Periprosthetic Knee Infection - Part 1: Risk Factors, Classification and Diagnosis / Infecção periprotética do joelho - Parte 1: Fatores de risco, classificação e diagnóstico

Abstract Infection is one of the most feared complications in the postoperative period of knee arthroplasties. With the progressive aging of the population and the increased incidence of degenerative joint diseases, there is an exponential increase in the number of arthroplasties performed and, consequently, in the number of postoperative infections. The diagnosis of these should follow a hierarchical protocol, with welldefined criteria, which lead to diagnostic conclusion, thus guiding the most appropriate treatment. The aim of the present update article is to present the main risk factors, classifications and, mainly, to guide diagnostic investigation in an organized manner.

Resumo A infecção é uma das complicações mais temidas no pós-operatório de artroplastias do joelho. Com o envelhecimento populacional progressivo e o aumento da incidência de doenças degenerativas articulares, observa-se um aumento exponencial do número de artroplastias realizadas e, consequentemente, do número de infecções pós-operatórias. O diagnóstico destas devem seguir um protocolo hierarquizado, com critérios bem definidos, que conduzam à conclusão diagnóstica, orientando, assim, o tratamento mais adequado. O objetivo do presente artigo de atualização é apresentar os principais fatores de risco, as classificações e, principalmente, guiar de forma organizada a investigação diagnóstica.

Preoperative serum albumin as a predictor of complications following total hip replacement in patients with rheumatoid arthritis / Albúmina sérica preoperatoria como un predictor de complicaciones posterior al reemplazo total de cadera en pacientes con artritis reumatoide

Abstract: Background: Rheumatoid arthritis is a chronic inflammatory disease characterized by polyarthritis with progressive articular wear, immunologic abnormalities and increasing physical limitation. Surgical correction with hip replacement comes as a successful solution for patients with advanced articular destruction. Following intervention, surgical site infection (SSI), venous thromboembolism, sepsis, renal and major cardiovascular complications are among the most cited in the literature. No consensus exists as to the detection of preoperative hypoalbuminemia in patients with rheumatoid arthritis. Methods: This study retrospectively evaluated the preoperative serum albumin of 75 patients with rheumatoid arthritis and analyzed its relevance in terms of appearance of postoperative complications with a six-month follow-up. Complications in the group of patients with low serum albumin and the group of patients with normal serum albumin were reviewed to identify the effect of each variable. Odds ratio for each variable was calculated (hospital readmission, surgical site infection, renal and cardiac complications, non-infectious wound complications and the presence of residual hip pain), as well as p-value and confidence intervals. Results: Surgical site infection showed a statistically significant relation with low serum albumin (OR: 6.125, p = 0.018) as did non-infectious wound complications (OR: 3.714, p = 0.026) and residual hip pain (OR: 3.149, p = 0.022). Conclusion: Preoperative low serum albumin has a direct relation with the rate of postoperative complications including SSI, non-infectious wound complications (seroma formation, wound dehiscence) and residual hip pain. Preoperative serum albumin is a reliable marker of nutrition, which may establish preventive strategies to reduce postoperative complications in patients with rheumatoid arthritis.

Resumen: Introducción: La artritis reumatoide es una enfermedad inflamatoria crónica con desgaste articular progresivo, anomalías inmunológicas y aumento de la limitación física. La corrección quirúrgica con el reemplazo de la cadera es una solución a la destrucción articular avanzada. Después de la intervención, la infección del sitio quirúrgico (SSI), el tromboembolismo venoso, la sepsis y las complicaciones cardiovasculares o renales se encuentran entre las más citadas en la literatura. No existe consenso en cuanto a la detección de hipoalbuminemia preoperatoria en pacientes con artritis reumatoide. Métodos: Estudio retrospectivo evaluando la albúmina de suero preoperatoria de 75 pacientes con artritis reumatoide, se analizó su importancia en términos de complicaciones postoperatorias en los primeros seis meses de seguimiento. Las complicaciones en el grupo de pacientes con albúmina de suero baja y el grupo de pacientes con albúmina de suero normal fueron repasadas para identificar el efecto de cada variable. Se calculó el odds ratio para cada variable (reingreso hospitalario, infección del sitio quirúrgico, complicaciones renales y cardíacas, complicaciones no infecciosas de la herida y presencia de dolor de cadera residual), así como el valor p y los intervalos de confianza. Resultados: La infección del sitio quirúrgico demostró una relación estadística significativa con la albúmina de suero baja (o: 6.125, p = 0.018) al igual que complicaciones no infecciosas de la herida (o: 3.714, p = 0.026) y dolor residual de la cadera (o: 3.149, p = 0.022). Conclusión: La albúmina sérica baja preoperatoria tiene una relación directa con la tasa de complicaciones postoperatorias: infección, formación de seromas, dehiscencia de la herida y dolor residual.

Infecciones asociadas a diálisis peritoneal en el paciente pediátrico: diagnóstico y tratamiento / Peritoneal dialysis-related infections in pediatric patients: diagnosis and treatment review

Resumen Las infecciones asociadas a diálisis peritoneal (DP), corresponden a la principal complicación de los pacientes pediátricos en esta terapia de reemplazo renal, disminuyendo la sobrevida de la membrana peritoneal y empeorando el pronóstico del paciente. El reconocimiento precoz y un tratamiento oportuno de éstas son fundamentales para preservar esta modalidad dialítica. Se presenta una revisión actualizada de la literatura científica, con el fin de entregar recomendaciones reproducibles en los distintos centros pediátricos que realizan diálisis peritoneal crónica en niños.

Peritoneal dialysis-related infections are the main complication in pediatric patients undergoing this renal replacement therapy, associating a high rate of morbidity, generating also a decreasing survival of the peritoneal membrane and worsening the patient outcome. We describe the recommended diagnostic and therapeutic modalities to treat dialysis-related in children.

Identification of post-cesarean surgical site infection: nursing consultation / Identificación de la infección de sitio quirúrgico después de la cesárea: consulta de enfermería / Identificação da infecção de sítio cirúrgico pós-cesariana: consulta de enfermagem

ABSTRACT Objective: To describe the profile of women in relation to their living conditions, health status and socio-demographic profile, correlating it with the presence of signs and symptoms suggestive of post-cesarean surgical site infection, identifying information to be considered in the puerperium consultation performed by nurses and proposing a roadmap for the systematization of care. Method: Quantitative, exploratory, descriptive, cross-sectional and retrospective review of medical records of women who had cesarean deliveries in 2014, in the city of São Paulo. Results: 89 medical records were analyzed, 62 of them with incomplete information. In 11, there was at least one of the signs and symptoms suggestive of infection. Conclusion: Given the results of the study, the systematization of puerperal consultation is essential. The roadmap is an instrument that can potentially improve the quality of service and the recording of information.

RESUMEN Objetivo: Describir el perfil de las mujeres en relación con sus condiciones de vida, de salud, así como el perfil sociodemográfico, que correlacionan con la presencia de signos y síntomas sugestivos de infección del sitio quirúrgico post-cesárea; identificar informaciones a ser consideradas en la consulta de puerperio realizada por el enfermero y proponer un itinerario para la sistematización de la asistencia. Método: Investigación cuantitativa, exploratoria, descriptiva, transversal y retrospectiva de revisión de prontuarios de mujeres que tuvieron parto cesárea en 2014, en el municipio de São Paulo. Resultados: Se analizaron 89 prontuarios, 62 de ellos con informaciones incompletas. En 11 de ellos, hubo la presencia de al menos uno de los signos y síntomas sugestivos de infección. Conclusión: Ante los resultados del estudio, la sistematización de la consulta puerperal es indispensable. El itinerario es un instrumento que puede potencialmente mejorar la calidad de la atención y el registro de las informaciones.

RESUMO Objetivo: Descrever o perfil das mulheres em relação às suas condições de vida, de saúde e perfil sociodemográfico, correlacionando com a presença de sinais e sintomas sugestivos de infecção do sítio cirúrgico pós-cesariana, identificar informações a serem consideradas na consulta de puerpério realizada pelo enfermeiro e propor um roteiro para a sistematização da assistência. Método: Pesquisa quantitativa, exploratória, descritiva, transversal e retrospectiva de revisão de prontuários de mulheres que tiveram parto cesariano em 2014, no município de São Paulo. Resultados: 89 prontuários foram analisados, 62 deles com informações incompletas. Em 11, houve a presença de, pelo menos, um dos sinais e sintomas sugestivos de infecção. Conclusão: Diante dos resultados do estudo, a sistematização da consulta puerperal é imprescindível. O roteiro é um instrumento que pode potencialmente melhorar a qualidade do atendimento e o registro das informações.

Risk factors and etiology of surgical site infection after radical neck dissection in patients with head and neck cancer

BACKGROUND/AIMS: Surgical site infection (SSI) is a major complication after radical neck dissection (RND) in patients with head and neck cancer (HNC). We investigated the incidence, risk factors, and etiology of SSI among patients who underwent RND. METHODS: A retrospective cohort study was performed on HNC patients, excluding those with thyroid cancer, who underwent first RND at a teaching hospital between January 2006 and June 2010. Medical records were collected and analyzed to evaluate the risk factors and microbiological etiologies. RESULTS: A total of 370 patients underwent first RND. The overall incidence of SSI was 19.7% (73/370). Multivariate analysis showed that male sex (odds ratio [OR], 4.281; p = 0.004), cardiovascular diseases (OR, 1.941; p = 0.020), large amount of blood loss during surgery (OR, 4.213; p = 0.001), and surgery lasting longer than 6 hours (OR, 4.213; p = 0.002) were significantly associated with SSI. The most common causative pathogen was Staphylococcus aureus (32.6%), and 93.2% of S. aureus isolates were methicillin-resistant. Klebsiella pneumoniae (13/92, 14.1%), Pseudomonas aeruginosa (11/92, 12.0%), and Enterococcus species (11/92, 12.0%) were also frequently detected. CONCLUSIONS: Based on our results, we predict that certain groups of patients are at high risk for SSIs after major HNC surgery. Preventive measures or close monitoring in these patients may be required to reduce the likelihood of postoperative SSIs. Furthermore, even though additional research is required, we would consider changing the prophylactic antibiotic regimens according to the causative organisms.

Recurrent Paecilomyces Keratitis in a Patient with Jones Tube after Conjunctivodacryocystorhinostomy

No abstract available.

Factors Affecting Treatment Outcome of Graft Infection Following Penetrating Keratoplasty

PURPOSE: To evaluate the factors affecting treatment outcome of graft infection following penetrating keratoplasty (PKP). METHODS: In this retrospective study, 28 patients who underwent PKP between January 2005 and January 2013 and who were diagnosed with graft infection were classified into a treatment success group or a treatment failure group. Demographic and clinical characteristics, as well as the results of the microbiologic investigation, were analyzed and compared. A subsequent binary logistic regression analysis was performed to identify the prognostic factors affecting treatment outcome. RESULTS: Graft infection occurred at a mean of 38.29 +/- 36.16 months (range, 1 to 96 months) after PKP. Seventeen patients developed bacterial keratitis, and 11 patients developed fungal keratitis. Overall, of the 28 patients, nine (32.1%) were classified in the treatment failure group. Multivariate analysis identified pre-existing graft failure (p = 0.019), interval longer than 72 hours between donor death and PKP (p = 0.010), and fungal infection (p = 0.026) as significant risk factors for treatment failure. CONCLUSIONS: Pre-existing graft failure, extended interval between donor death and PKP, and fungal infection were important risk factors for treatment failure of graft infection following PKP.

Particular Features of Surgical Site Infection in Posterior Lumbar Interbody Fusion

BACKGROUND: Previous reports have observed differences only in infection rates between posterolateral fusion and posterior lumbar interbody fusion (PLIF). There have been no reports that describe the particular features of surgical site infection (SSI) in PLIF. In this study, we endeavor to identify the distinguishing characteristics and risk factors of SSI in PLIF. METHODS: Our study undertook a review of a case series of an institute. Patients who had undergone PLIF consecutively in the author's hospital were reviewed. Two proactive procedures were introduced during the study period. One was irrigation of the autolocal bone, and the other was the intradiscal space irrigation with a nozzle. Infection rate and risk factors were analyzed. For subgroup analysis, the elapsed time to a diagnosis (ETD), clinical manifestations, hematologic findings, and causative bacteria were examined in patients with SSI. RESULTS: In a total of 1,831 cases, there were 30 cases of SSI (1.6%). Long operation time was an independent risk factor (p = 0.008), and local bone irrigation was an independent protective factor (p = 0.001). Two cases of referred SSI were included in the subgroup analysis. There were 6/32 (19%) superficial incisional infections (SII), 6/32 (19%) deep incisional infections (DII), and 20/32 (62%) organ/space infections (O/SI). The difference of incidence among three groups was significant (p = 0.002).The most common bacteria encountered were methicillin-resistant Staphylococcus epidermidis followed by methicillin-resistant S. aureus in incisional infections, and no growth followed by S. epidermidis in O/SI. ETD was 8.5 +/- 2.3 days in SII, 8.7 +/- 2.3 days in DII and 164.5 +/- 131.1 days in O/SI (p = 0.013). CONCLUSIONS: The rate of SSI in PLIF was 1.6%, with the most common type being O/SI. The causative bacteria of O/SI was of lower virulence than in the incisional infection, and thus diagnosis was delayed due to its latent and insidious feature. Contamination of auto-local bone was presumed attributable to the progression of SSI. Irrigation of auto-local bone helped in the reduction of SSI.

Infección asociada a reconstrucción del ligamento cruzado anterior. Intervención multimodal para reducir la tasa de infección / Infection associated with anterior cruciate ligament reconstruction

Introducción: Mientras la tasa internacional de infección de sitio quirúrgico (ISQ) asociada a plástica de ligamento cruzado anterior (PLCA) oscila entre 0,14 % y 5,7 %, la tasa nacional reportada por VIHDA es de 1,06 %. Aunque estas tasas resulten bajas, cuando las ISQ ocurren causan gran morbilidad. Debido a un aumento en la incidencia, tipo brote de ISQ asociada a PLCA observada en nuestro hospital se decidió implementar una intervención multimodal para reducir esta tasa. Objetivo: Evaluar el impacto de una intervención multimodal para prevenir las ISQ asociadas a PLCA en un hospital universitario. Material y métodos: A través de un estudio cuasi experimental (antes/después) se incluyeron prospectivamente los pacientes sometidos a PLCA, entre May-2012 y Ene-2014 (período intervención) luego de la implementación de las siguientes medidas preventivas: pesquisa de colonización por SAMR, baño pre-quirúrgico con clorhexidina al 2 %; ajuste del rasurado pre-quirúrgico; higiene de manos quirúrgica con productos de base alcohólica; antisepsia de piel con clorhexidina alcohólica al 2 %; ajuste de la profilaxis quirúrgica; reducción del tiempo de exposición ambiental del tendón(injerto). Como control se utilizó una cohorte retrospectiva de pacientes sometidos a PLCA entre Ene-2011 y Abr-2012 (período pre-intervención).). Durante el período intervención se realizó cultivo de los tendones antes de su implante. Resultados: En el periodo pre-intervención se registró una tasa de ISQ de 5,50 % (11/200), en el período intervención la tasa se redujo a 2,01 % (6/298) (diferencia 3,49 %; IC95 % 0,23 % a 6,74 %; p<0,05). Esta diferencia se debió sólo en ST-RI ya que en el grupo de HTH no hubo diferencia significativa. El 42,2% (122/289) de los tendones tuvieron cultivos + antes del implante...

Introduction: As the international rate of surgical site infection (SSI) associated with anterior cruciate ligament reconstruction (ACLR) ranges between 0.14% and 5.7%, the national rate reported by VIHDA is 1.06%. Although these rates are very low, when SSIs occur cause significant morbidity. Due to an increase in the incidence of SSI in ACLR observed in our hospital, we decided to implement a multimodal intervention to reduce this rate. Objective: To evaluate the impact of a multimodal intervention to prevent SSIs associated with ACLR in a University Hospital. Methods: Through a quasi-experimental study (before / after) were prospectively included all patients undergoing ACLR , between May 2012 and Jan-2014 (intervention period) after the implementation of the following preventive measures : screening for MRSA colonization, pre-operative bathing with chlorhexidine 2%; setting of pre-operative shaving; surgical hand hygiene with alcohol-based products; skin antisepsis with 2% chlorhexidine alcoholic; setting surgical prophylaxis and reducing the time of environmental exposure of the tendon. As a control, a retrospective cohort of patients undergoing ACLR between Jan-2011 and Feb-2012 (pre-intervention period) was used. During the intervention in the operating room and before implantation the tendons were culture. Results: The pre-intervention period rate of SSI was 5.50% (11/200). In the intervention period the rate was reduced to 2.01% (6/298) (difference 3.49% ; 95% CI 0.23% to 6.74%; p <0.05). This difference was due only to surgeries with hamstrings 42.2% (122/289) of the grafts had positive cultures before implantation...

Morbidity and mortality associated with arterial surgery site infections by resistant microorganisms / Morbimortalidade relacionada às infecções de ferida operatória ocasionadas por micro-organismos resistentes em cirurgias arteriais

Background: Surgical site infection is a severe complication of peripheral vascular surgery with high morbidity and mortality rates. Objective: To evaluate the morbidity and mortality of infections of peripheral artery surgery sites caused by resistant microorganisms. Methods: This was a prospective study of a cohort of patients who underwent peripheral artery revascularization procedures and developed surgical site infections between March 2007 and March 2011. Results: Mean age was 63.7 years; males accounted for 64.3% of all cases. The overall prevalence of bacterial resistance to antimicrobials was 65.7%. The most common microorganism identified was Staphylococcus aureus (30%). Comparison of the demographic and surgical characteristics of both subsets (resistant versus non-resistant) detected a significant difference in length of preoperative hospital stay (9.3 days vs. 3.7 days). The subset of patients with infections by resistant microorganisms had higher rates of reoperation, lower numbers of limb amputations and lower mortality, but the differences compared to the subset without resistant infections were not significant. Long-term survival was similar. Conclusions: This study detected no statistically significant differences in morbidity or mortality between subsets with surgical wound infections caused by resistant and not-resistant microorganisms...

Contexto: A infecção de ferida operatória é uma complicação grave da cirurgia vascular periférica e está associada a elevadas taxas de morbidade e mortalidade. Objetivo: Avaliar a morbidade e a mortalidade relacionadas às infecções de ferida operatória causadas por micro-organismos resistentes em cirurgias arteriais periféricas. Métodos: Coorte prospectiva envolvendo pacientes submetidos a procedimentos de revascularização arterial periférica que desenvolveram infecção de sítio cirúrgico, entre março de 2007 e março de 2011. Resultados: A média de idade desses pacientes foi de 63,7 anos; homens representaram 64,3% de todos os casos. A prevalência total de resistência bacteriana foi de 65,7%. O micro-organismo mais isolado foi o Staphylococcus aureus (30%). Comparando-se as características demográficas e cirúrgicas das duas amostras (com e sem resistência), foi demonstrado que o tempo de permanência hospitalar apresentou diferença significativa (9,3 dias × 3,7 dias). O grupo de pacientes portadores de infecção por micro-organismo resistente apresentou elevadas taxas de reoperação, amputação de membro inferior e mortalidade, porém sem diferença estatística quando comparado ao grupo sem resistência. No longo prazo, a sobrevida foi similar. Conclusão: este estudo não demonstrou diferença estatística quanto a morbidade e mortalidade entre os grupos com infecção de ferida operatória ocasionada por micro-organismos resistentes e não resistentes...

Chronic granulomatous inflammation of the abdominal wall after laparoscopy: a look at high level disinfection

Port site infections after laparoscopic surgery are a known complication and take away a lot of benefits attributed to the minimal access approach. Detecting the flora responsible is essential and atypical mycobacteria must also be considered. This case series is a compilation of the accounts of ten different patients with chronic granulomatous inflammation of the anterior abdominal wall presenting with port site discharging sinuses and lumps after laparoscopic surgery. Atypical mycobacterial infections must be considered in patients with persistent wound infections after laparoscopic surgery and warrants a revision of the high level disinfection [HLD] process.

Infecções de sítio cirúrgico na criança e no adolescente / Surgery infections in children and adolescents

Infecções de sítio cirúrgico (ISC) representam uma das principais infecções relacionadas à assistência à saúde e importante complicação na prática cirúrgica. Em Pediatria, as ISC representam 17% de todas as infecções relacionadas à assistência à saúde, mas a magnitude do problema precisa ser mais bem dimensionada. As ISC podem ser divididas em três categorias: incisional superficial, incisional profunda e órgãos ou cavidades. As ISC são diagnosticadas segundo os critérios do Centers for Disease Control and Prevention e, no Brasil, do Ministério da Saúde. A vigilância dessas infecções deve ser feita durante a internação e após a alta, pois significativo número se manifesta fora do hospital. Bactérias constituem a principal causa da infecção e são representadas principalmente pelos estafilococos. Para se estabelecer programa de prevenção e controle dessas infecções é importante conhecer os fatores de risco, tais como: idade, classificaçãoAmerican Society of Anesthesiology (ASA), tempo de internação préoperatório, uso inadequado de antibioticoprofilaxia, duração da cirurgia, potencial de contaminação da ferida cirúrgica, entre outros. As ISC podem ser passíveis de prevenção em mais de 60%, desde que medidas adequadas sejam instituídas. A adesão aos guidelines para prevenção de infecções cirúrgicas pode reduzir significativamente a sua incidência e custos relacionados...

Surgery infections constitute an important complication in the surgery practice and one of the main infections demanding health care. In Pediatrics, surgery infections represent 17 % of all infections demanding to health care, but the problem magnitude needs to be better and further assessed. Such infections can be divided in three categories: surface incisional, deep incisional, and organs or cavities. The surgery infections are diagnosed according to criteria proposed by the Centers for Diagnose Control and Prevention and, in Brazil, by the Ministry of Health. Such infections must be monitor during hospital admission and after discharge, as a significant number of occurrences take place outside the hospital. Bacteria ? mostly staphylococcus ? are usually the main cause of infection. Establishing a prevention and control program for such infections demand a deep understanding of such factors or risk as: age, American Society of Anesthesiology (ASA) classification, preoperative hospital stay, inadequate use of antibiotics, surgery duration, potential of surgery injury conamination. Surgery infections can be prevented in over 60 % of the cases, provided that adequate measures are taken. Compliance with preventive guidelines for surgery infections can significantly reduce incidence and related costs...

Queratopatía cristalina: diagnóstico clínico y microbiológico de una infección corneal infrecuente causada por el grupo Streptococcus mitis

El objetivo del presente informe es describir un caso de queratopatía cristalina causada por microorganismos pertenecientes al grupo Streptococcus mitis en una paciente que concurrió a la consulta oftalmológica por molestias en su ojo derecho. Al examen oftalmológico presentó un punto de sutura interrumpida de nylon 10-0 sin tensión y con secreciones mucosas adheridas. El punto flojo fue retirado bajo normas de asepsia. Se indicó colirio de moxifloxacina al 0,5 %; el ojo tuvo una evolución adecuada, con una correcta epitelización. Sin embargo, luego de 15 días desarrolló un infiltrado blanquecino arboriforme. Se tomó una muestra en el quirófano, enhebrando el trayecto intraestromal de la sutura retirada con sutura de vicryl 7-0. Se indicaron colirios de vancomicina con 50 mg/ml. El infiltrado se mantuvo estable durante 45 días, luego se incrementó el tamaño y se produjo necrosis tisular con peligro de perforación corneal. Se realizó un recubrimiento conjuntival bipediculado. La paciente evolucionó favorablemente y luego de la retracción espontánea del recubrimiento, se observó leucoma cicatrizal y neovasos corneales.

Crystalline keratopathy: an infrequent corneal infection produced by the Streptococcus mitis group. The objective of this report is to describe a case of crystalline keratopathy caused by the Streptococcus mitis group corresponding to a patient who attended hospital for discomfort in his right eye. The ophthalmological examination showed an interrupted stitch of 10-0 nylon suture without tension and with attached mucus secretions. The loose suture was removed under aseptic conditions. Moxifloxacin 0.5 % eye drops were topically indicated. The treated eye successfully epithelialized and evolved favorably. However, after 15 days, a white tree-shaped infiltrate developed. A corneal sample was taken in the operating room, threading the intrastromal path of the removed stitch with a 7-0 vicryl suture. Vancomycin 50 mg/ml drops were indicated. The infiltrate, which was stable for 45 days, later increased its size and tissue necrosis occurred with danger of corneal perforation. A bipedicle conjunctival flap was performed in the affected corneal area, which evolved favorably. After spontaneous conjunctival flap retraction, only corneal scarring and neovascularization outside the visual axis were observed.

A Case of Brain Abscess Caused by Propionibacterium acnes 13 Months after Neurosurgery and Confirmed by 16S rRNA Gene Sequencing / 대한진단검사의학회지

Propionibacterium acnes is a gram-positive anaerobic bacillus and a normal inhabitant of the skin. Although it is often considered a contaminant of blood cultures, it can occasionally cause serious infections, including postoperative central nervous system infections. Here, we report the case of a 70-yr-old man who developed a large cerebral abscess caused by P. acnes 13 months after neurosurgery. Immediate gram staining of the pus from his brain revealed the presence of gram-positive coccobacilli. However, colony growth was observed only after 5 days of culture. Therefore, we performed 16S rRNA gene sequencing of the pus specimen. The isolate was identified as P. acnes. The colonies developed 9 days after the initial culture. The API Rapid ID 32A test (bioMerieux, France) was performed using a colony, but an unacceptable profile was obtained. Then, the pus was transferred into the enrichment broths of the BACTEC FX (Becton Dickinson, USA) and BacT/Alert 3D (bioMerieux, Organon Teknika, USA) systems, but only the BACTEC FX system could detect growth after 5 days. We performed 16S rRNA gene sequencing and API Rapid 32A profiling with a colony recovered from Brucella agar, which was inoculated with the microbial growth in the enrichment broth from the BACTEC FX system. The organism was identified as P. acnes by both methods. This case suggests that 16S rRNA gene sequencing may be a useful alternative for identifying slowly growing P. acnes from specimens that do not show growth after 5 days of culture.

Late-Onset Citrobacter koseri Endophthalmitis with Suture Exposure after Secondary Intraocular Lens Implantation

A 54-year-old male patient was seen in clinic for ocular pain and decreased vision in the right eye with duration of two days. He underwent a cataract operation for his right eye 12 years ago, then a sclera-fixated secondary intraocular implantation and pars plana vitrectomy three years ago due to intraocular lens dislocation. At the initial visit, his visual acuity was restricted to the perception of hand motion. An edematous cornea, cells, flare with hypopyon, and exposed suture material at were observed at the six o'clock direction by slit lamp. Vitreous opacity was noted from B-scan ultrasonography. The patient was diagnosed with late-onset endophthalmitis and an intravitreal cocktail injection was done. On the next day, the hypopyon was aggravated, and therefore a pars plana vitrectomy was performed. A vitreous culture tested positive for Citrobacter koseri. After 12 weeks, the best corrected visual acuity of the right eye improved to 0.7 and a fundus examination revealed a relatively normal optic disc and retinal vasculature. We herein report the first case of endophthalmitis caused by Citrobacter koseri in Korea. Exposed suture material was suspected as the source of infection in this case and prompt surgical intervention resulted in a relatively good visual outcome.

Sistema de vigilancia postalta en una clínica privada / Postdischarge surveillance system in a private hospital

La tercera causa más frecuente de Infecciones Asociadas a la Atención de Salud [IAAS], es la Infección de Herida Operatoria [IHO], correspondiendo al 14% a 16% de todas las infecciones nosocomiales. La mayoría de las IAAS pueden detectarse durante la hospitalización, sin embargo actualmente algunas IHO se presentan cuando los pacientes están en su domicilio y solo se diagnostican cuando vuelven a control. Para su pesquisa se utilizan diversos tipos de vigilancia epidemiológica, realizadas de forma activa, selectiva, sistemática y permanente. El objetivo de este proyecto es determinar la necesidad de implementar un sistema de vigilancia post alta, para detectar IHO en intervenciones quirúrgicas limpias, en un establecimiento hospitalario privado ubicado en retrospectiva de fichas clínicas entre septiembre a noviembre de 2007, para comparar las IHO post- alta encontradas, con las registradas por el comité de infecciones intrahospitalarias [IlH]. Los registros de cirugías a examinar son cirugías de mama, prostatectomías, tiroidectomías e histerectomías. Para la recolección de datos se utiliza una hoja de registro post alta. Los aspectos analizados la hoja de registro post alta son: tipo y distribución de cirugías, tiempo de estadía hospitalaria, registro del control postoperatorio, descripción de herida operatoria en el control postoperatorio. Se revisaron 175 fichas de las cuales se encontró una IHO adicional a la registrada por el comité de lIH. No es posible recomendar la aplicación de manera sistemática de este sistema de vigilancia, debido al bajo porcentaje de infección en Santiago. Se realiza una revisión cirugías limpias.

The third most common cause of Nosocomial Infections [NI] are Surgical Site Infections [SSI], counting for approximately 14% to 16% of all NI. Most SSls can be diagnosed while patients are still hospitalized, but some of them can only be detected once patients return to the hospital from home for their postoperative medical visit. For their identification, several epidemiologic surveillance methods are utilized, all of them carried out in an active, selective and systematic way. The purpose of this study is to determine the need of implementing a post discharge surveillance system to detect SSI in clean surgical wounds after surgery in a private facility located in Santiago. We performed a retrospective review of medical records of breast surgery, prostatectomies, thyroidectomies and hysterectomies operated between September and November 2007, looking for postdischarge SSI. We compared our findings with those reported by the NI Committee. Specially designed data collection sheet was utilized for every patient. We registered the type and distribution of surgeries, total hospital stay, postoperative medical visit and the type of surgical wound. SSls were identified, according to their clinical description. 175 patient's records were reviewed. Only one additional SSI was detected. We believe it is not possible to recommend a sistematic retrospective surveillance method like the one we described because of the low frequency of SSI in these types of surgeries.

Vigilância pós-alta das infecções de sítio cirúrgico em crianças e adolescentes em um hospital universitário de Belo Horizonte, Minas Gerais, Brasil / Post-discharge surveillance of children and adolescents treated for surgical site infections at a university hospital in Belo Horizonte, Minas Gerais State, Brazil

As infecções hospitalares são as principais complicações na prática cirúrgica e, dentre estas, as infecções de sítio cirúrgico são as mais freqüentes. Apesar dessas infecções poderem se manifestar após a alta, no Brasil, a maioria dos serviços não faz vigilância pós-alta. Para avaliar a importância dessa vigilância e o perfil das infecções em crianças e adolescentes, acompanhou-se uma coorte de 730 pacientes cirúrgicos de um hospital universitário de Belo Horizonte, Minas Gerais, Brasil, de 1999 a 2001. Calculou-se a incidência acumulada, aplicou-se o teste t de Student na comparação de médias e o método de Kaplan-Meier na análise do tempo de ocorrência das infecções; considerou-se significativo o valor p < 0,05. Foram diagnosticadas 87 infecções de sítio cirúrgico na coorte estudada, sendo 37 por cento após a alta hospitalar. A taxa de incidência de infecções de sítio cirúrgico foi de 11,9 por cento; mas seria apenas de 7,5 por cento sem o controle pós-alta. Verificou-se no grupo dos pacientes com infecções identificadas após a alta uma média de aparecimento das infecções de 11,3 ± 6,4 dias; que os tempos de permanência pré e pós-operatórios foram significativamente menores em relação aos pacientes com infecções intra-hospitalares. O estudo indica que a vigilância pós-alta é importante para se conhecer a real incidência das infecções de sítio cirúrgico.

Hospital infections are the main complications in surgical practice. Surgical site infections are the most frequent, and can manifest after hospital discharge. In Brazil, the majority of clinical services do not maintain infection surveillance after discharge. In order to evaluate the importance of such surveillance and the profile of these post-discharge infections, a cohort of 730 child and adolescent surgical patients was followed in a teaching hospital, from 1999 to 2001. The accumulated incidence was calculated. Student's t test was used to compare mean values and the Kaplan-Meier method to analyze the period until infection, using a p value of < 0.05. A total of 87 surgical site infections were diagnosed, 37 percent of which after discharge. The overall surgical infection rate was 11.9 percent; without outpatient follow-up, the rate would have been 7.5 percent. Post-charge infections were diagnosed after a mean of 11.3 ± 6.4 days, and in these patients the preoperative and postoperative hospital stays were significantly lower than in the group with in-hospital infections. The study indicates the importance of post-discharge surveillance in determining the real incidence of surgical site infections.

An "epidemic" of post cataract surgery endophthalmitis by a new organism.

We report a case series of endophthalmitis by an organism hitherto not reported in the eye. Nineteen of 63 cataract patients operated in a high-volume setup were urgently referred to us with acute onset of decreased vision one to two days following cataract surgery. All patients had clinical evidence of acute endophthalmitis with severe anterior chamber exudative reaction. Vitreous tap was done in three representative patients and repeated intravitreal injections were given as per established protocol. The vitreous sample from all three patients grew Enterobacter amnigenus Biogroup II, a gram-negative bacillus which, to the best of our knowledge, has never been reported in the eye. With prompt and accurate microbiological support, it was possible to salvage 17 of these eyes without performing vitrectomy. Six eyes regained 6/200 or better vision.

Evaluation of underreported surgical site infection evidenced by post-discharge surveillance / Evaluación de la sub notificación de infección del sitio quirúrgico evidenciada a través de la vigilancia después del alta / Avaliação da subnotificação da infecção do sítio cirúrgico evidenciada pela vigilância pós-alta

The Surgical Site Infection (SSI) has been pointed as one of the most important infection sites. This study aimed to determine the surgical site infection incidence during hospitalization and the impact of notification after discharge through two methods. This prospective study was carried out in the digestive system surgery service (DSS) of two general hospitals of São Paulo, in the period from August, 2001 to March, 2002. Incidence levels of 6.7 percent and 4.5 percent were notified in the institutions A and B respectively. The incidence of SSI after discharge in the institution A was 27 percent and 13.4 percent in the institution B. Surveillance after discharge evidenced global rates of 33.7 percent and 17.9 percent for institutions A and B respectively. The rates of infection increased 5.02 and 3.98 times respectively in institutions A and B.

La Infección del sitio quirúrgico (ISQ) ha aparecido como uno de los más importantes sitios de infección. La finalidad de este estudio fue determinar la incidencia de la infección del sitio quirúrgico durante la internación y el impacto de la notificación después del alta a través de dos métodos. Se trató de un estudio prospectivo, en el servicio de cirugía del sistema digestivo (CSD) de dos hospitales generales de São Paulo, en el periodo de agosto de 2001 a marzo de 2002. Se diagnosticaron durante la internación una incidencia de 6,7 por ciento y de 4,5 por ciento para las instituciones A y B, respectivamente. Analizándose la incidencia de ISQ, después del alta, en la institución A esto era del 27 por ciento y del 13,4 por ciento en la institución B. De esta manera, con la vigilancia después del alta, se verificó una tasa global del 33,7 por ciento y del 17,9 por ciento de ISQ para las instituciones A y B, respectivamente, significando un incremento de la tasa de infección en 5,02 y 3,98 veces para las instituciones respectivas.

A infecção do sítio cirúrgico (ISC) tem sido apontada como um dos mais importantes sítios de infecção. Este estudo objetivou determinar a incidência da infecção do sítio cirúrgico durante a internação, e o impacto da notificação pós-alta por meio de dois métodos. Trata-se de estudo prospectivo, realizado no serviço de cirurgia do aparelho digestivo (CAD) de dois hospitais gerais de São Paulo, no período de agosto de 2001 a março de 2002. Durante a internação, foi notificada incidência de 6,7 e de 4,5 por cento para as instituições A e B, respectivamente. Analisando-se a incidência da ISC, após a alta, na instituição A foi de 27 por cento e de 13,4 por cento na B. A realização da vigilância pós-alta evidenciou taxa global de 33,7 e 17,9 por cento de ISC para as instituições A e B, respectivamente, representando incremento da taxa de infecção em 5,02 e 3,98 vezes para as respectivas instituições.