Effect of 1% sodium alendronate in the non-surgical treatment of periodontal intraosseous defects: a 6-month clinical trial

Abstract Background and objectives Few studies have evaluated the effect of the topical application of sodium alendronate (ALN) on the treatment of intrabuccal bone defects, especially those caused by periodontitis. This 6-month randomized placebo controlled clinical trial aimed at evaluating the effect of non-surgical periodontal treatment associated with the use of 1% ALN, through clinical evaluations and cone-beam computed tomography (CBCT). Material and Methods Twenty individuals with chronic periodontitis underwent periodontal examination at the baseline as well as 3 and 6 months after periodontal treatment, registering clinical attachment level (CAL), periodontal probing depth (PPD), and bleeding on probing (BOP) as the clinical outcomes. After manual scaling and root planing, 40 bilateral sites with interproximal vertical bone defects were randomly treated with either 1% ALN gel or a placebo. Bone defects were evaluated through CBCT at the baseline and 6 months post-treatment. The clinical and CBCT parameters were compared using the Wilcoxon and Friedman tests (p<0.05). Results Although ALN produced a greater CAL gain when compared to the placebo at 6 months post-treatment (p=0.021), both treatments produced similar effects on the PPD, BOP, and bone height. Significant differences in bone fill were observed only in patients of the ALN group (4.5 to 3.8 mm; p=0.003) at 6 months post-treatment. Conclusions Topical application of 1% ALN might be a beneficial adjuvant to non-surgical periodontal therapy.

Infecciones osteoarticulares en pacientes del Hospital del Instituto de Seguridad del Trabajador (IST) de Viña del Mar: periodo 2012-2013 / Osteoarticular infections in patients of the Hospital del Instituto de Seguridad del Trabajador in Viña del Mar (Chile): period 2012-2013

INTRODUCCIÓN: Las infecciones osteoarticulares son un desafío frecuente en la práctica traumatológica diaria. En Chile y en los distintos hospitales de la región de Valparaíso son escasos los trabajos con relación al tema, lo que es fundamental para optimizar el tratamiento, tanto quirúrgico como médico, de estas infecciones. OBJETIVOS: Describir las infecciones osteoarticulares del Hospital del IST de Viña del Mar durante el periodo 2012-2013. MATERIALES Y MÉTODO: Trabajo descriptivo retrospectivo de una serie de casos. Se revisaron las fichas clínicas de los pacientes que cursaron con alguna infección osteoarticular y se obtuvieron los datos demográficos y clínicos de cada paciente. RESULTADOS: Treinta pacientes fueron incluidos. Dieciséis (53,3%) fueron hombres con un promedio de edad de 38,5años. El 50% correspondieron a infecciones asociadas a la atención de salud. Las principales infecciones fueron asociadas a material de osteosíntesis. El agente más frecuente fue el Staphylococcus aureus meticilinosensible (SAMS). En la mayoría de los casos se realizó aseo quirúrgico, toma de cultivos e inicio de antibióticos con ceftriaxona más clindamicina. CONCLUSIONES: Las infecciones osteoarticulares ocurrieron principalmente en hombres jóvenes, fueron infecciones asociadas a material de osteosíntesis y producidas por SAMS.

INTRODUCTION: Osteoarticular infections are a common challenge in everyday trauma practice. In Chile, and in different hospitals in the region of Valparaiso, there are few studies on the issue, which is essential to optimise both surgical and medical treatment of these infections. OBJECTIVES: To describe the osteoarticular infections in the Hospital del Instituto de Seguridad del Trabajador (IST) of Viña del Mar during the 2012-2013 period. MATERIALS AND METHODS: A retrospective descriptive study was performed on a series of cases. A review was made of the medical records of patients with any osteoarticular infection. Demographic and clinical data were obtained from each patient. RESULTS: Of the total of 30 patients included, 16 (53.3%) were male with a mean age of 38.5 years. Half (50%) of the infections were associated with health care. Major infections were associated with osteosynthesis material. The most frequent agent was Methicillin Susceptible Staphylococcus aureus (MSSA). In most cases surgical cleanliness, taking of microbiological cultures, and antibiotic treatment with ceftriaxone plus clindamycin, was performed. CONCLUSIONS: Osteoarticular infections occurred mainly in young men, were infections associated to osteosynthesis material, and caused by MSSA.

Outpatient parenteral antimicrobial therapy for orthopedic infections – a successful public healthcare experience in Brazil

Abstract Treatment of orthopedic infections usually requires prolonged antimicrobial therapy, ranging from 14 days up to 6 months. Nowadays, rising levels of antimicrobial resistance demands parenteral therapy for many patients. Outpatient parenteral antimicrobial therapy (OPAT) is a modality that allows treatment out of hospital in these situations. In Brazil, where a public universal healthcare system allows full coverage for all citizens, implantation and dissemination of OPAT programs would be beneficial for patients and for the system, because it would allow a better allocation of health resources. The Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da USP (IOT) started, in July 2013, a partnership with municipal health authorities in Sao Paulo, Brazil, in order to initiate an OPAT program in which patients discharged from that hospital would be able to continue antimicrobial therapy at primary care facilities. When necessary, patients could also receive their therapy at the day-hospital located at IOT. Primary care nursing and physician staff were trained about antimicrobial infusion and peripherally inserted central catheter manipulation. An OPAT specific antimicrobial protocol was designed and a special reference and counter-reference organized. As a result, 450 primary healthcare professionals were trained. In the first year of this program, 116 patients were discharged for OPAT. Chronic and acute osteomyelitis were most frequent diagnosis. Teicoplanin, ertapenem and tigecycline were the most used drugs. Duration of treatment varied from 10 to 180 days (average 101, median 42). Total sum of days in OPAT regimen was 11,698. Only 3 patients presented adverse effects. Partnership between services of different levels of complexity allowed implantation of a safe and effective public healthcare OPAT program for treatment of orthopedic infections. This program can serve as a model for developing similar strategies in other regions of Brazil and Latin America.

Cotrimoxazol en infecciones óseas: toxicidad e impacto clínico y económico / Cotrimoxazole in bone-related infections: toxicity and clinical and economic impact

Background: Cotrimoxazole is a therapeutic option for bone-related infections but is associated to hyperkalemia and renal failure. Tolerance to this drug may reduce length of stay (LOS) and hospital charges. Aims: To evaluate renal, potassium toxicity, clinical outcome, and use of hospital resources in patients treated with cotrimoxazole for bone-related infections. Methods: Retrospective analysis of adult patients with bone-related infections confirmed by culture and treated with this drug. Serum potassium and creatinine levels were analyzed during follow-up and risk factors for hyperkalemia were searched. Length of stay (LOS) and hospital charges were compared. Clinical outcome was evaluated as a secondary endpoint. Results: From 2011 to 2014, 23 patients were identified (mean age 64.7 years). Diabetes mellitus, peripheral vascular disease, and previous amputations prevalence were high (82.6%, 47.8%, and 43.5%, respectively). Median serum potassium concentration increased significantly at first control (4.35 mEq/L to 4.9 mEq/L; p < 0.001), and also creatinine serum concentration (0.9 to 1.1 mg/dL; p < 0.05). Seven patients developed hyperkalemia. Cotrimoxazole was discontinued in 10 patients (43.5%), and in 6, discharge was postponed. Drugs active against the renin-angiotensin system (DAARAS) were associated with kyperkalemia (OR 10.8 IC95 1.37-85; p < 0.05). LOS was higher among patients with cotrimoxazole toxicity (median LOS 56 versus 30 days, p < 0.05). Patients with no cotrimoxazole interruption had less drug-related hospital charges (median values of 563 versus 2820 USD, respectively; p < 0.01). Conclusions: Cotrimoxazole use must be monitored in order to detect hyperkalemia or renal toxicity and suspend its prescription. Patients that use DAARAS have a higher risk of kyperkalemia. LOS and drug-related hospital charges are reduced when patients can tolerate cotrimoxazole.

Antecedentes: Cotrimoxazol es una alternativa en infecciones óseas pero se ha asociado al desarrollo de falla renal e hiperkalemia. Objetivo: Evaluar toxicidad renal, hiperkalemia, estadía y gastos hospitalarios y evolución clínica en un grupo de pacientes con infecciones óseas tratados con este compuesto. Pacientes y Métodos: Estudio retrospectivo-descriptivo de pacientes adultos con infecciones óseas confirmadas con cultivos y tratados con este compuesto. Seguimiento de creatinina y kalemia y búsqueda de factores de riesgo para hiperkalemia, comparación de gastos y estadía hospitalaria y análisis de eficacia clínica. Resultados: Desde el año 2011 al 2014 se identificaron 23 pacientes (promedio de edad 64,7 años). La prevalencia de diabetes mellitus tipo 2 (82,6%), enfermedad vascular periférica (47,8%) y amputaciones previas (43,5%) fue elevada. La mediana de la kalemia basal aumentó significativamente al primer control (4,35 a 4,9 mEq/L) al igual que la creatinina plasmática (0,9 a 1,1 mg/dL). Siete pacientes desarrollaron hiperkalemia (30,4%). Se suspendió cotrimoxazol en 10 casos (43,5%) y en 6 casos se postergó el alta. El uso de fármacos activos contra el sistema renina-angiotensina (FASRA) se asoció a hiperkalemia (OR 10,8 IC95 1,37-85; p < 0,05). La estadía hospitalaria fue mayor en el grupo con toxicidad a cotrimoxazol (mediana de 56 versus 30 días; p < 0,05) y los pacientes sin suspensión de terapia tuvieron menos gastos por fármacos (medianas de 563 vs 2.820 USD, p < 0,01). Conclusiones: El uso de cotrimoxazol debe ser monitorizado para detectar hiperkalemia o toxicidad renal y suspender su prescripción. Los pacientes que usan FASRA tienen mayor riesgo de hiperkalemia. La estadía y gastos hospitalarios por fármacos son menores en pacientes que toleran el cotrimoxazol.

Cintigrafía ósea trifásica con Tc-99mMDP en el diagnóstico y manejo de infecciones osteoarticulares agudas en niños / Three-phase bone cintigraphy with Tc-99mMDP in the diagnosis and management of acute osteoarticular infections in children

One of the most important causes of residual damage in skeleton is incompletely treated osteoarticular infections (OAI). Goal: to assess the value of emergency three-phase bone scan (3FBS) in the evaluation of OAI. Methods: Thirty-eight children were studied with 54 3FBS. Results: Global analysis: 76% of the cases were principally articular; staphylococcus germs and hip's affection were the common. Nine patients with preoperative scan were positive with 16 foci, 86% confirmed by surgery cultivate. Seven children had negative 3FBS without posterior clinical symptomatology; in 5 of them it was demonstrated soft tissue involvement with normal osteoblastic phase. In 14/17 cases evaluated after surgical intervention, there was a relation between the scan and the clinical course. In two of those cases, in the 3FBS a new location was found. Conclusion: 3FBS is a helpful tool in the diagnosis and assessment of acute OAI in pediatric population. A positive 3FBS is highly accurate for OAI and a negative one rules it out securely.

La principal causa de daño esquelético residual son las infecciones osteoarticulares (IOA) con un tratamiento inadecuado. Objetivo: Determinar el valor del cintigrama óseo trifásico (CO3F) de urgencia en la evaluación de IOA. Material y método: Se estudiaron 38 niños en quienes se efectuaron 54 CO3F. Resultados: Análisis Global: 76% de los casos fueron principalmente articulares; el germen más frecuente fue Staphylococcus y la articulación más afectada la cadera. Nueve pacientes con CO3F preoperatorio fueron positivos con 16 focos, 86% confirmados con cultivo quirúrgico. Siete niños tuvieron CO3F negativo sin sintomatología clínica posterior. En cinco casos el estudio fue negativo para compromiso osteoarticular, pero se demostró compromiso de partes blandas con fase osteoblástica normal. En 14 de 17 casos evaluados post-cirugía, hubo relación entre el CO3F y la evolución clínica, en dos de esos casos en el CO3F se encontró una nueva localización. Conclusión: El CO3F es una herramienta útil en el diagnóstico y evaluación de las IOA agudas en población pediátrica. Un CO3F positivo es altamente seguro de IOA y uno negativo lo descarta con certeza.

Nuevas modalidades terapéuticas en el uso de teicoplanina / [New therapeutic strategies with teicoplanin]

Teicoplanin is a glycopeptide antibiotic with similar spectrum to vancomycin. However, unlike this drug, teicoplanin can be administered by i.v. or i.m. route once daily thanks to its long half-life (88 to 182 hours). This pharmacokinetic characteristic is particularly interesting in infections that require extended antimicrobial therapy, where new therapeutic strategies may be considered. Long-term treatment with teicoplanin proved effective in the treatment of bone and joint infections due to methicillin-resistant staphylococci. Teicoplanin administered three times a week yields comparable clinical efficacy than daily administration with considerably improved cost-effectiveness. This aspect merits special attention, particularly when evaluating prolonged outpatient antibiotic therapy regimens. For synergic effects it is possible to associate teicoplanin with other antibiotics. Chronic suppressive antibiotic therapy with teicoplanin may be an alternative in carefully selected patients, particularly those carrying prosthetic devices.

Uso de antibióticos locales en el tratamiento de infecciones osteoarticulares / Use of local antibiotics in the treatment of osteo articular infections

La vancomicina cumple con los requisitos farmacológicos para ser agregado al cemento polimetilmetacrilato (PMMA). Este antibiótico es liberado del implante de cemento logrando elevados niveles en la zona operatoria por un período prolongado y con una efectiva acción antimicrobiana. En el período de junio 98 a mayo 99 fueron tratados 7 pacientes con una osteosíntesis infectada, 5 de ellas por staphylococcus aureus methicilina resistentes (SAMR), en quienes no se había logrado controlar la infección pese a múltiples cirugías previas y terapia antibiótica sistémica prolongada. El tratamiento consistió en un nuevo aseo quirúrgico complementado con un implante local de vacomicina en forma de perlas confeccionadas manualmente durante la cirugía. En 6 de los 7 pacientes con esta única intervención quirúrgica se logró controlar en forma definitiva la infección. La vancomicina tiene la ventaja de su disponibilidad en nuestro médio nacional así como la efectividad contra SAMR. Este implante de vancomicina al igual que en otras infecciones osteoarticulares siempre debe ser considerado como un arma terapéutica complementaria al aseo quirúrgico necesario para el tratamiento de estas infecciones

Transitional [intravenous to oral] antibiotic therapy

Most clinicians feel the best clinical outcome occurs when patients are treated for serious infections with injections for the entire illness. Unfortunately, this type of prescribing style results in considerable indirect costs such as those involved in increased labor [nursing, pharmacy, intravenous technician time], supplies [needles, syringes, intravenous solutions, administration sets, infusion pumps] and nosocomial bacteremia.It now appears from pharmacodynamic and pharmacoeconomic information that this traditional prescribing behavior should change in the management of many infectious diseases, particularly in those clinically stable patients who can ingest or digest a medication. With the presence of numerous antibiotics with high bioavailability, many infections in such patients can now be successfully treated with an oral agent. This review provides examples of common infections [such as community- and hospital-acquired pneumonias, intra-abdominal infections, urinary tract infections, and skin, soft tissue, and bone infections] in which oral therapy can replace parenteral agents