Dosing and treatment duration of suppressive antimicrobial therapy in orthopedic implant infections: a cohort study.

Introduction: Limited data inform about the optimal dosing and duration of suppressive antimicrobial therapy (SAT) for orthopedic implant infection (OII). We aimed to compare the effectiveness of low-dosage with standard-dosage SAT and evaluate the safety of stopping SAT. Methods: All patients with OII treated with SAT from 2011 to 2022 were retrospectively included. Data were extracted from electronic patient files. Low-dosage SAT was defined as antimicrobial therapy dosed lower than the standard dosage recommended for OII. The association of dosing strategy and other factors with failure-free survival were assessed by Kaplan-Meier and Cox proportional hazard models. Results: One-hundred-and-eight patients were included. The median follow-up time after SAT initiation was 21 months (interquartile range (IQR) 10-42 months). SAT was successful in 74 patients (69 %). Low-dosage SAT ( n = 82 ) was not associated with failure in univariate (hazard ratio (HR) 1.23, 95 % confidence interval (CI) 0.53-2.83) and multivariate analyses (HR 1.24, 95 % CI 0.54-2.90). In 25 patients (23 %), SAT was stopped after a median treatment duration of 26 months. In this group, one patient (4 %) developed a relapse. Conclusions: In this study, low-dosage SAT was as effective as standard dosage SAT. Moreover, stopping SAT after 2 to 3 years may be justified in patients with a good clinical course. These findings warrant further research on optimal dosing and duration of SAT and on the durability of in vivo biofilms.

Eradication of community-onset Methicillin-resistant Staphylococcus aureus carriage: a narrative review.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) colonization increases infection risk in both patients and healthy individuals. Decolonization therapy has been proven to reduce S. aureus infections, but data on the effectiveness of individual decolonization strategies in community-onset MRSA carriage are scarce. OBJECTIVES: The aim of this narrative review was to summarize the evidence on strategies for the elimination of MRSA colonization in community-onset MRSA carriers. SOURCES: PubMed database was searched for studies on MRSA eradication, from inception to July 2023. CONTENT: Topical therapy is proven to be effective in nasal-only carriage and in temporary load reduction. Mupirocin nasal ointment in combination with chlorhexidine body wash is highly effective in nasal-only MRSA carriers in the community as well. In patients with extra-nasal colonization, addition of orally administered antibiotics likely increases success rates compared with topical therapy alone. Studies on systemic treatment of extra-nasal MRSA decolonization are subject to a high heterogeneity of antimicrobial agents, treatment duration, and control groups. The majority of evidence supports the use of a combination of topical therapy with rifampin and another antimicrobial agent. Decolonization treatment with probiotics is a promising novel non-antibiotic strategy. However, achieving long-term decolonization is more likely in countries with low MRSA prevalence, given the risk of recolonization in a context of high MRSA prevalence. IMPLICATIONS: The decision to pursue community-onset MRSA eradication treatment in the individual patient should be based on the combination of the treatment objective (short-term bacterial load reduction in health care settings vs. long-term eradication in community settings), and the likelihood of successful decolonization. The latter is influenced by both individual risk factors for treatment failure, and the risk of recolonization. The addition of a combination of systemic antibiotics is rational for extra-nasal long-term decolonization. To determine the most effective systemic antimicrobial agents in MRSA decolonization, more research is needed.

Convalescent Plasma in a Patient with Protracted COVID-19 and Secondary Hypogammaglobulinemia Due to Chronic Lymphocytic Leukemia: Buying Time to Develop Immunity?

It is not exactly clear yet which type of immune response prevails to accomplish viral clearance in coronavirus disease 2019 (COVID-19). Studying a patient with chronic lymphocytic leukemia and hypogammaglobulinemia who suffered from COVID-19 provided insight in the immunological responses after treatment with COVID-19 convalescent plasma (CCP). Treatment consisted of oxygen, repeated glucocorticosteroids and multiple dosages of CCP guided by antibody levels. Retrospectively performed humoral and cellular immunity analysis made clear that not every serological test for COVID-19 is appropriate for follow-up of sufficient neutralizing antibodies after CCP. In retrospect, we think that CCP merely bought time for this patient to develop an adequate cellular immune response which led to viral clearance and ultimately clinical recovery.

[Adults with chickenpox in the tropics]. / Volwassenen met waterpokken in de tropen.

In our hospital in the Dutch Caribbean, it is not uncommon for adults to be admitted for chickenpox infection. In contrast to the situation in temperate climates, not all adults are infected during childhood. Therefore, hospital staff are tested when first employed; of those aged between 20-29 years, 40% do not have antibodies against the varicella-zoster virus (VZV). We describe three cases of adults, aged 37, 51 and 90 years respectively, who presented with chickenpox. Compared to children, the clinical course in adults is more severe with the potential risk of life-threatening complications. In pregnancy or concomitant T cell immune deficiency, risk of a fulminant course is even higher. Treatment with aciclovir or valaciclovir is effective and associated with few side-effects. Passive immunization with VZV-immunoglobulin is indicated within 96 hours of exposure, typically followed by acyclovir or valaciclovir. As migration occurs from low endemic tropical areas to high endemic temperate areas, we should be aware of the risk of adult chickenpox in these migrants.