Impact of Bundled Intervention on Outcomes of Patients Undergoing Clean Orthopedic Surgeries With Hardware Implants: Small Prospective Randomized Controlled Trial.

Background: Prosthesis-related infections (PRIs) and surgical site infections (SSIs) remain one of the most devastating complications among patients undergoing clean orthopedic surgeries. Prevention strategies are critical to reduce infection rates in orthopedic surgeries. The current study aimed to determine the effectiveness of a set of evidence-based practices (bundled intervention) in reducing the incidence of PRIs and SSIs among patients undergoing clean orthopedic surgeries with hardware implants. Patients and Methods: A prospective, interventional randomized controlled trial was conducted for a period of three years. A total of 597 patients were enrolled, and depending on their Staphylococcus aureus carrier status were categorized into carrier group (n = 98) and non-carrier group (n = 499). Only carrier group patients were analyzed for effectiveness of bundled interventions, after being randomly assigned to two subgroups: interventional carrier group (ICG; n = 50) and non-interventional carrier group (NICG; n = 48). Results: Of the 597 patients, 98 (16.4%) were colonized with Staphylococcus aureus, among whom 9 (19.4%) had methicillin resistance. During follow-up, overall infection rate of 1.1% was observed (PRI, 0.3%; SSI, 0.8%). There was no case of PRI/SSI in the ICG. However, in the NICG, one patient developed SSI because of methicillin-resistant Staphylococcus aureus. An endogenous source of infection was demonstrated by pulsed field gel electrophoresis (PFGE). The SSI rate was higher in the NICG (p = 0.002). In the non-carrier group (n = 499), SSIs/PRIs occurred among 1.2% of the patients, because of organisms other than Staphylococcus aureus. Conclusions: Benefit of bundle intervention approach could be demonstrated. Further studies assessing the effectiveness of the individual components of the bundle can inform clinical practice greatly.

Genital ulcer disease: A review.

Genital ulcer disease (GUD) continues to be an important cause of morbidity and mortality worldwide. It is an important risk factor for the acquisition of HIV. GUD is mainly caused by five sexually transmitted infections. Three pathogens most frequently associated with GUD are herpes simplex virus 2 (HSV-2), Treponema pallidum, and Haemophilus ducreyi. Although their prevalence varies among different geographical regions, HSV-2 is the leading cause of this syndrome globally. In recent years, there has been an epidemiological transition of HSV-1 with a growing role of this virus as a causative agent of GUD. GUD may present with unique features depending on the etiological agent that can help clinicians identify the etiology and start treatment. However, owing to atypical presentations and co-infections, an accurate clinical diagnosis is often a challenge without confirmatory laboratory tests. Standard methods used to detect the causative pathogens of GUD have limitations. Molecular methods can provide a more sensitive and rapid microbiological diagnosis, with detection of the pathogen from the clinical sample directly. In situations where no laboratory support is available, the syndromic approach for management should be followed. The current scenario, clinical presentation (typical and atypical), laboratory diagnosis, and management of GUD will be discussed in this review. We searched PubMed literature and Google search engine using the terms "genital ulcer disease," "epidemiology of genital ulcer disease," and "clinical features of genital ulcer disease and atypical presentations" and relevant literature was selected to provide current perspectives of GUD.

Mycoplasma genitalium: A new superbug.

Mycoplasma genitalium (MG) is an emerging sexually transmitted pathogen. It is an important cause of nongonococcal urethritis in men and is associated with cervicitis and pelvic inflammatory disease in women, putting them at risk of infertility. Multiple factors that aid pathogenesis of MG include its ability of adhesion, gliding motility, and intracellular invasion by means of the tip organelle. Through intracellular localization and antigenic variation, MG could result in treatment-resistant chronic infection. There are limited data on the prevalence of MG in Indian patients with urogenital syndromes. Recently, a high prevalence of extra genital infection with MG has been reported. Molecular assays are the major diagnostic techniques of MG infection. Antimicrobial agents such as macrolides, along with fluoroquinolones, are the treatment of choice for MG infections. The issue of drug resistance to azithromycin and fluoroquinolones in MG is rising globally. As molecular tests are becoming available for MG, both for the diagnosis and the detection of antimicrobial resistance, any patient with MG infection should then be tested for antimicrobial resistance. Consideration of MG as a cause of sexually transmitted disease in the Indian population is crucial in diagnostic algorithms and treatment strategies. The purpose of this review is to understand the prevalence of MG in different clinical scenarios, molecular mechanisms of pathogenesis, current status of antimicrobial resistance, and its impact on MG treatment.

Mycoplasma hominis: An under recognized pathogen.

Mycoplasma hominis, a commensal of the genital tract, is a potential underestimated pathogen causing both genitourinary and extragenital infections including neonatal infections. Septic arthritis, prosthetic joint infection, central nervous system (CNS) infections, infective endocarditis and abscess formation are common extragenital infections associated mainly with immunocompromised patients. Mycoplasma hominis lipoproteins play an important role in pathogenicity and directly interact with the host immune system. Polymerase chain reaction (PCR) is the mainstay of diagnosis. Increasing resistance to tetracyclines and quinolones which are used for treatment, is a matter of global concern. We reviewed PubMed literature and Google search engine on the recent developments of association of Mycoplasma hominis with various diseases, pathogenesis, diagnosis and treatment.

Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis, and Ureaplasma spp. Coinfection in an HIV-Positive Homosexual Man.

A 21-year-old human immunodeficiency virus-positive male patient presented with complaints of multiple hyperpigmented verrucous papules over his perianal area. He reported having unprotected anal and oral sex with multiple male partners. On examination, superficial ill-defined perianal erosions were present. A first void urine sample and clinician-collected rectal and oropharyngeal swabs were sent for the detection of Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis , and Ureaplasma spp. Rectal swab tested positive for all the four pathogens. Oropharyngeal swab and urine samples tested positive for C. trachomatis . The patient was treated with doxycycline and moxifloxacin. This case underscores the importance of screening of men who have sex with men for possible coinfections with multiple sexually transmitted pathogens.

Distribution of Chlamydia trachomatis omp A genotypes in patients attending a sexually transmitted disease outpatient clinic in New Delhi, India.

Background & objectives: Limited data are available on the typing of Chlamydia trachomatis in India. Serovars D to K of C. trachomatis are chiefly responsible for urogenital infections. Thus, this study was conducted to determine the distribution of C. trachomatis serovars in patients with urogenital infections and to characterize omp A gene of the detected C. trachomatis isolates by sequence analysis. Presence of other co-infections was also evaluated. Methods: Endocervical swabs were collected from 324 women and urethral swabs/urine were collected from 193 men attending the sexually transmitted diseases outpatient clinic. The samples were screened for C. trachomatis by cryptic plasmid PCR and omp A gene PCR. Genotyping was performed by PCR-restriction fragment length polymorphism (RFLP) and sequencing of the omp A gene. Samples were screened for genital mycoplasmas, Neisseria gonorrhoeae, Treponema pallidum and human immunodeficiency virus (HIV). Results: C. trachomatis was found in 15.0 per cent men and 10.8 per cent women. Serovar D was the most prevalent followed by serovars E, F, I and G. Twenty two C. trachomatis isolates were selected for omp A gene sequencing. No mixed infection was found. Variability in omp A sequences was seen in 31.8 per cent cases. Both PCR-RFLP and omp A gene sequencing showed concordant results. The presence of Ureaplasma spp. and Mycoplasma hominis was observed in 18.7 and 9.5 per cent patients, respectively. Co-infection of C. trachomatis was significantly associated with Ureaplasma urealyticum and HIV. Interpretation & conclusions: The high occurence of C. trachomatis infections warrants its screening in addition to other sexually transmitted infections namely U. urealyticum and HIV. Genotyping of the omp A gene may provide additional information for vaccine development.

Herpes simplex virus type 2 and cytomegalovirus perigenital ulcer in an HIV infected woman.

We report a case of mucocutaneous Herpes Simplex Virus (HSV)-2 and Cytomegalovirus (CMV) infection in a 39-year-old female with acquired immunodeficiency syndrome, who presented with a perigenital ulcer. The patient was receiving antiretroviral treatment (ART) for 3 months before presentation. Scraping from the perigenital ulcer was positive for HSV-2 and Treponema pallidum using polymerase chain reactions (PCR). The extent and duration of the lesions led us to consider the possibility of coinfection with CMV. The patient also tested positive for CMV by PCR. On subsequent follow-up after 8 weeks, the genital lesions had healed completely. This is possibly ascribable to the ART, which led to significant immune reconstitution.

Sexually transmitted infections: Need for extragenital screening.

Extragenital infections can occur concurrently with simultaneous urogenital infections. Extragenital sites are believed to serve as hidden reservoirs and play a critical role in their transmission. The etiological relationship of the most widespread Sexually transmitted diseases (STD) pathogen to reproductive tract has long been established, but the distribution to extragenital sites appears to be infrequent and its correlation with the sexual practice still requires to be investigated. Optimal-screening strategies for extragenital infections are largely unknown. However, there is a lack of data on clinical outcomes and optimal treatment regimens for rectal and pharyngeal extragenital infections. Further studies are needed in settings other than reproductive health and STD clinics, especially in primary care clinics and resource-limited settings.