RESUMO
OBJECTIVES: Persons with opioid use disorder (OUD) suffer disproportionately from morbidity and mortality related to serious addiction-related infections requiring hospitalization. Long-acting buprenorphine (LAB) is an underused medication for OUD that may facilitate linkage to care and treatment retention when administered before hospital discharge. Transition onto buprenorphine in the inpatient setting is often complicated by pain, active infection management, potential surgical interventions, and risk of opioid withdrawal in transition from full agonists to a partial agonist. METHODS: The COMMIT Trial is a randomized controlled trial evaluating LAB administered by infectious disease physicians and hospitalists compared with treatment as usual for persons with OUD hospitalized with infections. We report a case series of participants on full agonist opioids including methadone who were transitioned to sublingual buprenorphine using low-dose ( microdosing ) strategies followed by LAB injection. RESULTS: Seven participants with current opioid use disorder and life-threatening infections, all with significant concurrent pain and many requiring surgical intervention, underwent low-dose transitions starting at buccal buprenorphine doses ranging from 225 µg to 300 µg 3 times a day on the first day. All were well tolerated with average time to LAB injection of 7.5 days (range, 5-10 days). CONCLUSIONS: Inpatient low-dose buprenorphine transition from full agonist opioids including methadone onto LAB is feasible even in those with complex hospitalizations for concurrent infections and/or surgery. This strategy facilitates dosing of LAB before hospital discharge when risk of opioid relapse and overdose are significant.
Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Humanos , Analgésicos Opioides , Buprenorfina/uso terapêutico , Pacientes Internados , Metadona , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Dor/tratamento farmacológicoRESUMO
We present the case of a 19-year-old man with an open fracture of the tibia and fibula secondary to an accident with an all-terrain vehicle. He underwent operative excisional irrigation, debridement, and fixation on the day of injury. His course was complicated by nonunion of the tibia fracture. Infection is a common factor in fracture nonunion, even in patients who receive appropriate surgical and antimicrobial management. Paenibacillus turicensis, an organism adapted to survive in the environment via spore formation, was responsible for nonunion in our patient. A brief discussion of this unusual organism, fracture nonunion, and the role of infection in etiology of nonunion follows.
RESUMO
BACKGROUND: Hospitalization with co-occurring opioid use disorder (OUD) and infections presents a critical time to intervene to improve outcomes for these intertwined epidemics that are typically managed separately. A surge in life-threatening infectious diseases associated with injection drug use, including bacterial and fungal infections, HIV, and HCV accounts for substantial healthcare utilization, morbidity, and mortality. Infectious Disease (ID) specialists manage severe infections that require hospitalization and are a logical resource to engage patients in medication treatment for OUD (MOUD). An injectable long-acting monthly formulation of buprenorphine (LAB) has a potential advantage for initiating MOUD within hospital settings and bridging to treatment after discharge. METHODS: A randomized multi-site trial tests a new model of care (ID/LAB) in which OUD and infections are managed by ID specialists and hospitalists using LAB coupled with referrals to community resources for long-term MOUD. A sample of 200 adults admitted to three U.S. hospitals for OUD and infections are randomly assigned 1:1 to ID/LAB or treatment as usual (TAU). The primary outcome measure is the proportion of patients enrolled in effective MOUD at 12 weeks after randomization. Secondary outcomes include relapse to opioid use, adherence to infectious disease treatment, infection morbidity and mortality, and drug overdose. RESULTS: We describe the design, procedures, statistical analysis, and early implementation issues of this randomized trial. CONCLUSIONS: Study findings will provide insight into the feasibility and effectiveness of integrated treatment of OUD and serious infections and have the potential to reduce morbidity and mortality in this vulnerable population.
Assuntos
Buprenorfina , Prestação Integrada de Cuidados de Saúde , Transtornos Relacionados ao Uso de Opioides , Adulto , Buprenorfina/uso terapêutico , Humanos , Recidiva Local de Neoplasia , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológicoRESUMO
CASE: We describe the case of an 85-year-old woman who presented with worsening right hip pain after a conversion hip replacement. Subsequent imaging demonstrated a gas-containing collection in the lateral thigh. She was taken to the operating room for irrigation and debridement, where intraoperative cultures returned positive for Clostridium difficile. Surgical management was followed by a prolonged course of antibiotics. CONCLUSIONS: Clostridium difficile as the etiology of infection in a conversion arthroplasty is exceedingly rare. Orthopaedic surgeons and infectious disease specialists should consider C. diff as a potential cause of infection in conversion hip arthroplasty because management options will need to be tailored.
Assuntos
Artroplastia de Quadril/efeitos adversos , Clostridioides difficile/isolamento & purificação , Infecções por Clostridium/etiologia , Infecção da Ferida Cirúrgica/microbiologia , Idoso de 80 Anos ou mais , Infecções por Clostridium/diagnóstico por imagem , Infecções por Clostridium/cirurgia , Feminino , Fraturas do Quadril/cirurgia , Humanos , Infecção da Ferida Cirúrgica/diagnóstico por imagem , Infecção da Ferida Cirúrgica/cirurgiaRESUMO
Open fractures are often associated with high-energy trauma and have an increased risk of infection because of surrounding soft-tissue damage and the introduction of environmental contaminants that may communicate with the fracture site. The Gustilo-Anderson classification of open fractures has been used to guide prophylactic antibiotic therapy because different types of open fracture have been shown to have varying rates of surgical site infections with different combinations of pathogens. Prophylactic treatment with various classes of antibiotics, including penicillins and cephalosporins, aminoglycosides, and fluoroquinolones, has evolved over the past half century. More recently, broader spectrum agents including monobactams and glycopeptides have been used for additional coverage. Duration of antibiotic therapy remains variable between institutions, and antibiotic choice is not standardized. Coverage for nosocomial and multidrug-resistant organisms is an ongoing area of clinical research.
Assuntos
Antibacterianos/classificação , Antibioticoprofilaxia , Fraturas Expostas/complicações , Infecção dos Ferimentos/etiologia , Infecção dos Ferimentos/prevenção & controle , Antibacterianos/administração & dosagem , Infecção Hospitalar/etiologia , Infecção Hospitalar/microbiologia , Infecção Hospitalar/prevenção & controle , Farmacorresistência Bacteriana , Resistência a Múltiplos Medicamentos , Humanos , Infecção dos Ferimentos/microbiologiaRESUMO
CASE: We describe a case of septic hip arthritis and enterocutaneous fistula formation caused by the seeding of a hip joint during hip arthroscopy performed in the setting of a psoas abscess. Treatment consisted of multiple debridements and femoral head resection with subsequent total hip arthroplasty. CONCLUSIONS: This case highlights the importance of a thorough history, physical examination, and assessment of available imaging before proceeding to surgery, even when the procedure is one considered to have minimal risks, such as arthroscopy.
Assuntos
Artrite Infecciosa/etiologia , Artroscopia/efeitos adversos , Doença de Crohn/complicações , Fístula Intestinal/complicações , Complicações Pós-Operatórias/etiologia , Abscesso do Psoas/complicações , Adulto , Artrite Infecciosa/diagnóstico por imagem , Erros de Diagnóstico , Articulação do Quadril/diagnóstico por imagem , Articulação do Quadril/cirurgia , Humanos , Fístula Intestinal/diagnóstico por imagem , Imageamento por Ressonância Magnética , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Abscesso do Psoas/diagnóstico por imagem , RadiografiaAssuntos
Exantema/fisiopatologia , Exantema/terapia , Traumatismos dos Dedos/fisiopatologia , Traumatismos dos Dedos/terapia , Manejo da Dor/normas , Dor/tratamento farmacológico , Guias de Prática Clínica como Assunto , Matadouros , Exantema/diagnóstico , Traumatismos dos Dedos/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Dor/diagnósticoAssuntos
Fixação Interna de Fraturas/efeitos adversos , Fusariose/microbiologia , Fusarium/isolamento & purificação , Fixadores Internos/microbiologia , Osteomielite/microbiologia , Antifúngicos/uso terapêutico , Fusarium/classificação , Humanos , Imunocompetência , Masculino , Pessoa de Meia-Idade , Osteomielite/tratamento farmacológico , Osteomielite/cirurgia , Voriconazol/uso terapêuticoRESUMO
BACKGROUND: Early postoperative infection (EPI) following hardware placement in patients with malleolar fractures is a serious complication. Identifying factors that place patients at risk for early infection may help target interventions to prevent infections. METHODS: Data for the study included all adult patients who underwent operative management for closed malleolar fracture from 2006 to 2013 in the National Surgical Quality Improvement Program database. Characteristics of patients with and without EPI were compared using univariate tests. Logistic regression was used to perform a multivariable analysis of risk factors for EPI while controlling for covariates. Length of stay was analyzed using a generalized linear model. RESULTS: The analysis sample included 7054 patients, of whom 116 developed EPI. Patients with EPI were slightly older on average, more likely to have diabetes, and had higher anesthesia class. Multivariable analysis identified several risk factors for EPI, including diabetes (odds ratio [OR] = 2.6; 95% CI = 1.5-4.5; P < .0001), American Society of Anaesthesiology (ASA) class 3+ (OR = 2.3; 95% CI = 1.03-5.0; P = .04), unclean surgery (OR = 2.4; 95% CI = 1.3-4.2; P < .0001), and inpatient location (OR 1.7, 1.1-2.7; P = .01). After controlling for other factors, EPI was not significantly associated with a longer hospital stay (0.2 days, P = .55). CONCLUSION: In the 30 days after hardware placement for malleolar fracture, infection occurs with increased frequency in older patients, diabetics, those with higher anesthesia class, and in the setting of unclean surgery and inpatient operative location. Patients with the identified risk factors should be followed closely for development of infection. LEVELS OF EVIDENCE: Level III: Retrospective cohort study.
Assuntos
Fraturas do Tornozelo/cirurgia , Fixação Interna de Fraturas/efeitos adversos , Consolidação da Fratura/fisiologia , Infecção da Ferida Cirúrgica/terapia , Adolescente , Adulto , Idoso , Fraturas do Tornozelo/diagnóstico por imagem , Antibacterianos/uso terapêutico , Estudos de Coortes , Bases de Dados Factuais , Drenagem/métodos , Feminino , Seguimentos , Fixação Interna de Fraturas/métodos , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/tratamento farmacológico , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/diagnóstico , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
Fibrosing mediastinitis (FM), also known as granulomatous or sclerosing mediastinitis, is an uncommon but serious cause of chest symptoms. Due to an infectious or inflammatory challenge, production of collagen occurs in the confined space of the mediastinum. Collagen formation leads to compression of vital structures, resulting in cough, chest pain and dyspnea. The majority of cases of FM occur as a result of prior exposure to Histoplasma capsulatum. The following is a case of a previously healthy young woman who presented with a 3-month history of cough, chest pain and trouble breathing, and was subsequently found to have fibrosing mediastinitis. Fibrosing mediastinitis should be considered in the differential diagnosis of cough, chest pain and dyspnea, primarily when findings such as increased venous pressure are present on physical exam and hilar abnormalities are seen on chest radiograph. Clinical presentation, diagnosis and management of fibrosing mediastinitis are discussed.