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This article outlines some promising future concepts against postoperative spinal implant infections on the basis of today available literature. The ever-adapting bacteria causing this common complication compel a corresponding continuous research about best effective treatment. The aim is to give a perspective on several future attack-points: surgical infection prevention strategies such as technical optimization of implants and surgical technique; faster diagnostic tools to detect infection, especially in the context of late infections with low-virulent germs and with regard to decision-making in the course of the surgical workflow; and combined surgical and medical treatment options against implant infections. The surgical treatment section will also state open issues concerning implant removal, and the medical treatment section will give an outlook to promising medical alternatives in a post-antibiotic era. To keep up in this field will be important to retain spine surgery in the future as the state-of-the-art treatment option for mandatory spinal interventions in the presence of tumor or trauma and even more so as an attractive option for patients with degenerative spinal disorder for improvement of their life quality.

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide. Bacterial co-infections are associated with unfavourable outcomes in respiratory viral infections; however, microbiological and antibiotic data related to COVID-19 are sparse. Adequate use of antibiotics in line with antibiotic stewardship (ABS) principles is warranted during the pandemic. We performed a retrospective study of clinical and microbiological characteristics of 140 COVID-19 patients admitted between February and April 2020 to a German University hospital, with a focus on bacterial co-infections and antimicrobial therapy. The final date of follow-up was 6 May 2020. Clinical data of 140 COVID-19 patients were recorded: The median age was 63.5 (range 17–99) years; 64% were males. According to the implemented local ABS guidelines, the most commonly used antibiotic regimen was ampicillin/sulbactam (41.5%) with a median duration of 6 (range 1–13) days. Urinary antigen tests for Legionella pneumophila and Streptococcus peumoniae were negative in all cases. In critically ill patients admitted to intensive care units (n = 50), co-infections with Enterobacterales (34.0%) and Aspergillus fumigatus (18.0%) were detected. Blood cultures collected at admission showed a diagnostic yield of 4.2%. Bacterial and fungal co-infections are rare in COVID-19 patients and are mainly prevalent in critically ill patients. Further studies are needed to assess the impact of antimicrobial therapy on therapeutic outcome in COVID-19 patients to prevent antimicrobial overuse. ABS guidelines could help in optimising the management of COVID-19. Investigation of microbial patterns of infectious complications in critically ill COVID-19 patients is also required.

Hintergrund: Betalaktamantibiotika (BLA) sind fur viele bakterielle Infektionen die Therapie der Wahl. Vermeintliche BLA-Allergien werden haufig von

Summary Background Beta-lactam antibiotics (BLA) are the treatment of choice for a large number of bacterial infections. Putative BLA allergies are often reported by patients, but rarely confirmed. Many patients do not receive BLA due to suspected allergy. There is no systematic approach to risk stratification in the case of a history of suspected BLA allergy. Methods Using the available stratification programs and taking current guidelines into account, an algorithm for risk stratification, including recommendations on the use of antibiotics in cases of compellingly indicated BLA despite suspected BLA allergy, was formulated by the authors for their maximum care university hospital. Results The hospital is in great need of recommendations on how to deal with BLA allergies. Patient-reported information in the history forms the basis for classifying the reactions into four risk categories: (1) BLA allergy excluded, (2) benign delayed reaction, (3) immediate reaction, and (4) severe cutaneous and extracutaneous drug reaction. Recommendations strictly depend on this classification and range from use of full-dose BLA or use of BLA under certain conditions (e.g., two-stage dose escalation, non-cross-reactive BLA only) to prohibiting all BLA and the use of alternative non-BLA. In case of suspected immediate or delayed allergic reactions, there is an additional recommendation regarding subsequent allergy testing during a symptom-free interval. Conclusion Triage of patients with suspected BLA is urgently required. While allergy testing, including provocation testing, represents the most reliable solution, this is not feasible in all patients due to the high prevalence of BLA allergies. The risk stratification algorithm developed for the authors’ hospital represents a tool suitable to making a contribution to rational antibiotic therapy.

Perioperative antibiotic prophylaxis is an established concept to reduce the risk of surgical-site infections; however, the optimal treatment duration in prosthetic breast reconstruction is still controversial. This study evaluated a potential association between the perioperative antibiotic prophylaxis duration (≤24 hours versus24 hours) and incidence of postoperative surgical-site infections in immediate implant-based breast reconstruction in breast cancer patients.A descriptive, retrospective analysis of surgical-site infections after immediate implant-based breast reconstruction in breast cancer patients between January of 2011 and December of 2018 was performed. The incidence of postoperative surgical-site infections in patients with more than 24 hours of perioperative antibiotic prophylaxis was compared to patients treated for 24 hours or less.A total of 240 patients who met criteria were included. There were no relevant epidemiologic, clinical, or histopathologic differences between groups. Surgical-site infections as defined by the Centers for Disease Control and Prevention criteria occurred in 25.8 percent. A risk factor-adjusted analysis by a prespecified multiple logistic regression model showed that 24 hours or less of perioperative antibiotic prophylaxis was not inferior to treatment for more than 24 hours. The upper limit of the one-sided 95 percent confidence interval of the risk difference was 9.4 percent (below the prespecified noninferiority margin of 10 percent leading to statistical significance). Risk factors for a surgical-site infection included obesity and postoperative wound complications.The study found no association between short-course perioperative antibiotic prophylaxis (≤24 hours) and an increased rate of postoperative surgical-site infection. This is of high clinical relevance because short-course treatment can help reduce side effects and the emergence of antimicrobial resistance and prevent surgical-site infections as effectively as a prolonged perioperative antibiotic prophylaxis course.Therapeutic, III.

Background: Institutional programs such as antibiotic stewardship (ABS) programs offer possibilities to monitor and modify antibiotic usage with the aim of reducing antibiotic resistance. In orthop...

Due to the increasing number of endoprosthetic joint replacement operations in older patients as well as in patients with severe primary diseases and comorbidities, the number of revision operations is continuously increasing due to infections. The infection of an endoprosthesis represents a complex clinical picture. This article provides a detailed overview of the treatment of periprosthetic infections with a focus on the diagnostic approach and treatment decision-making. A differentiation is made in periprosthetic infections between infections with a mature or immature biofilm on the surface of the implant. Depending on this, different treatment concepts are available. Highly acute infections represent an orthopedic/surgical emergency in artificial as well as in native joints. Low-grade infections play a role particularly in the area of exchange endoprosthetics. The greatest possible success is achieved only by the interplay of a timely diagnosis, sufficient surgical approach and individualized anti-infective treatment.

ZusammenfassungDie Implantatlockerung ist eine klinisch relevante Komplikation nach operativer Stabilisierung der Wirbelsäule. Neben biomechanischen Gründen wird die chronische Infektion als Ursache diskutiert. Eine differenzialdiagnostische Unterscheidung ist oft schwierig, da diese sog. „low-grade“-Infektionen durch niedrig virulente Mikroorganismen ausgelöst werden und sich häufig mit einer subtilen klinischen Symptomatik manifestieren. Der Erregernachweis mit konventionellen mikrobiologischen Verfahren ist durch die Ausbildung eines Biofilms auf der Implantatoberfläche erschwert. Die Diagnosestellung der „low-grade“-Infektionen ist daher eine besondere Herausforderung und erfordert den richtigen Einsatz und die adäquate Interpretation verschiedener diagnostischer Verfahren. Mit der Sonikation kann der Biofilm von Implantaten abgelöst und die Sensitivität der mikrobiologische Diagnostik verbessert werden. Für eine erfolgreiche Therapie Implantat-assoziierter Infektionen ist neben der diagnostischen Aufarbeitung ein abgestimmtes operatives und antibiotisches Vorgehen wichtig. Nach der Entlassung aus dem stationären Bereich sollte eine weitere Anbindung an das Zentrum und der Austausch mit den ambulant/weiterbetreuenden Kollegen gewährleistet sein.

Joint infections are a great challenge for the treating physicians. Infection of a native joint can result in the rapid destruction of the joint if treatment is inadequate or delayed and is associated with severe life-threatening diseases, such as sepsis. This article presents a detailed overview of the treatment of joint infections of native joints with a focus on the diagnostic approach and treatment decisions. Infections in native joints are caused either endogenously by hematogenic spreading or are caused by exogenous factors. A relevant proportion of joint infections in native joints occur in connection with iatrogenic measures, such as operations, synovial punctures and joint infiltrations. Fundamentally, acute infections represent an orthopedic surgical emergency, which is associated with the necessity for immediate operative measures. The best possible success can only be achieved by an interaction between early diagnosis, an adequate surgical approach and a tailor-made anti-infectious treatment. This is also the case with periprosthetic infections, which will be dealt with in detail in a second article.

Background Cholangitis is a common complication after endoscopic retrograde cholangiography (ERC). Objectives To evaluate antimicrobial coatings for biliary plastic stents in relation to efficacy against biliary pathogens, drug release and toxicity. Methods Biliary plastic stents were prepared by coating using a polylactide drug carrier. Stent coatings contained 4% (w/w) drug content of Resomer-octenidine (RO), Resomer-octenidine and citrate (ROC), Resomer-triclosan (RT) or Resomer-gentamicin (RG). Drug-release kinetics, antimicrobial efficacies of coated biliary stents against biliary pathogens and biocompatibilities were tested. Antimicrobial efficacy measurements included MIC testing, zone of inhibition (ZOI) assays and log reduction in bacterial suspensions. Results Continuous drug release was observed in all antimicrobial stent coatings for at least 168 h with an initial peak within the first 24 h. RT-, ROC- and RG-coated stents resulted in the following log reductions in suspensions: Escherichia coli (-0.3, -7.4 and -6.6, respectively); Enterococcus faecalis (-0.05, -6.3 and -3.9, respectively); and Candida albicans (-0.04, -1.5 and -0.2, respectively). ROC had the highest log reduction in suspension and the most favourable time course of ZOI (≥2 mm, over 72 h) against all tested pathogens. Although RT coatings showed the lowest MICs, they had the lowest ZOIs after 24 h. Concerning RO, acceptable biocompatibility could only be reached by adding a citrate component. RG showed the largest ZOI after 24 h against E. coli (19.3 mm) and E. faecalis (5.1 mm), whereas the ZOI was lower against C. albicans (1.3 mm) compared with ROC (3.7 mm). Conclusions ROC corresponds most closely to the requirements of an ideal antimicrobial stent coating to prevent post-ERC cholangitis, showing the highest log reduction in pathogen counts, the most favourable time course of ZOI and high biocompatibility.

Background: Coronavirus disease 2019 (COVID-19) has become a pandemic. Bacterial superinfections seem to be associated with higher mortality in COVID-19 patients in intensive care units (ICUs). However, details on the prevalence and species distribution of secondary infections are limited. Moreover, the increasing use of dexamethasone may pose an additional risk of superinfections.Methods: We performed a single-center retrospective study of the clinical and microbiological characteristics of 154 COVID-19 patients admitted to the ICU between March 2020 and January 2021, focusing on bacterial infections, use of antimicrobial agents and dexamethasone therapy.Results: The median age was 68 years; 67.5% of the patients were men. Critically ill COVID-19 patients were treated with dexamethasone since July 2020 (second wave), which was not common during the first wave of the pandemic. In the dexamethasone group (n=90, 58.4%), respiratory pathogens were detected more frequently, as were multidrug-resistant pathogens. The number of patients with polymicrobial detection of respiratory pathogens was significantly increased (p=0.013). The most frequently detected species were Enterobacterales, Staphylococcus aureus, and Aspergillus fumigatus. The rates of bloodstream infections did not differ between the groups. The use of dexamethasone in ICU COVID-19 patients was associated with higher rates of respiratory infectious complications.Conclusions: Secondary infections are present in a substantial fraction of critically ill COVID-19 patients. Respiratory pathogens were detectable in the majority of COVID-19 ICU patients. The use of dexamethasone poses a potential risk of secondary pulmonary infections. Infectious complications in patients with dexamethasone therapy could be associated with worse outcomes.

Background: A wide range of mortality rates has been reported in COVID-19 patients on the intensive care unit. We wanted to describe the clinical course and determine the mortality rate in our institution’s intensive care units.Methods: To this end, we performed a retrospective cohort study of 50 COVID-19 patients admitted to the ICU at a large German tertiary university hospital. Clinical features are reported with a focus on ICU interventions, such as mechanical ventilation, prone positioning and extracorporeal organ support. Outcome is presented using a 7-point ordinal scale on day 28 and 60 following ICU admission.Results: The median age was 64 years, 78% were male. LDH and D-Dimers were elevated, and patients were low on Vitamin D. ARDS incidence was 75%, and 43/50 patients needed invasive ventilation. 22/50 patients intermittently needed prone positioning, and 7/50 required ECMO. The interval from onset of the first symptoms to admission to the hospital and to the ICU was shorter in non-survivors than in survivors. By day 60 after ICU admission, 52% of the patients had been discharged. 60-day mortality rate was 32%; 37% for ventilated patients, and 42% for those requiring both: ventilation and renal replacement therapy.Conclusions: Early deterioration might be seen as a warning signal for unfavourable outcome. Lung-protective ventilation including prone positioning remain the mainstay of the treatment.

Durch die weltweit steigenden Zahlen an „coronavirus disease 2019“(COVID-19)-Infektionen besteht fur samtliche Kliniken die Aufgabe, sich der Herausforderung einer Pandemie zu stellen. Es gilt insbesondere auch fur die Notaufnahmen, sich auf vollstandig veranderte Arbeitsablaufe vorzubereiten und sie umzusetzen. Dies betrifft insbesondere den Bereich Patientenscreening und -selektion (Triage). Auch mit anderen Fachbereichen wie der Hygiene, Infektiologie oder Virologie muss Hand in Hand zusammengearbeitet werden, um vor, wahrend und nach Abschluss der Diagnostik entsprechende Behandlungskonzepte zu realisieren. Daruber hinaus sind Kommunikation und Qualitats- und Risikomanagement nebst den klinischen Bereichen von hoher Relevanz. Dieser Artikel beschreibt an einem Beispiel, wie sich Notaufnahmen hier am Beispiel COVID-19 (coronavirus disease 2019) konkret und praxisnah auf eine Pandemie vorbereiten konnen.

Aims and Objectives: A major obstacle for the treatment of prosthetic joint infections (PJIs) is the identification of the organism causing it. While the diagnostic criteria ruling PJIs in or out have become ever more accurate, detecting the causative pathogen(s) still relies mostly on conventional culture. The aim of this study was to evaluate the diagnostic potential of a second generation multiplex PCR assay (Unyvero ITI G2, Curetis AG, Holzgerlingen, Germany) used on synovial fluid specimens. Materials and Methods: Prospectively collected frozen joint fluid specimens from 26 patients undergoing arthroplasty revision surgery of the hip or knee for any reason were tested as per the manufacturer’s protocol. The sensitivity and specificity were calculated using the Chi-squared-test and a combination of the serum CRP level, leukocyte count, erythrocyte sedimentation rate, joint fluid culture, tissue biopsy culture, and tissue biopsy histology served as gold standard. Results: Of the 26 cases included in the study, 15 were infected and 11 aseptic. Conventional joint fluid culture showed a sensitivity 0.67 and a specificity of 0.91. Joint fluid multiplex PCR yielded a sensitivity of 0.8 and a specificity of 1.0. Conclusion: This is the first study to assess the second generation Unyvero ITI cartridge on joint fluid aspirate for the detection of prosthetic joint infection. In our setting, the method achieved a higher diagnostic accuracy than conventional culture. We conclude that, to improve pathogen detection before revision surgery, this method represents a valuable tool.

The two-stage revision protocol is the gold standard for controlling and treating low-grade prosthetic joint infections of total hip and total knee arthroplasty. The antibiotic pause for diagnostic reasons before reconstruction (stage two) is discussed in relation to the persistence of the infection and the development of resistant bacterial strains. Serological markers and a synovial analysis are commonly used to exclude the persistence of infection. Therefore, we asked (1) is the serological testing of C-reactive protein and leucocytes a valuable tool to predict a persistence of infection? and (2) what is the role of synovial aspiration of Plymethylmethacrylat (PMMA) spacers in hip and knee joints? One hundred twelve patients who were MSIS criteria-positive for a prosthetic joint infection were studied, including 45 total hip arthroplasties (THA) and 67 total knee artrhoplasties (TKA) patients. All patients were treated with a two-stage-protocol using a mobile PMMA spacer after a 14-day antibiotic-free interval, during which we measured serological markers (C-reactive protein and leucocytes) and performed synovial aspiration (white blood cell count, polymorphonuclear cell percentage, and microbiological culture) in these patients and compared the results with those of their long-term-follow-up (mean follow-up 27 months, range 24–36 months). Of the 112 patients, 89 patients (79.5%; 95% CI 72–86.9) exhibited infection control after a two-stage exchange, and we detected most methicillin-resistant, coagulase-negative Staphylococci (CoNS) in cases of a persistent infection. The mean sensitivity of serum C-reactive protein in the patients was 0.43 (range 0.23–0.64), and the mean specificity was 0.73 (range 0.64–0.82). For serum leucocytes, the mean sensitivity was 0.09 (range 0–0.29), and the mean specificity was 0.81 (range 0.7–0.92). The mean sensitivity for the WBC count in the synovial fluid (PMMA spacer aspiration) was 0.1 (range 0–0.29), and the mean specificity was 0.79 (range 0.68–0.92). For the PMN percentage, the mean sensitivity was 0.1 (range 0–0.29), and the mean specificity was 0.79 (range 0.68–0.92). No cut-off values could be established for C-reactive protein, leucocytes, WBC count and PMN percentage due to the low AUC. No reliable markers were identified for the long-term persistence of infection. C-reactive protein and leucocytes were often elevated, even when the infection was controlled. In addition, normalized serum markers did not exclude the persistence of infection during follow-up. The synovial analysis of the WBC count and PMN percentage did not predict the persistence of infection. However, microbiological synovial fluid analysis is often misleading due to false positive microbiological cultures, which results in overtreatment.

ZusammenfassungDer Behandlungserfolg implantatassoziierter Infektionen ist in hohem Maße von einer angemessenen Diagnostik abhängig. Insbesondere „low-grade“-Infektionen präsentieren sich oft mit wenig ausgeprägten und unspezifischen klinischen Symptomen und erfordern deshalb eine optimierte diagnostische Aufarbeitung. Für die Diagnosestellung werden Anamnese, klinische Zeichen, Laborparameter, bildgebende Verfahren sowie histologische und mikrobiologische Untersuchungen herangezogen. Mikroorganismen bilden auf Implantatoberflächen einen Biofilm aus amorpher Polymermatrix, in der die Bakterien eingebettet sind. Dies erschwert den Nachweis der verursachenden Erreger mit konventionellen mikrobiologischen Methoden. Mittels Sonikation können Biofilme durch Ultraschallwellen von Oberflächen abgelöst und die resultierende Sonikationsflüssigkeit anschließend mikrobiologisch analysiert werden. Mit diesem Verfahren gelingt die Erregeridentifikation bei implantatassoziierten Infektionen deutlich häufiger und ermöglicht somit eine gezielte Antibiotikatherapie.

Osteosyntheseassoziierte Infektionen stellen eine schwerwiegende Komplikation nach Frakturversorgung dar. Die Therapie erfordert, insbesondere aufgrund der Biofilmproblematik, einen optimalen Behandlungsalgorithmus. Durch die interdisziplinare Zusammenarbeit zwischen Unfallchirurgen, Infektiologen und Mikrobiologen kann ein abgestimmtes chirurgisches und antibiotisches Behandlungskonzept angewendet und der Therapieerfolg masgeblich beeinflusst werden. Ziele der Behandlung sind in erster Linie die Ermoglichung der Frakturheilung und die Vermeidung einer chronischen Osteomyelitis. Eine Eradikation der Infektion ist durch chirurgisches Debridement, Wechsel oder Entfernung des Implantats und einer adaquaten Antibiotikatherapie moglich. In ausgewahlten Fallen konnen eine suppressive Therapie bis zur Frakturkonsolidation und die spatere Entfernung des Implantats vorgenommen werden.

Osteosyntheseassoziierte Infektionen treten in 1–5 % bei geschlossenen und in bis zu 30 % der offenen Frakturen auf. Drei Kriterien beschreiben osteosyntheseassoziierte Infektionen, welche die Behandlung wesentlich beeinflussen: Zeitpunkt des Auftretens der Infektion in Bezug zur initialen Operation (fruh vs. spat), Pathogenese der Infektentstehung (exogen, hamatogen oder direkt von benachbartem Fokus) und die Zeitdauer der Infektion (akut vs. chronisch). Die Diagnosestellung osteosyntheseassoziierter Infektionen stellt immer eine Herausforderung dar, da sich insbesondere Low-grade-Infektionen oft mit unspezifischen und diskreten klinischen Symptomen prasentieren. Die Diagnose stutzt sich auf Anamnese, klinisches Erscheinungsbild, Bildgebung, mikrobiologische und histologische Analysen. Ruheschmerzen, eine Fruhlockerung bzw. eine mechanisch nicht erklarbare Pseudarthrose sind infektionsverdachtig und mussen abgeklart werden. Eine perkutane Fistel, eine putride Wundsekretion oder ein freiliegendes Implantat bestatigen die implantatassoziierte Infektion. Ein erhohtes C‑reaktives Protein ist weder sensitiv noch spezifisch genug, um eine chronische osteosyntheseassoziierte Infektion zu sichern. In der Beurteilung von osteosyntheseassoziierten Infektionen kann bereits die Bildgebung wegweisend sein. Radiologische Zeichen wie periimplantare Osteolysen und Lockerungen, unruhige Kallusbildung, Pseudarthrosen oder auch Sequesterbildung konnen Hinweise auf das Vorliegen einer Infektion sein. Intraoperativ entnommene mikrobiologische und histologische Gewebeproben sowie die Sonikation von entfernten Implantaten vervollstandigen die Diagnostik und fuhren meist zur spezifischen Erregeridentifikation.

Due to the increasing number of endoprosthetic joint replacement operations in older patients as well as in patients with severe primary diseases and comorbidities, the number of revision operations is continuously increasing due to infections. The infection of an endoprosthesis represents a complex clinical picture. This article provides a detailed overview of the treatment of periprosthetic infections with a focus on the diagnostic approach and treatment decision-making. A differentiation is made in periprosthetic infections between infections with a mature or immature biofilm on the surface of the implant. Depending on this, different treatment concepts are available. Highly acute infections represent an orthopedic/surgical emergency in artificial as well as in native joints. Low-grade infections play a role particularly in the area of exchange endoprosthetics. The greatest possible success is achieved only by the interplay of a timely diagnosis, sufficient surgical approach and individualized anti-infective treatment.

Background A major obstacle for the treatment of prosthetic joint infection (PJI) is the identification of the underlying causative organism. While the diagnostic criteria ruling PJI in or out have become ever more accurate, the detection of the causative pathogen(s) still relies mostly on conventional and time-consuming microbial culture. The aim of this study was to evaluate the diagnostic potential of a second-generation multiplex PCR assay (Unyvero ITI G2, Curetis AG, Holzgerlingen, Germany) used on synovial fluid specimens. Our hypothesis was that the method would yield a higher diagnostic accuracy in the pre-operative workup than synovial fluid culture. Thus, a more precise classification of septic and aseptic prosthesis failure could be achieved before revision surgery. Methods Prospectively collected frozen joint fluid specimens from 26 patients undergoing arthroplasty revision surgery of the hip or knee were tested as per the manufacturer’s protocol. Sensitivities, specificities, positive and negative predictive values as well as positive and negative likelihood ratios with corresponding confidence intervals were estimated using the statistical software R. A combination of the serum C-reactive protein (CRP) level, leukocyte count, erythrocyte sedimentation rate, joint fluid culture, tissue biopsy culture, and tissue biopsy histology served as the gold standard. Results Of the 26 patients included in the study, 15 were infected and 11 were aseptic. Conventional joint fluid culture showed a sensitivity of 0.67 and a specificity of 0.91. Joint fluid multiplex PCR yielded a sensitivity of 0.8 and a specificity of 1.0. Conclusions Using the second-generation Unyvero ITI cartridge on joint fluid aspirate for the detection of prosthetic joint infection, we were able to achieve a higher diagnostic accuracy than with conventional culture. We conclude that to improve pathogen detection before revision surgery, this method represents a valuable and practicable tool.

Objectives To assess the admission prevalence of third-generation cephalosporin-resistant Enterobacterales (3GCREB) and to assess whether risk factors vary by β-lactamase genotype. Methods Adult patients were recruited within 72 h of admission to general wards of six university hospitals in 2014 and 2015. Rectal swabs were screened for 3GCREB and isolates were analysed phenotypically and genotypically. Patients were questioned on potential risk factors. Multivariable analyses were performed to identify risk factors for 3GCREB colonization and for specific β-lactamases. Results Of 8753 patients screened, 828 were 3GCREB positive (9.5%). Eight hundred and thirteen isolates were available for genotyping. CTX-M-15 was the most common ESBL (38.0%), followed by CTX-M-1 (22.5%), CTX-M-14 (8.7%), CTX-M-27 (7.5%) and SHV-ESBL (4.4%). AmpC was found in 11.9%. Interestingly, 18 Escherichia coli isolates were AmpC positive, 12 of which (67%) contained AmpC on a gene of plasmid origin [CMY (n = 10), DHA (n = 2)]. Risk factors for 3GCREB colonization varied by genotype. Recent antibiotic exposure and prior colonization by antibiotic-resistant bacteria were risk factors for all β-lactamases except CTX-M-14 and CTX-M-27. Travel outside Europe was a risk factor for CTX-M-15 and CTX-M-27 [adjusted OR (aOR) 3.49, 95% CI 2.88–4.24 and aOR 2.73, 95% CI 1.68–4.43]. A previous stay in a long-term care facility was associated with CTX-M-14 (aOR 3.01, 95% CI 1.98–4.59). A preceding hospital stay in Germany increased the risk of CTX-M-15 (aOR 1.27, 95% CI 1.14–1.41), while a prior hospital stay in other European countries increased the risk of SHV-ESBL colonization (aOR 3.85, 95% CI 1.67–8.92). Conclusions The detection of different ESBL types is associated with specific risk factor sets that might represent distinct sources of colonization and ESBL-specific dissemination routes.

Background/aim Prosthetic joint infections (PJI) are difficult to diagnose and treat. For a correct diagnosis, an array of information has to be processed and weighted. Successful treatment depends on the diagnosis, timing, and surgical strategy paired with treatment of the infectious agent. The complexity and interdisciplinarity needed cause difficulties concerning decision-making, the communication between disciplines, and the execution of a treatment strategy. The aim of this study was to develop a software platform to enhance the collection of information for the diagnosis of PJI, the interdisciplinary decision-making process, the communication between team members, and continuous evaluation of treatment. Patients and methods In regular planning sessions with an information technology (IT) specialist, a concept for an IT solution was chosen and the tool was designed in an interdisciplinary approach. Results The tool has been used as a trial version since June 2017. It consists of 14 user interfaces with 431 items. A total of 117 patients with 118 infections have been entered and the strategy decided upon and communicated using 298 infection board documents outlining the treatment. The tool is now being used to organize the infections board agenda, schedule patient case discussions, document the relevant data and treatment plan, as well as communicate with the other teams involved in the treatment. Conclusion Using the developed tool enables the infections team to work collaboratively and under division of labor on each case, rendering the work flow more efficient for each team member.

Die implantatassoziierte (oder auch periprothetische) Infektion (PPI) stellt nicht nur fur den Patienten, sondern auch fur die behandelnden Arzte und das Gesundheitssystem eine auserordentliche Herausforderung dar. Wie wird eine PPI sicher diagnostiziert? Wie kann der Prothesenerhalt gelingen?

Increasing rates of periprosthetic joint infections (PJI) will present orthopedic surgeons and the health care system with challenges in the next few years. New concepts in diagnostic and surgical pathways allow specialized centers to offer differentiated therapy of PJI.This article presents an overview of recent treatment concepts for PJI of the hip emphasizing diagnosis and the clinical approach.A selective literature search was performed focusing on evidence-based concepts including diagnostics, surgical treatment, and biofilm active antibiotics.PJI of the hip are classified as mature biofilm or immature biofilm infections. The most important step in the diagnostic procedure is to identify the pathogen and its antimicrobial susceptibility. Preoperative joint aspiration and leukocyte count, differentiation, and microbiological culture should be standard. Arthroscopic biopsy may be necessary to identify the pathogen. Depending on the biofilm maturity and the antimicrobial susceptibility, implant retention or two-stage revisions should be performed. Combination of surgical therapy and biofilm-active antibiotics are of utmost importance for successful treatment.PJI represents a significant challenge for the orthopedic surgeon. Evidence-based and standardized clinical pathways are necessary for accurate and rapid diagnosis as well as patient-specific treatment concepts.

Sonication of explanted prostheses improved the microbiological diagnosis of periprosthetic joint infections (PJI). We evaluated the performance of automated multiplex polymerase chain reaction (PCR) using sonication fluid for the microbiological diagnosis of PJI. In a prospective cohort using uniform definition criteria for PJI, explanted joint prostheses were investigated by sonication and the resulting sonication fluid was analyzed by culture and multiplex PCR. McNemar’s Chi-squared test was used to compare the performance of diagnostic tests. Among 111 patients, PJI was diagnosed in 78 (70%) and aseptic failure in 33 (30%). For the diagnosis of PJI, the sensitivity and specificity of periprosthetic tissue culture was 51 and 100%, of sonication fluid culture 58 and 100%, and of sonication fluid PCR 51 and 94%, respectively. Among 70 microorganisms, periprosthetic tissue culture grew 52 (74%), sonication fluid culture grew 50 (71%) and sonication fluid PCR detected 37 pathogens (53%). If only organisms are considered, for which primers are included in the test panel, PCR detected 37 of 58 pathogens (64%). The sonication fluid PCR missed 19 pathogens (predominantly oral streptococci and anaerobes), whereas 7 additional microorganisms were detected only by PCR (including Cutibacterium spp. and coagulase-negative staphylococci). The performance of multiplex PCR using sonication fluid is comparable to culture of periprosthetic tissue or sonication fluid. The advantages of PCR are short processing time (

Implant-associated infections represent a serious complication following fracture management. Due to biofilm formation, an optimized treatment strategy is required to treat these infections. Interdisciplinary cooperation between trauma surgeon, infectious diseases specialist and microbiologist enables the deployment of a concerted surgical and antibiotic treatment concept, which significantly influences treatment success. Fracture healing and chronic osteomyelitis prevention are the primary treatment goals. In general, the eradication of infection is possible with surgical debridement, change or removal of the implant and adequate antibiotic therapy. In some cases, suppressive therapy until consolidation of fracture and later removal of the implant is an option.

Summary Background Knowledge of the bacterial spectrum for acute cholangitis is essential for adequate empiric antibiotic treatment. Aim To analyse the relation of proton pump inhibitors (PPI) with biliary pathogens in patients with acute cholangitis. Methods This retrospective study identified 278 patients with 318 acute cholangitis episodes using an endoscopic database. The relationship between PPI and microbiological outcomes was assessed by logistic and poisson regression analysis for binary and count data. Results In total, 882 pathogens were isolated, of which, 120 cholangitis episodes occurred with PPI; 198 cholangitis episodes without PPI. Multivariate poisson regression analysis showed that PPI use resulted in a 23% increase in the number of biliary pathogens [3.14 vs. 2.55 (Δ = 0.59), P

As part of the multicentre Antibiotic Therapy Optimisation Study (ATHOS), minimum inhibitory concentrations (MICs) were determined for cephalosporins alone and in combination with the β-lactamase inhibitors tazobactam, clavulanic acid and avibactam against third-generation cephalosporin-resistant Escherichia coli, Klebsiella spp. and Enterobacter spp. isolates collected in German hospitals. MIC50/90 values were 0.25–4 mg/L for cefepime/tazobactam, 0.25–2 mg/L for ceftazidime/avibactam, 0.125–0.5 mg/L for ceftaroline/avibactam, 0.5–4 mg/L for cefpodoxime/clavulanic acid and 0.25–1 mg/L for aztreonam/avibactam, depending on the underlying resistance mechanism and organism. Based on in vitro testing, β-lactam antibiotics play an important role in the treatment of infections due to β-lactamase-producing organisms.

Background Animal models serve as an important tool to understand peri-implant infection. Most of the models use high bacterial loads (>104 colony forming units, CFU) to provide high infection rates. Therefore these animals evolve rather similarly, making comparison between groups and statistical analysis possible. On the other hand, to mimic clinical constellation of surgery-related infections the use of low amounts of bacteria would be more advantageous. Methods We developed a metaphyseal rat model of peri-implant bone infection with low amount of bacterial loads (102 and 103 CFU of Staphylococcus aureus) and investigated osseointegration of the implants coated with hydroxyapatite (HA) and low-dosed HA-silver (HA-Ag). Non-infected implants served as controls. After 6 weeks rats were sacrificed and implants evaluated for osseointegration and infection. Results Infection of implanted devices was reliably induced, independently whether 102 or 103 CFU of S. aureus were inoculated and HA or HA-Ag coated implants were used. No systemic infection was present in any of the animals at the time of sacrifice, and no animal developed acute infection requiring premature sacrifice. All CFU counts of the implant and the bone at sacrifice were significantly higher than the inoculated load (p

OBJECTIVE The aim of the study was to analyze the microbial colonization rate as well as the spectrum and number of microorganisms in relation to the indwelling time of pancreatic stents. METHODS Forty pancreatic stents were prepared according to a standardized protocol and subsequently sonicated to optimize bacterial release from the biofilm on the stents. RESULTS Two hundred forty-six microorganisms were identified. Thirty-nine of 40 stents were colonized with microorganisms. Aerobic gram-positive microorganisms (106/246 [43%]) accounted for the greatest proportion. The predominant microorganisms were Streptococcus species (46/246 [19%]), which were isolated from 27 (68%) of 40 stents. Stents with a short indwelling time (3-13 days) were mainly colonized with aerobic gram-positive bacteria (82%) and Candida species (63%). In contrast, anaerobes (P < 0.01, 69% vs 18%) and aerobic gram-negative microorganisms (P < 0.01, 93% vs 45%) such as Enterobacteriaceae (P < 0.01, 86% vs 27%) were significantly more present on stents with a long indwelling time (29-93 days), compared with stents with a short indwelling time. CONCLUSIONS Microbial analysis of pancreatic duct stents revealed a very high colonization rate. Furthermore, the spectrum and number of microorganisms altered with the indwelling time of the stent. However, clinical relevance of our findings remains unclear.

OBJECTIVES To assess the risk factors for increased antimicrobial resistance among Enterobacteriaceae representing the most common biliary pathogens. METHODS A retrospective analysis was conducted of 276 patients with acute cholangitis treated at a German tertiary centre between April 1996 and May 2009. The resistance patterns among Enterobacteriaceae isolated from blood/bile cultures were compared and related to age, sex, the genesis of the cholangitis and the type and number of previous interventional procedures [percutaneous transhepatic cholangiography (PTC)/endoscopic retrograde cholangiography (ERC)]. Univariate and multivariate generalized estimation equation models were used to compute ORs with corresponding 95% CIs for the binomial outcomes. RESULTS According to the univariate analysis, patients undergoing stent therapy had a smaller proportion of Enterobacteriaceae with susceptibility to quinolones (ofloxacin/ciprofloxacin) (184/239 versus 205/221; P

Summary Summary background Knowledge of bacterial spectrum for acute cholangitis is essential for adequate empiric antibiotic treatment. Main focus of the study was to analyse the spectrum of pathogens in acute cholangitis with and without biliary endoprosthesis. Methods Retrospective cohort study of 1024 patients with acute cholangitis treated at a German tertiary center. Results 447 cholangitis episodes with positive bile and/or blood cultures obtained from 388 patients were studied. In total, 1088 pathogen were isolated. The predominant strains were Enterococcus species (25%), followed by Escherichia coli (18%) and Klebsiella species (14%). Bacteraemia was mainly caused by E. coli (91/282; 32%) and Enterococcus species (550/282; 18%). The incidences of Enterococcus species [121(74%) vs. 89(60%); p = 0.011] and non-fermenters [41(25%) vs. 16(11%); p = 0.001] were significantly higher in cholangitis episodes with biliary endoprosthesis compared to cholangitis episodes without biliary endoprosthesis. In particular, more Pseudomonas aeruginosa [27(16%) vs. 12(8%); p = 0.027] and Enterococcus faecium [59(36%) vs. 34(23%); p = 0.013] were isolated from patients with a biliary endoprosthesis. Conclusions Unlike cholangitis without stent, the presence of biliary endoprosthesis in patients with cholangitis can serve as a surrogate indicator of nosocomial pathogens and therefore should be considered, when selecting empiric antimicrobial therapy.