Executive summary: Guidelines for the diagnosis and treatment of septic arthritis in adults and children, developed by the GEIO (SEIMC), SEIP and SECOT / Resumen ejecutivo: Guía de diagnóstico y tratamiento de la artritis séptica en adultos y niños de GEIO (SEIMC), SEIP y SECOT

Infection of a native joint, commonly referred to as septic arthritis, is a medical emergency because of the risk of joint destruction and subsequent sequelae. Its diagnosis requires a high level of suspicion. These guidelines for the diagnosis and treatment of septic arthritis in children and adults are intended for use by any physician caring for patients with suspected or confirmed septic arthritis. They have been developed by a multidisciplinary panel with representatives from the Bone and Joint Infections Study Group (GEIO) belonging to the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Paediatric Infections (SEIP) and the Spanish Society of Orthopaedic Surgery and Traumatology (SECOT), and two rheumatologists. The recommendations are based on evidence derived from a systematic literature review and, failing that, on the opinion of the experts who prepared these guidelines. A detailed description of the background, methods, summary of evidence, the rationale supporting each recommendation, and gaps in knowledge can be found online in the complete document.(AU)

La infección de una articulación nativa, generalmente denominada artritis séptica, constituye una urgencia médica por el riesgo de destrucción articular y las consecuentes secuelas. Su diagnóstico requiere un alto nivel de sospecha. Esta guía de diagnóstico y tratamiento de la artritis séptica en niños y adultos está destinada a cualquier médico que atienda pacientes con sospecha de artritis séptica o artritis séptica confirmada. La guía ha sido elaborada por un panel multidisciplinar en el que están representados el Grupo de Estudio de Infecciones Osteoarticulares (GEIO) de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), la Sociedad Española de Infectología Pediátrica (SEIP) y la Sociedad Española de Cirugía Ortopédica y Traumatología (SECOT); además han participado dos reumatólogos. Las recomendaciones se basan en la evidencia proporcionada por una revisión sistemática de la literatura y, en su defecto, en la opinión de los expertos que han elaborado la presente guía. En el texto completo online se hace una descripción detallada de los antecedentes, métodos, resumen de la evidencia, fundamentos que apoyan cada recomendación y las lagunas de conocimiento existentes.(AU)

Timing of implant-removal in late acute periprosthetic joint infection: A multicenter observational study.

OBJECTIVES: We evaluated the treatment outcome in late acute (LA) periprosthetic joint infections (PJI) treated with debridement and implant retention (DAIR) versus implant removal. METHODS: In a large multicenter study, LA PJIs of the hip and knee were retrospectively evaluated. Failure was defined as: PJI related death, prosthesis removal or the need for suppressive antibiotic therapy. LA PJI was defined as acute symptoms <3 weeks in patients more than 3 months after the index surgery and with a history of normal joint function. RESULTS: 445 patients were included, comprising 340 cases treated with DAIR and 105 cases treated with implant removal (19% one-stage revision (n = 20), 74.3% two-stage revision (n = 78) and 6.7% definitive implant removal (n = 7). Overall failure in patients treated with DAIR was 45.0% (153/340) compared to 24.8% (26/105) for implant removal (p < 0.001). Difference in failure rate remained after 1:1 propensity-score matching. A preoperative CRIME80-score ≥3 (OR 2.9), PJI caused by S. aureus (OR 1.8) and implant retention (OR 3.1) were independent predictors for failure in the multivariate analysis. CONCLUSION: DAIR is a viable surgical treatment for most patients with LA PJI, but implant removal should be considered in a subset of patients, especially in those with a CRIME80-score ≥3.

Infección de prótesis articular por Peptostreptococcus canis y Bacteroides pyogenes / Peptostreptococcus canis and Bacteroides pyogenes prosthetic joint infection

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Clinical outcome and risk factors for failure in late acute prosthetic joint infections treated with debridement and implant retention.

OBJECTIVES: Debridement, antibiotics and implant retention (DAIR) is the recommended treatment for all acute prosthetic joint infections (PJI), but its efficacy in patients with late acute (LA) PJI is not well described. METHODS: Patients diagnosed with LA PJI between 2005 and 2015 were retrospectively evaluated. LA PJI was defined as the development of acute symptoms (≤ 3 weeks) occurring ≥ 3 months after arthroplasty. Failure was defined as: (i) the need for implant removal, (ii) infection related death, (iii) the need for suppressive antibiotic therapy and/or (iv) relapse or reinfection during follow-up. RESULTS: 340 patients from 27 centers were included. The overall failure rate was 45.0% (153/340). Failure was dominated by Staphylococcus aureus PJI (54.7%, 76/139). Significant independent preoperative risk factors for failure according to the multivariate analysis were: fracture as indication for the prosthesis (odds ratio (OR) 5.4), rheumatoid arthritis (OR 5.1), age above 80 years (OR 2.6), male gender (OR 2.0) and C-reactive protein > 150 mg/L (OR 2.0). Exchanging the mobile components during DAIR was the strongest predictor for treatment success (OR 0.35). CONCLUSION: LA PJIs have a high failure rate. Treatment strategies should be individualized according to patients' age, comorbidity, clinical presentation and microorganism causing the infection.

Infecciones relacionadas con las prótesis articulares: incidencia, factores de riesgo, características clínicas y pronóstico / Arthroplasty-related infection: incidence, risk factors, clinical features, and outcome

INTRODUCCIÓN. Existe escasa información acerca de la incidencia y factores de riesgo para las infecciones protésicas en España, así como sobre el tratamiento clínico global de estos pacientes. MÉTODOS. Estudio de incidencia de infección de localización quirúrgica (ILQ) en cirugía de prótesis de cadera y rodilla entre 2001 y 2005; estudio de factores de riesgo para ILQ mediante regresión logística multivariante en435 pacientes intervenidos. Descripción de una cohorte de 58 casos consecutivos de infección protésica. RESULTADOS. La incidencia de ILQ en función de los estratos del índice NNIS (National Nosocomial Infection Surveillance) en artroplastias de cadera y rodilla fue del1,86 y el 1,62% (NNIS 0); el 3,72 y el 2,02% (NNIS 1),y el 7,20 y el 6,71% (NNIS 2-3), respectivamente. Los factores de riesgo identificados para la ILQ fueron la artroplastia secundaria, la duración del sondaje urinario y la cirugía de la cadera. En la cohorte de casos de infección protésica, el 50% tenía infecciones tipo I (precoces) o III(hematógenas). Los cocos gram positivos fueron la causa más frecuente. El tratamiento quirúrgico inicial fue desbridamiento con conservación de la prótesis en 10 pacientes, retirada de ésta en 40 y no se intervinieron 8;al año de seguimiento habían curado 39 (67%), recidivado o en tratamiento supresor crónico estaban 12 (21%) y habían fallecido 7 (12%).CONCLUSIONES. La incidencia de infección protésica en nuestro país es similar a la de otros centros españoles, y superior a la del sistema NNIS. Hemos identificado un factor de riesgo de ILQ modificable (sondaje). Es deseable un mayor consenso para el tratamiento clínico de los pacientes(AU)

INTRODUCTION. There is little information about the overall incidence, risk factors, and clinical management of arthroplasty-related infection in Spain. METHODS. The incidence of surgical site infection (SSI)in hip and knee arthroplasty from 2001 to 2005 was determined. Risk factors for SSI were investigated in435 patients using multivariate logistic regression analysis. Clinical features and treatment were examined in a cohort of 58 consecutive patients with joint arthroplasty infection. RESULTS. The percentages of SSI in hip and knee arthroplastystratified according to the National Nosocomial Infection Surveillance (NNIS) index were 1.86% and 1.62%(NNIS 0), 3.72% and 2.02% (NNIS 1), and 7.20% and6.71% (NNIS 2-3), respectively. The risk factors identified for developing SSI included secondary arthroplasty, duration of urinary catheterization, and hip arthroplasty. Fifty percent of patients with arthroplasty infection had type I (early) or III (hematogenous) infection. Gram-positivecocci were the most frequent causes. Initial therapy consisted in debridement with preservation of the prosthesis (10 patients) or removal of the prosthesis(40 patients); surgery was not performed in 8 patients. After one year of follow up, 39 patients (67%) were considered cured, 12 (21%) had a recurrence or were under chronic suppressive antimicrobial therapy, and 7 (12%) had died. CONCLUSIONS. The incidence of SSI in our center is similar to that of other Spanish hospitals, but is higher than the notified incidence in the NNIS system. A modifiable risk factor (urinary catheterization) has been identified. Greater consensus for the management of these patientsis desirable (AU)

Seroprevalencia de infecciones por el virus del Nilo Occidental en la población general del sur de España / West Nile virus past infections in the general population of Southern Spain

Objective. To analyze the prevalence of past and recent infections by West Nile virus (WNV) and the risk factors associated with WNV exposure in a representative population from southern Spain. Methods. Sample size was established for an estimated prevalence of past WNV infections of 5 6 2.5% in 504 subjects. A pre-stratification was performed according to age distribution and place of residence. After random telephone solicitation and acquisition of informed consent, a serum sample was collected and an epidemiologic survey performed on all participating subjects. Samples were tested with ELISA-IgG and MAC-ELISA to detect specific IgG and IgM antibodies; results were confirmed by the plaque reduction neutralization test (PRNT). Multivariate analysis using a forward stepwise logistic regression model was performed to assess potential risk factors associated with WNV exposure. Results. Prevalence of past WNV infections confirmed by PRNT in the 504 participants was 0.6%, affecting mainly older persons (mean age 65 6 23 vs. 34 6 22 years; P 5 0.018), those living in rural areas (5.4% vs. 0% in urban areas; P 5 0.01), and individuals with risk professions (prevalence 2.8% vs. 0%; P 5 0.048). None of the five recent infections detected by MAC-ELISA was confirmed by PRNT. Conclusions. These results strongly suggest past circulation and exposure of the human population to WNV in southern Spain (AU)

Objetivo. Analizar la prevalencia de infecciones pasadas y recientes por el virus del Nilo Occidental (VNO), así como los factores de riesgo asociados con la exposición al mismo, en una muestra representativa de la población del sur de España. Métodos. El tamaño de la muestra se estableció para una seroprevalencia de infección pasada del 5 6 2,5% en 504 sujetos, preestratificándose ésta por edad y lugar de residencia. Los voluntarios se incluyeron tras solicitud telefónica y consentimiento, y a todos ellos se les realizó una extracción de suero y una encuesta epidemiológica. Las muestras se analizaron para detectar IgG e IgM específicas, mediante enzimoinmunoensayo (ELISA-IgG) y enzimoinmunoensayo por captura (MAC-ELISA), confirmando ulteriormente los resultados positivos mediantereducción-neutralización en placa (PRNT. Finalmente se realizó un análisis de regresión logística multivariante paso a paso hacia delante para determinar los posibles factores asociados con la exposición al VNO. Resultados. La prevalencia de infecciones por VNO confirmadas por PRNT en los 504 sujetos incluidos fue del 0,6%, y se vieron principalmente afectadas las personas de mayor edad (edad media 65 6 23 frente a 34 6 22 años; p 5 0,018), las que vivían en áreas rurales (prevalencia del 5,4% frente al 0% en áreas urbanas; p 5 0,01), y las personas con profesiones de riesgo (prevalencia del 2,8% frente al 0%; p 5 0,048). Por el contrario, ninguna de las infecciones recientes detectadas por MAC-ELISA fue confirmada ulteriormente por PRNT. Conclusiones. Estos resultados apoyan firmemente la circulación en el pasado del VNO, así como la exposición humana del mismo, en áreas del sur de España (AU)

Características epidemiológicas, clínicas y pronósticas de la infección por Stenotrophomonas maltophilia / Epidemiology, clinical features and prognosis of infections due to Stenotrophomonas maltophilia

Introducción. Stenotrophomonas maltophilia es un patógeno multirresistente que se está aislando con frecuencia creciente de pacientes predispuestos. Hay pocos estudios que hayan evaluado su epidemiología y relevancia clínica en pacientes de un hospital general. Métodos. Estudio prospectivo de la cohorte de casos de infección por S. maltophilia entre enero de 1998 y enero de 2001 en el Hospital Universitario Virgen Macarena de Sevilla. Se recogieron variables demográficas, enfermedades de base, gravedad al ingreso (índice APACHE II), procedimientos invasivos, uso previo de antimicrobianos, repercusión sistémica, tratamiento y mortalidad. Resultados. S. maltophilia se aisló en muestras clínicas de 87 pacientes, de los cuales se incluyeron los 45 casos (52%) en los que se consideró que estaba causando infección. El 40% estaba en unidad de cuidados intensivos (UCI) y el 13% eran ambulatorios. La infección se consideró asociada a la atención sanitaria en el 91%. El 82% habían recibido antibióticos. El tipo de infección más frecuente fue la neumonía seguida de otras infecciones respiratorias, urinarias y de piel y tejidos blandos. Presentaron sepsis grave o shock séptico el 12%. El tratamiento antimicrobiano más utilizado fue trimetoprima-sulfametoxazol (60%). La mortalidad bruta fue del 44%; el único factor asociado a la mortalidad bruta fue el índice APACHE II. La mortalidad atribuible a la infección fue del 13%, y sólo ocurrió en pacientes con neumonía. Conclusión. S. maltophilia causa un amplio espectro de infecciones asociadas a la atención sanitaria en pacientes predispuestos, aunque la mitad de los pacientes en que se aisló se consideraron sólo colonizados. La mortalidad bruta se asocia con la gravedad basal. La neumonía se asocia con elevada mortalidad (AU)

Introduction. Stenotrophomonas maltophilia is a multiresistant pathogen that is being isolated with increasing frequency from patients with predisposing factors. Few studies have assessed the epidemiology and clinical relevance of this pathogen in various types of patients from general hospitals. Methods. This is a prospective study performed in the cohort of patients with infection due to S. maltophilia in Hospital Univeritario Virgen Macarena (Seville, Spain) between January 1998 and January 2001. The following data were collected: demographics, underlying diseases, APACHE II score at admission, invasive procedures, previous antimicrobial treatment, systemic response, therapy and outcome. Results. S. maltophilia was isolated from a clinical sample in 87 patients and was considered to be the cause of infection in 45 (52%) of them, who were included in the study. Among the total, 40% were in the ICU and 13% were outpatients. The infection was considered health care-associated in 91%; 82% had received antimicrobial treatment. The most frequent type of infection was pneumonia, followed by other infections of the respiratory tract, urinary tract infections, and skin and soft tissue infections. Criteria for severe sepsis or septic shock were present in 12%. The most common antimicrobials used were the combination trimethoprim-sulfamethoxazole (60%). Crude mortality was 44% and the only associated variable was the APACHE II score. Infection-related mortality was 13%; all deaths occurred in patients with pneumonia. Conclusion. S. maltophilia caused a wide range of health care-associated infections in debilitated patients, even though half the patients from whom the organism was isolated were considered only colonized. Crude mortality was associated with the severity of the baseline situation. Pneumonia was associated with high mortality (AU)