wipe protocol appears to reduce the risk of periprosthetic infections after TKA, primarily in those patients with medium and high risk. Although future multicenter randomized trials will need to confirm these preliminary findings, the intervention is inexpensive and is unlikely to be risky and therefore might be considered on the basis of this retrospective, comparative study.

Level III, therapeutic study.

Periprosthetic hip infections are among the most catastrophic complications after total hip arthroplasty (THA). We had previously proven that the use of chlorhexidine cloths before surgery may help decrease these infections; hence, we increased the size of the previously reported cohort.

(1) Does a preadmission chlorhexidine cloth skin preparation protocol decrease the risk of surgical site infection in patients undergoing THA? (2) When stratified using the National Healthcare Safety Network (NHSN) risk categories, which categories are associated with risk reduction from the preadmission chlorhexidine preparation protocol?

Between 2007 and 2013, a group of 998 patients used chlorhexidine cloths before surgery, whereas a group of 2846 patients did not use them and underwent standard perioperative disinfection only. Patient records were reviewed to determine the development of periprosthetic infection in both groups of patients.

Patients without the preoperative chlorhexidine gluconate disinfection protocol had a higher risk of infections (infections with protocol: six of 995 [0.6%]; infections in control: 46 of 2846 [1.62%]; relative risk: 2.68 [95% confidence interval {CI}, 1.15-0.26]; p = 0.0226). When stratified based on risk category, no differences were detected; preadmission chlorhexidine preparation was not associated with reduced infection risk for low, medium, and high NHSN risk categories (p = 0.386, 0.153, and 0.196, respectively).

The results of our study suggest that this cloth application appears to reduce the risk of infection in patients undergoing THA. When stratified by risk categories, we found no difference in the infection rate, but these findings were underpowered. Although future multicenter randomized trials will need to confirm these preliminary findings, the intervention is inexpensive and is unlikely to be risky and so might be considered on the basis of this retrospective, comparative study.

Level III, therapeutic study.

There has been concern that HIV-positive patients may be more susceptible to delayed infection (>1 month) after treatment of open fractures with orthopaedic implants. To date, the longest published follow-up for such patients is 6 months.

Long-term follow-up to identify rates of delayed implant sepsis in open fractures treated with internal fixation, in HIV positive patients and controls.

Prospective observational study. Between March 2011 and April 2012, we attempted to contact all patients who were enrolled into a study looking at outcomes of open fractures treated with internal fixation between May 2008 and March 2009. Telephone questionnaires were used to screen for implant sepsis, and patients received clinical assessments at our research clinic.

Of 101 patients with in situ implants, we were able to follow 51 patients. Of the initial 33 HIV-positive patients, 13 were reassessed as part of this study. Only 1 of 13 HIV-positive patients developed delayed implant sepsis following a grade 3B open tibia fracture. Two of 23 HIV-negative patients developed delayed implant sepsis.

With an average follow-up period of 39 months (range=34-43 months), this is the longest follow-up period to evaluate HIV-positive patients with open fractures who received orthopaedic implants. Despite its limitations of poor follow up, it provides the strongest available evidence that in our setting HIV positive patients are not at higher risk of delayed sepsis, and we would not suggest routine removal of metal work in these patients.

Despite significant improvements over the past several decades in diagnosis, treatment and prevention of periprosthetic joint infection (PJI), it still remains a major challenge following total joint arthroplasty. Given the devastating nature and accelerated incidence of PJI, prevention is the most important strategy to deal with this challenging problem and should start from identifying risk factors. Understanding and well-organized optimization of these risk factors in individuals before elective arthroplasty are essential to the ultimate success in reducing the incidence of PJI. Even though some risk factors such as demographic characteristics are seldom changeable, they allow more accurate expectation regarding individual risks of PJI and thus, make proper counseling for shared preoperative decision-making possible. Others that increase the risk of PJI, but are potentially modifiable should be optimized prior to elective arthroplasty. Although remarkable advances have been achieved in past decades, many questions regarding standardized practice to prevent this catastrophic complication remain unanswered. The current study provide a comprehensive knowledge regarding risk factors based on general principles to control surgical site infection by the review of current literature and also share own practice at our institution to provide practical and better understandings.

Bacterial colonization and biofilm formation on an orthopedic implant surface is one of the worst possible outcomes of orthopedic intervention in terms of both patient prognosis and healthcare costs. Making the problem even more vexing is the fact that infections are often caused by events beyond the control of the operating surgeon and may manifest weeks to months after the initial surgery. Herein, we review the costs and consequences of implant infection as well as the methods of prevention and management. In particular, we focus on coatings and other forms of implant surface modification in a manner that imparts some antimicrobial benefit to the implant device. Such coatings can be classified generally based on their mode of action: surface adhesion prevention, bactericidal, antimicrobial-eluting, osseointegration promotion, and combinations of the above. Despite several advances in the efficacy of these antimicrobial methods, a remaining major challenge is ensuring retention of the antimicrobial activity over a period of months to years postoperation, an issue that has so far been inadequately addressed. Finally, we provide an overview of additional figures of merit that will determine whether a given antimicrobial surface modification warrants adoption for clinical use.

Pasteurella multocida is a rare cause of prosthetic joint infection. This infection generally follows significant animal contact, usually licks and scratches. We report a case of P multocida infection that was treated with linezolid with salvage of the implant. Linezolid is generally active against Gram-positive organisms only with the exception of Pasteurella, which is Gram-negative. We extensively review the previous reported cases of implant infection with P multocida.

We evaluated a prosthesis-retaining treatment protocol for prosthetic joint infection in patients presenting at a mean of 116 days (range 10-1216 days) after primary arthroplasty. Our regime involved irrigation and debridement followed by implantation of biodegradable gentamicin loaded sponges which do not require removal after implantation. Of 34 patients with a deep infection after total hip arthroplasty, Twenty-five were treated successfully, with a mean follow-up of 35 months. There were no permanent complications. This success rate is comparable to earlier studies. Early initiation of treatment demonstrated a tendency for better results, and late chronic infections had a worse outcome. Because the sponges are degradable, a number of further surgical procedures were avoided.

Gentamicin (G) and vancomycin (V) concentrations in drainage fluids obtained from patients during the first 24 hours after implantation of antibiotic-loaded polymethylmethacrylate (PMMA) spacers in two-stage revision of infected total hip arthroplasty were studied. The inhibitory activity of drainage fluids against different multiresistant clinical isolates was investigated as well. Seven hips were treated by implantation of industrial G-loaded spacers. Vancomycin was added by manually mixing with PMMA bone cement. Serum and drainage fluid samples were collected 1, 4, and 24 hours after spacer implantation. Antibiotics concentrations and drains bactericidal titer of combination were determined against multiresistant staphylococcal strains. The release of G and V from PMMA cement at the site of infection was prompt and effective. Serum levels were below the limit of detection. The local release kinetics of G and V from PMMA cement was similar, exerting a pronounced, combined inhibitory effect in the implant site. The inhibitory activity of drainage fluids showed substantial intersubject variability related to antibiotic concentrations and differed according to the pathogens tested. Gentamicin and vancomycin were released from temporary hip spacers at bactericidal concentrations, and their use in combination exerted strong inhibition against methicillin-resistant S. aureus and Coagulase Negative Staphylococci strains.

Total shoulder arthroplasty infections are rare, depending on the use of antibiotic prophylaxis, the local blood supply, the axial load gradient and the proximal location of the shoulder. The purpose of this study was to evaluate the results of treatment for infections in total shoulder arthroplasty and septic arthritis using a preformed antibiotic-loaded spacer.

Seven shoulders in as many patients were treated for infected arthroplasty or septic arthritis without previous surgery. A preformed antibiotic-loaded spacer was always applied. Patients were evaluated at the final follow-up with the Constant Score (CS), the Secec Elbow Score (SES), and the American Shoulder and Elbow Society Score (ASESS).

The mean follow-up was 40, 71 months after spacer implant. Infection was always confirmed preoperatively by the leukocyte and neutrophil counts in the aspirated synovial fluid, and intra-operative biopsy and pathologic analysis. Positive bacterial cultures were found in 5 cases: 3 MRSA and 2 Staphylococcus epidermidis. The mean SES increased from 34.43 before spacer implant to 77.29 at final follow-up, ASESS ranged from 14.86 to 21.14, and CS from 40.28 to 79.14.

A preformed antibiotic-loaded spacer is intended to release gentamicin alone, but we can consider adding vancomycin to increase antibiotic spectrum. An early diagnosis and an immediate treatment can prevent a persistent infection and severe soft-tissue damage. The use of a preformed antibiotic spacer allows maintaining joint function at the intermediate stage in two-stage treatment.

The purpose of this study was to evaluate the incidence of surgical site infections in total hip arthroplasty patients who used an advance pre-admission cutaneous surgical preparation protocol and to compare these results to a cohort of patients who did not use the protocol. Between 2007 and 2010, 557 patients used the chlorhexidine cloths and 1901 patients did not use the cloths. Patient records were reviewed to determine the incidence of deep incisional and periprosthetic infections. A statistically significant lower incidence of infections occurred in patients who used the chlorhexidine cloths (0.5%) when compared to patients undergoing in-hospital perioperative skin preparation only (1.7%). These results confirm prior studies suggesting this as an effective method to prevent periprosthetic hip arthroplasty infections.

Secondary antimicrobial prophylaxis involves the use of ≥ 1 antimicrobial agent just prior to the time when a diagnostic/therapeutic procedure, which may induce infection, is to be performed. In the context of this article, antimicrobial agent(s) are administered to patients with ≥ 1 implanted prosthetic device in order to prevent metastatic seeding of the device(s) during bacteremia induced by a diagnostic/therapeutic procedure. Antimicrobial agents used in this context are only administered periprocedurally. Secondary antimicrobial prophylaxis of endocarditis in recipients of cardiac prosthetic materials (including valves, shunts, conduits, and patches) has been reasonably well established. However, secondary antimicrobial prophylaxis in recipients of other types of prosthetic devices has been the subject of much controversy, with a wide variety of recommendations being made.

The purpose of this article was to conduct a narrative review of the published literature on the topic of secondary antimicrobial prophylaxis in recipients of noncardiac prosthetic devices and make evidence-based recommendations for each type of device, where possible.

Medline/PubMed and EMBASE databases were searched for English-language articles published from 1950 to the present (January 2012). Search terms included "prophylaxis," "antibiotics," "antimicrobials," "prosthetic devices," "prosthesis-related infections," "bacteremia," the names of the individual types of prosthetic devices, and the names of the individual procedures potentially inducing bacteremia. Articles dealing with any aspect relevant to this topic were eligible for review. The bibliographies of retrieved articles were also carefully scanned to identify any articles not previously identified.

Based on review of the available literature, secondary antimicrobial prophylaxis is justified in only a few specific circumstances. For recipients of prosthetic vascular grafts/stents, hemodialysis arteriovenous shunts, and ventriculoatrial/ventriculovenous shunts, prophylaxis is warranted during the initial 6 months, initial 6 weeks, and at all times after implantation/revision, respectively, when dental procedures capable of inducing high-level bacteremia are planned. Prosthetic joint recipients should receive prophylaxis in the following 3 circumstances: 1) patient is to undergo dental procedure(s) capable of inducing high-level bacteremia plus either the patient is still within 2 years of device implantation/revision or the patient has ≥ 1 risk factor for hematogenous prosthetic joint infection; 2) patient is to undergo genitourinary tract procedure(s) capable of inducing high-level bacteremia plus the patient has ≥ 1 risk factor for high-risk bacteriuria; and 3) patient is to undergo perforating dermatologic surgery on the oral mucosa or at skin sites at increased risk for surgical site infection plus patient has ≥ 1 risk factor for hematogenous prosthetic joint infection. The data are inadequate to justify secondary antimicrobial prophylaxis for recipients of other types of prosthetic devices. On the basis of 9 surveys of prescriber behavior, it is apparent that there exists, over a wide geographic area, a wide disconnect between clinical practice and the secondary antimicrobial prophylaxis guidelines issued by the professional organizations representing these prescribers. Antimicrobial agent overuse was especially problematic among orthopedic and colorectal surgeons, urologists, and family practitioners. Dentists and maxillofacial surgeons followed guidelines more closely.

Device-, procedure-, and patient characteristic-dependent factors elicited over many years have narrowed down the secondary antimicrobial prophylaxis recommendations for noncardiac prosthetic devices to a small number. Despite this, physician prescribers frequently do not follow prophylaxis guidelines established by their own professional organizations. Risk-benefit and cost-effectiveness studies have found that no prophylaxis is actually superior to universal prophylaxis, likely due to known antimicrobial toxicities, such as anaphylactic/anaphylactoid reactions and Clostridium difficile-associated disease. Much work remains in establishing and extending the scientific basis for secondary antimicrobial prophylaxis and transforming this knowledge into appropriate action by the clinician.

Polymethyl methacrylate (PMMA) is widely used to treat traumatic head injuries (cranioplasty) and orthopedic injuries (bone cement), but there is a problem with implant-centered infections. With organisms such as Acinetobacter baumannii and methicillin-resistant staphylococcus aureus developing resistance to antibiotics, there is a need for novel antimicrobial delivery mechanisms without risk of developing resistant organisms.

To develop a novel antimicrobial implant material by generating silver nanoparticles (AgNP) in situ in PMMA.

All PMMA samples with AgNP's (AgNP-PMMA) released Ag(+) ions in vitro for over 28 days. In vitro antimicrobial assays revealed that these samples (even samples with the slowest release rate) inhibited 99.9% of bacteria against four different strains of bacteria. Long-term antimicrobial assay showed a continued antibacterial effect past 28 days. Some AgNP-loaded PMMA groups had comparable Durometer-D hardness (a measure of degree of cure) and modulus to control PMMA, but all experimental groups had slightly lower ultimate transverse strengths.

AgNP-PMMA demonstrated a tremendously broad-spectrum and long-intermediate-term antimicrobial effect with comparable mechanical properties to control PMMA. Current efforts are focused on further improving mechanical properties by reducing AgNP loading and assessing fatigue properties.

An emerging concern with metal-on-metal total hip arthroplasty is metal-induced hypersensitivity. Currently, this is a diagnosis of exclusion in patients with groin pain after metal-on-metal total hip arthroplasty. We describe a patient presenting nearly a year after arthroplasty with incisional drainage. Infection was presumed; but preoperative studies were nondefinitive, and the wound was explored. The operative cultures were negative; the histology revealed lymphocytic vasculitis. The patient recovered uneventfully after exchange to a metal polyethylene bearing couple. We believe that metal-induced hypersensitivity should be considered with draining wounds with this bearing couple if infection cannot be proven.

We present two cases of infected primary total hip replacements (THR) where only one of the two components exhibited loosening. Both were revised using a two stage, one component revision technique, replacing the loose component only. In the first case the acetabular component was revised leaving the original femoral stem in situ. In the second case, the femoral component was revised, leaving the original acetabular cup undisturbed. Both patients remained infection free at three and half and three years follow up respectively.

The extensive and ever-increasing use of long-term prosthetic devices has improved quality of life and survival for many patients. Prosthetic device-related infection occurs infrequently but is associated with significant morbidity and mortality. Management is challenging, often requiring prolonged antimicrobial therapy and surgical intervention. Better understanding of the interaction between microorganisms, devices, and the host should improve the ability to manage device-related infections. This article reviews recent advances in the diagnosis and treatment of infections associated with indwelling medical devices, highlighting those associated with prosthetic joints, cerebrospinal fluid shunts, and prosthetic heart valves.

Human activities have resulted in substantial, large-scale environmental modifications, especially in the past century. Ecologists and evolutionary biologists are increasingly coming to realize that parasites and pathogens, like free-living organisms, evolve as the consequence of these anthropogenic changes. Although this area now commands the attention of a variety of researchers, a broad predictive framework is lacking, mainly because the links between human activities, the environment and parasite evolution are complex. From empirical and theoretical examples chosen in the literature, we give an overview of the ways in which humans can directly or indirectly influence the evolution of different traits in parasites (e.g. specificity, virulence, polymorphism). We discuss the role of direct and indirect factors as diverse as habitat fragmentation, pollution, biodiversity loss, climate change, introduction of species, use of vaccines and antibiotics, ageing of the population, etc. We also present challenging questions for further research. Understanding the links between anthropogenic changes and parasite evolution needs to become a cornerstone of public health planning, economic development and conservation biology.

Prosthetic joint infections are an uncommon complication of joint replacement surgery, but are associated with significant morbidity and costs when they do occur. Gram-positive cocci, in particular Staphylococcus aureus and Staphylococcus epidermidis, are the most commonly recovered microorganisms (>or=50% of all isolates). About 60% of prosthetic joint infections probably occur by direct contamination during the operative procedure. Certain systemic conditions in the patients, as well as foreign material, have been identified as risk factors for prosthetic joint infection. The clinical diagnosis is only certain when there are sinus tracts that reach the prosthesis or purulent secretion is obtained from joint aspiration or during open surgery. The treatment of an infected joint prosthesis must be individualised, but it generally involves both systemic antibiotics and surgical intervention. Exchange arthroplasty in one or two stages continues to be the standard approach to management. Prosthesis retention, in conjunction with debridement and prolonged (for at least 3 months) oral antibiotic therapy, can be an alternative for early postoperative or late acute haematogenous infections, when the duration of symptoms is less than 1 month, the implant is stable, and the pathogen is relatively avirulent and sensitive to an orally well absorbed antibiotic. Good results have been achieved under these conditions in staphylococcal infections with rifampin associated with quinolones and other antibiotics, e.g., cotrimoxazole, fusidic acid, and linezolid.

Success in the treatment of infected orthopedic prosthesis requires the best surgical approach in combination with prolonged optimum targeted antimicrobial therapy. In choosing the surgical option, one must consider the type of infection, condition of the bone stock and soft tissue, the virulence and antimicrobial susceptibility of the pathogen, the general health and projected longevity of the patient, and the experience of the surgeon. If surgery is not possible, an alternative is long-term oral antimicrobial suppression to maintain a functioning prosthesis. Treatment must be individualized for a specific infection in a specific patient.

Prosthetic joint infections are a cause of increasing morbidity and medical expenditure.

To determine the incidence and the clinical and the epidemiological characteristics of knee and hip prosthetic infections (PI) in patients undergoing elective surgery in five Catalonian hospitals. To determine the predictive factors of PI.

A total of 425 patients operated on between 8 January and 8 July 2001 were prospectively followed for a period of two years. The cumulative incidence, incidence rate and effect measures were determined. Logistic regression was used to identify variables associated with PI.

Average age was 71 years and 63.1% were women. Antibiotic prophylaxis with cefazolin was given to 44.7% of the patients, with a mean duration of two days. Prophylaxis was administered during anesthesia induction in 75.6% of the patients. Among the total, 63.4% of the patients were ASA 2. Microbiological confirmation was obtained in all the infected patients; Staphylococcus epidermidis was found in 58%. Fourteen PI were diagnosed, 71% during the first 3 months, with a cumulative incidence of 3.29% and a 3-month incidence rate of 63 patients/10,000 patients/month. Diabetes mellitus was the only variable related to PI in the multivariate analysis: 3.18, 95% CI (1.1-9.9).

The cumulative incidence of PI was slightly higher than that seen in other studies. Variations were observed in the antibiotic used for prophylaxis, and the place where it was administered. PI occurred 3.18 times more frequently in diabetic patients.

This study aimed to examine the effects of multimedia with printed nursing guides in patient education on the improvement of self-efficacy, functional activity and length of hospitalization in patients with hip replacement. A quasi-experimental design was used. Control group received a routine care, whereas experimental group was given the multimedia with printed nursing guides. In the multimedia, CD is a collection of nursing instructions in the format of multimedia such as video and audio recorded into a CD. The result showed there are statistically different between experimental and control groups on self-efficacy (t = -7.93, P < 0.001), functional activities (t = 4.33, P < 0.001), and length of hospitalization (t = 2.54, P < 0.05). The findings indicated experimental group achieved higher self-efficacy with the help of multimedia with printed nursing guides. Control group needed more assistance in performing functional activities. Length of hospitalization was significantly shorter in experimental group than in control group. To better adapt to continual human resource reduction and to improve nursing service quality, wider applications of multimedia with printed nursing guides in patient education may be worthwhile.

We have prospectively studied the outcome of infections associated with implants which were retained and treated using a standardised antimicrobial protocol. Over a period of four years, we studied 24 consecutive patients who had symptoms of infection for less than one year, a stable implant, no sinus tract and a known pathogen which was susceptible to recommended antimicrobial agents. The infections involved hip prostheses (14), knee prostheses (5), an internal fixation device (4), and an ankle prosthesis (1). Twenty patients had a successful outcome at a median follow-up of 3.7 years (1.8 to 4.7); four had failure of the implant after a median follow-up of 1.2 years (0.3 to 2.5). The probability of survival without failure of treatment was 96% at one year (95% confidence interval (CI) 88 to 100), 92% at two years (95% CI 80 to 100) and 86% at three years (95% CI 72 to 100). Patients with a short-term infection but with a stable implant, no sinus tract and a known pathogen may be successfully treated by retention of the implant and the use of a standardised regimen of antimicrobial treatment.

Despite immense improvements, periprosthetic infection continues to compromise the result of otherwise successful joint arthroplasty. There are various limitations in the treatment of periprosthetic infection, the most important of which is the inability to deliver antibiotics to the local tissue without the need for intravenous administration. We have developed a novel route to covalently tether vancomycin to a metal (titanium) surface, which showed effective bactericidal activity because of a vancomycin coupling. The chemistry of tethering does not affect the biological activity of the biofactors that are attached to the metal surface. This technology holds great promise for the manufacturing of "smart" implants that can be self protective against periprosthetic infection, or can be used for the treatment of periprosthetic infections when they occur.

The number of indwelling medical devices is escalating, and an increasing proportion of device-related infections are being caused by Candida spp. Candida spp. produce biofilms on synthetic materials, which facilitates adhesion of the organisms to devices and renders them relatively refractory to medical therapy. Management of device-related Candida infections can be challenging. Removal of the infected device is generally needed to establish cure of Candida infections of medical devices. However, since the pathogenesis of Candida bloodstream infection is complicated, more studies are necessary to determine the role of catheter exchange in patients with both gastrointestinal tract mucositis and indwelling catheters. The medical and economic impact of these infections is enormous.

Orthopedic implant infections are significant because of their morbidity, a tendency to serious relapses and an elevated health cost.

To study prognostic factors and the influence of long-term antibiotic treatment on the evolution of orthopedic implant infections.

This prospective study was performed in 110 patients with orthopedic implant infections. Clinical, analytical, and microbiological studies, as well as gammagraphy with Tc, Ga and labeled leukocytes, were performed in all patients. Controls were carried out at 7, 15 and 30 days after starting treatment, every 3 months thereafter until the end of treatment, and every 6 months thereafter up to one year after stopping treatment. Initial antibiotic treatment was prescribed according to the epidemiological characteristic of the type of infection and was modified according to the microorganism isolated. Duration of treatment was established by patient and implant characteristics, severity of infection and evolution of the process, and it was adjusted to criteria of cure, failure and relapse.

Among the 110 cases, 63 were women and 37 men, with a mean age of 59.6 years (range 18-79 years). Implants included 72 joint prostheses (42 knee, 29 hip and 1 shoulder) and 38 bone implants. Microbiological documentation was obtained in 60%; among these, 60.6% were gram-positive cocci, with a predominance of staphylococci, 33.3% were gram-negative bacilli and 6.1% were anaerobic microorganims. Prognostic factors significantly associated with failure or relapse included previous joint surgery, previous hospital stay longer than 15 days, diabetes, microbiological isolation and treatment with cefuroxim plus rifampicin. Mean treatment duration was 9.8 months (range 2-17 months). Antibiotic treatment consisted of the following: 61 cases received fluorquinolones or cotrimoxazole plus rifampicin, 29 received cefuroxime-axetil plus rifampicin and the remaining 20 received monotherapy. Among 110 cases, 91 cured (83%). Treatment failures or relapses were observed in 19 (17%) patients; 26.7% of the latter were related to the implants. Tolerance to long-term antibiotic treatment was good.Conclusion. Long-term antibiotic treatment lasting a mean of 9.8 months had a positive influence on the evolution of orthopedic implant infections.

Five patients undergoing total knee arthroplasty (TKA) received 800 mg intravenous teicoplanin systemically 2.5 hours before surgery and 15 patients received 200 mg teicoplanin into a foot vein in the leg to be treated. Samples of bone, synovia, subcutaneous tissue, and skin were collected at 20, 40, and 60 minutes after tourniquet inflation and at the end of surgery. None of the study subjects experienced adverse effects, adverse events, or infections during the postoperative and follow-up period. Mean teicoplanin concentration in the collected tissue ranged from 1.52 to 5.81 mg/L after regional prophylaxis and from 0.9 to 2.94 mg/L after systemic prophylaxis. Bone and soft tissue penetration of teicoplanin after regional prophylaxis with 200 mg is at least comparable with that achieved after systemic prophylaxis with 800 mg. Regional prophylaxis in TKA appears to be safe and valuable. Higher dosages of teicoplanin seem to be needed to ensure coverage against coagulase negative staphylococci.

Though uncommon, prosthetic joint infections are a devastating complication of total joint replacement surgeries and are a cause of significant morbidity. Although complete removal of all foreign material followed by a prolonged course of directed antibiotic therapy is the optimal treatment for such infections, many factors, such as patient health, cost, available bone stock, and timing of infection influence the type of treatment that is chosen. We review the different treatment options for prosthetic joint infections, including surgical modalities and antibiotic choice, duration, and suppression.

We describe a case of Salmonella enteritidis infection of a prosthetic knee joint that was cured with ceftriaxone therapy for 6 weeks and replacement of the tibial component of the prosthesis. Eleven other cases of salmonella prosthetic joint infection have been reported in the English-language literature. Five infections occurred within 20 days of prosthesis placement, and seven occurred several months to years later; ten of 12 infections involved hip prostheses. Nine of 12 patients who had prosthesis removal were cured of the infection. Two of the three patients with retention of the prosthesis required long-term suppressive antibiotic therapy.

The prosthetic infection is a serious complication due to diagnostic problems.

To determinate epidemiological characteristics, and clinical patterns of infections associated to prosthetic materials to improve the diagnosis and management.

From december 1992 to december 1999, 110 patients with prosthetic infections were prospectively evaluated. Diagnosis was made according to standard microbiological, clinical and radiological criteria.

The incidence was 5.1% (110/1,400) prosthetic materials insert in the period of study. The average age was 59.6 years (range 18-79), and the majority of patients 63 (57.2%) were female. Forty-two (38%) suffered a total knee replacement, 29 (26%) a total hip replacement, 1 (1%) shoulder replacement and 38 (34%) autogenous bone gratting. In 29 patients (26.3%) a previous chronic disease had been diagnosed (diabetes, neoplasis, rheumatoid arthritis). Previous use of antibiotics was detected in 58 patients (51%), being ciprofloxacin the most frequently used. An etiological diagnosis was reached in 66 patients (60%), isolated grampositive in 58.2%, gramnegative in 32.8%, fundamentally by Staphylococcus sp. and P. aeruginosa respectively. In 9% anaerobe were isolated. There were early infections in 67 cases, delayed in 25, and late in 18. All the patients had local pain and flogotiv signs as initial findings, whereas 46 (41.8%) developed osteocutaneous fistula and only 5 (4.5%) presented temperature.

Prosthetic infection is a frequent complication after articular replacement, and grampositive cocci predominate as ethilogical agents. Sistemic clinical manifestations are uncommon.

The use of antibacterial prophylaxis of postoperative infections is firmly established within clean-contaminated procedures. For clean procedures, prophylaxis has traditionally been reserved for operations involving foreign-body implantation. However, evidence that postoperative infections from non-prosthetic clean procedures are highly under-reported suggests that prophylaxis is also advisable, at least for some non-prosthetic procedures, such as breast surgery and herniorrhaphy. Although cefazolin is recommended by current guidelines, cefuroxime and cefamandole have a broader antimicrobial spectrum and should be preferred in clean prosthetic surgery prophylaxis. In this type of surgery glycopeptides are not recommended for routine use but may have a role for major prosthetic implantation in units with a high incidence of methicillin-resistant staphylococci. In the case of clean-contaminated procedures, cefazolin is recommended for routine use, although colorectal procedures require an agent with improved anti-anaerobic activity. In addition, experience has shown that obstetric/gynaecological, gastroduodenal and biliary tract surgery and appendectomy all require broad-spectrum antibacterial prophylaxis. Suitable agents include cefoxitin, cefotetan, ureidopenicillins and beta-lactam/beta-lactamase inhibitor combinations. The traditional surgical classification scheme needs to be replaced with a classification that additionally accounts for patient-specific risk factors. The limitations of the current scheme may partly explain why current guidelines are so seldom followed in clinical practice.

Staphylococci account for approximately 70% of postoperative infections in orthopedic prosthetic surgery, with the leading organism being Staphylococcus epidermidis. Therefore, the antibiotics most widely used for prophylaxis are cefazolin, cefamandole and cefuroxime, by virtue of their excellent activity against these pathogens. However, methicillin-resistant coagulase-positive and -negative staphylococci are increasingly being reported as the causative agents of postoperative infection in clean prosthetic surgery, therefore prompting the use of glycopeptide antibiotics (vancomycin and teicoplanin) in the prophylaxis for total joint replacement, particularly in hospitals in which there is high methicillin-resistance among these pathogens. Furthermore, in total primary knee replacement (TKR) performed with tourniquet application, regional prophylaxis with teicoplanin (i.e. the injection of teicoplanin into a foot vein of the leg to be operated on after occlusion of the systemic circulation by inflating the tourniquet) has been shown to be a safe and valuable prophylactic technique. Apart from providing teicoplanin concentrations in the operative field higher than those achievable by conventional systemic prophylaxis (i.e. by injecting the antibiotic into an arm vein before application of the tourniquet), regional prophylaxis was found in a prospective, controlled, open study on patients undergoing primary monolateral or bilateral TKR to result in a rate of postoperative infection similar to those achievable with conventional prophylactic regimens.

Orthopedic implants have revolutionized treatment of bone fractures and noninfectious joint arthritis. Today, the risk for orthopedic device-related infection (ODRI) is <1%-2%. However, the absolute number of patients with infection continuously increases as the number of patients requiring such implants grows. Treatment of ODRIs most frequently includes long-term antimicrobial treatment and removal of the implant. Recent evidence from observational trials and 1 randomized clinical trial indicate that a subset of patients can be successfully treated with retention of the implant. Patients eligible for such a treatment must meet the following criteria: acute infection defined as signs and symptoms lasting <14-28 days, an unambiguous diagnosis based on histopathology and microbiology, a stable implant, and susceptibility of the microorganism to an effective orally available antimicrobial agent.

This study evaluates the effectiveness of a protocol implemented to induce behavioural modifications in healthcare workers (HCWs). A preoperative antibiotic prophylaxis protocol for surgical procedures in clean and clean-contaminated wounds was used. The study was conducted in a 300-bed Italian university hospital between 1998 and 1999. The protocol's impact was analysed by retrospective examination of the clinical records for selected common surgical procedures. The study also investigated the reasons for the low compliance with the protocol through a focus group methodology. We examined 723 surgical procedures and the overall compliance was 30.8% (56/182) before the implementation of the protocol and 45.2% (76/168) after 1 year (P< or = 0.01). During the same period compliance with the use of antibiotics increased when antibiotics were recommended by the protocol (5/115 vs. 19/109, P< or = 0.01) and use decreased when they were not (51/67 vs. 57/59, P< or = 0.01). As reported in the focus groups, reasons for low compliance included hospital policy weaknesses in protocol definition and implementation and the cultural behaviour of HCWs. Our results reinforce previous findings that monitoring the effectiveness of protocol implementation in the medical care setting is essential. Critical points that might increase the effectiveness of protocol implementation have also been identified.

Optimal management of infected total hip arthroplasty poses a major challenge to clinicians. Exchange arthroplasty is usually advocated but has high rates of surgical morbidity and is expensive. Debridement with prosthesis retention is associated with less morbidity, but high rates of relapsed infection have been described. To estimate the effectiveness and cost-effectiveness of these 2 strategies among older patients, we used a Markov model to simulate patients' projected lifetime clinical course in hypothetical cohorts of 65-year-old and frail 80-year-old men and women. Initial debridement and retention increased life expectancy 2.2-2.6 quality-adjusted life months and had a favorable cost-effectiveness ratio in all cohorts. Results were most sensitive to the annual rate of relapse after debridement and age at initial diagnosis of infection. In the absence of prospective clinical trials, debridement and retention is a reasonable strategy for treatment of older persons with staphylococcal or streptococcal infection and a nonloosened prosthesis.