Recommendations for the Prevention and Management of Deep Brain Stimulation Infections Based on 26-Year Single-Center Experience.

INTRODUCTION: Infections related to deep brain stimulation (DBS) can lead to discontinuation of the treatment and increased morbidity. Various measures of reducing infection rates have been proposed in the literature, but scientific consensus is lacking. The aim of this study was to report a 26-year single center experience of DBS infections and provide recommendations for the prevention and management of them. METHODS: The retrospective analysis consisted of 978 DBS surgeries performed at Oulu University Hospital (OUH) from 1997 to 2022. This included 342 primary or reimplantations of DBS electrodes and 559 primary or reimplantations of implantable pulse generator (IPG). Infections within approximately 1 year after the surgery without secondary cause were considered surgical-site infections (SSIs). χ2 test was used to compare infection rates before and after 2013, when the systematic implementation of infection prevention measures was started. RESULTS: A total of 35 DBS implants were found to be infected. The number of SSIs was 30, of which 29 were originally operated in OUH leading to a center-specific infection rate of 3.1%. Of the SSIs, 17.2% occurred after IPG replacement. Staphylococcus aureus was found in 75.0% of cultures and 32.1% were mixed infections. The treatment of SSIs included aggressive surgical revision combined with cefuroxime and vancomycin antibiotics, as most patients in the initial conservative treatment group eventually required surgical revision. A statistically significant difference in infection rates before and after the implementation of preventative measures was not observed (risk ratio 2.20, 95% confidence interval 0.94-5.75, p = 0.051), despite over two-fold difference in the incidence of SSIs. CONCLUSION: Our findings show that the rates of surgical infections are low in modern DBS, but due to their serious consequences, preventative measures should be implemented. We highlight that mixed infections should be accounted for in the antibiotic selection. Furthermore, our treatment recommendation includes aggressive surgical revision combined with antibiotic treatment.

Positive Francisella tularensis meningitis outcome despite delayed identification: a case report.

Francisella tularensis is a Gram-negative bacteria, that may cause a zoonotic disease, tularemia. Here, we describe a patient case, where a previously healthy young woman in Northern Finland contacted health care because of fever and headache. Due to the symptoms and lack of further diagnostic tools in primary health care, she was transferred to University Hospital (UH) where ampicillin and ceftriaxone was given empirically. A cerebrospinal fluid sample (CSF) was drawn showing small Gram-negative rods that grew on chocolate agar after 2 days of incubation. Matrix-assisted laser-desorption-ionization time of-flight (Maldi-tof) did not provide identification, but the bacteria was interpreted as sensitive to ciprofloxacin and the treatment was changed to ciprofloxacin. During the time the patient was infected, there were several positive tularemia samples found in the area. Therefore, an in house tularemia nucleic acid method (PCR) was used on the bacterial culture. Additionally, 16S rDNA sequencing was performed and these methods identified the bacteria as F. tularensis. Fortunately, the patient recovered completely with ciprofloxacin and was discharged without any complications. Our case underlines the need to understand the limits of specific diagnostic methods, such as Maldi-tof, used in clinical laboratory settings. It also highlights the need of both clinicians and laboratory staff to be aware of the many clinical presentations of tularemia when working in an endemic area.

Tracing local and regional clusters of carbapenemase-producing Klebsiella pneumoniae ST512 with whole genome sequencing, Finland, 2013 to 2018.

BackgroundTwo epidemiologically-unrelated clusters of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae were detected among several healthcare facilities (HCF) in Finland by routine surveillance using whole genome sequencing (WGS).AimThe objective was to investigate transmission chains to stop further spread of the responsible strain.MethodsIn this observational retrospective study, cases were defined as patients with K. pneumoniae KPC-3 sequence type (ST)512 strain detected in Finland from August 2013 to May 2018. Environmental specimens were obtained from surfaces, sinks and toilets in affected wards. WGS was performed on K. pneumoniae cultures using Illumina MiSeq platform and data were analysed using Ridom SeqShere software K. pneumoniae core genome multilocus sequence typing (cgMLST) scheme. Epidemiological information of the cases was provided by HCFs.ResultsWe identified 20 cases in six HCFs: cluster 1 included 18 cases in five HCFs and cluster 2 two cases in one HCF. In cluster 1, a link with a foreign country was unclear, 6/18 cases without overlapping stay had occupied the same room in one of the five HCFs within > 3 years. In cluster 2, the index case was transferred from abroad, both cases occupied the same room 8 months apart. A strain identical to that of the two cases in cgMLST was isolated from the toilet of the room, suggesting a clonal origin.ConclusionsThe clusters were mostly related to case transfer between facilities and likely involved environmental transmission. We show that CPE surveillance using WGS and collaboration between hospitals are crucial to identify clusters and trace transmission chains.

Infection triples the cost of a primary joint arthroplasty.

BACKGROUND: In Europe few studies have analyzed the costs of treating aseptic revisions and prosthetic joint infections with either debridement, antibiotics and implant retention or two-stage revision, as compared to the cost of a primary total joint arthroplasty. METHODS: The purpose was to analyze the costs of total joint arthroplasties, aseptic revisions and prosthetic joint infections treated with debridement, antibiotics and implant retention or a two-stage revision. We conducted a retrospective cohort study of patients who had a total joint arthroplasty in the Oulu University Hospital during the three-year period from 2013 to 2015. The costs were divided to specific services (e.g. procedure costs, ward care costs, laboratory). Actual costs obtained from the hospital's financial database were used for analysis. RESULTS: There were 1708 total joint arthroplasties without complications, 18 aseptic revisions and 42 prosthetic joint infections eligible for analysis. The mean cost of a total joint arthroplasty was €7200, the excess cost of an aseptic revision was €10,900 and the excess cost of a prosthetic joint infection was €18,900 (total joint arthroplasty vs. infection, p < .0001). The excess cost was €12,800 for debridement, antibiotics and implant retention treatment and €44,600 for a two-stage revision (p < .0001). The two most expensive services were ward care and procedures. CONCLUSIONS: Infection tripled the cost of a total joint arthroplasty. The cost of two-stage revisions were triple that of debridement, antibiotics and implant retention treatment.

Adherence to hand hygiene guidelines - significance of measuring fidelity.

AIMS AND OBJECTIVES: The aim was to evaluate the usability of fidelity measures in compliance evaluation of hand hygiene. BACKGROUND: Adherence to hand hygiene guidelines is important in terms of patient safety. Compliance measures seldom describe how exactly the guidelines are followed. DESIGN AND METHODS: A cross-sectional observation study in a university hospital setting was conducted. Direct observation by trained staff was performed using a standardised observation form supplemented by fidelity criteria. A total of 830 occasions were observed in 13 units. Descriptive statistics (frequency, mean, percentages and range) were used as well as compliance rate by using a standard web-based tool. In addition, the binomial standard normal deviate test was conducted for comparing different methods used in evaluation of hand hygiene and in comparison between professional groups. RESULTS: Measuring fidelity to guidelines was revealed to be useful in uncovering gaps in hand hygiene practices. The main gap related to too short duration of hand rubbing. Thus, although compliance with hand hygiene guidelines measured using a standard web-based tool was satisfactory, the degree of how exactly the guidelines were followed seemed to be critical. CONCLUSIONS: Combining the measurement of fidelity to guidelines with the compliance rate is beneficial in revealing inconsistency between optimal and actual hand hygiene behaviour. RELEVANCE TO CLINICAL PRACTICE: Evaluating fidelity measures is useful in terms of revealing the gaps between optimal and actual performance in hand hygiene. Fidelity measures are suitable in different healthcare contexts and easy to measure according to the relevant indicators of fidelity, such as the length of hand rubbing. Knowing the gap facilitates improvements in clinical practice.

Predictors of treatment outcome in prosthetic joint infections treated with prosthesis retention.

PURPOSE: The reported success rates of debridement, antibiotics, and implant retention (DAIR) for prosthetic joint infections (PJIs) vary widely. Several risk factors have been described for treatment failure, but they vary between studies. The purpose of this study was to evaluate the predictors of DAIR failure in PJI treatment and to assess the efficacy of rifampin combined with ciprofloxacin versus rifampin combined with other antibiotics in staphylococcal PJIs. METHODS: Patients with PJI that underwent DAIR for the first time between February 2001 and August 2009 were identified retrospectively in the hospital's patient databases. A total of 113 PJI cases with early postoperative or acute haematogenous PJI were followed for up to two years from the start of treatment. RESULTS: In univariate analysis, variables significantly associated with treatment failure were acute haematogenous infections (p = 0.022), leucocyte count at admission > 10 × 10(9)/l (p < 0.01), pain in the joint (p < 0.01), and ineffective empirical antibiotics (p < 0.01). In a multivariate Cox model, leucocyte count > 10 × 10(9)/l and ineffective empirical antibiotics were significant risk factors for failure. Compared to rifampin-ciprofloxacin, the hazard ratio (HR) for treatment failure was significantly increased in the rifampin-other antibiotics group (HR 6.0, 95% CI 1.5-28.8, p = 0.014) and the group treated without rifampin (HR 14.4, 95% CI 3.1-66.9, p < 0.01). CONCLUSIONS: Rifampin-ciprofloxacin combination therapy was significantly more effective than rifampin combined with other antibiotics. Effective empirical antibiotics are essential for successful PJI treatment.

Two-stage revision for prosthetic joint infection: outcome and role of reimplantation microbiology in 107 cases.

Two-stage revision is widely used for the treatment of prosthetic joint infections. However, the duration of antibiotic treatment between stages and role of reimplantation microbiology are controversial. The purpose of this study was to evaluate the outcome and influence of the reimplantation microbiology of two-staged revisions with 6 weeks of antibiotic treatment. We retrospectively reviewed 107 patients treated with two-stage revision between 2001 and 2009. The overall treatment success rate was 94.4%. The reimplantation cultures were positive in 5/97 (5.2%) cases, and only one of them failed. Therefore, we achieved excellent results with a 6-week course of antibiotics between stages in two-stage revision. Positive reimplantation cultures do not seem to be associated with worse outcomes.