Distribution of Underlying Causative Organisms, Patient Age, and Survival in Spontaneous spondylodiscitis with Special Focus on Elderly Patients

Background and Objective spondylodiscitis is becoming a more frequently encountered diagnosis in our clinical practice. Multimorbid and especially older patients build up a relevant portion of cases. The goal of our study was to evaluate our clinical data and to reveal specifics concerning elderly patients with spontaneous spondylodiscitis. Patients and Methods We retrospectively analyzed clinical data for the years from 2012 to 2014. The search was conducted on the basis of the International Classification of Diseases, 10th Revision (ICD-10) diagnoses for spondylodiscitis. Postoperative infections were not included in this study. All cases were evaluated in terms of infectious agents (in blood culture and/or computerized tomography [CT]-guided or surgical biopsy), age, and overall survival. Results Fifty-one patients with spontaneous spondylodiscitis were identified. The most frequent pathogen was methicillin-sensitive Staphylococcus aureus (MSSA; n = 21; 41.17%). Escherichia coli and S. epidermidis were each found in four patients each (7.84%). Methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa, and S. hominis were found in three cases (5.88%). Other bacteria were found in one case (each 1.96 %). In 12 cases, there was no bacteria growth (23.53%). One of these patients revealed to have a tuberculosis infection, diagnosed after the study period (in 2015). Two-thirds of the patients were ≥65 years old (n = 34). All three patients with MRSA were >65 years old. Three of seven patients <50 years had IV drug abuse (42.86%). In these patients, rather rare infectious agents for spondylodiscitis were found (P. aeruginosa, S. hominis, Citrobacter). Mortality was 7.84% (n = 4). All of these patients were ≥67 years old, three of four (75%) were ≥75 years old. Conclusion Our study of spontaneous spondylodiscitis showed a stronger representation of older patients (>65 years). Lethal outcome exclusively concerned the older age group. S. aureus was the most frequent pathogen as shown previously. MRSA infections might be more common in the older age group. Rare causative organisms mainly occurred in patients with iv drug abuse. Further evaluation through randomized multicenter studies focusing on the different subgroups and comorbidities in larger populations and correlation with appropriate treatment options is necessary.

P1299 Right sided infective endocarditis with paradoxical embolization

Background Right sided infective endocarditis (IE) accounts for 5-10% of IE cases, systemic embolization is uncommon and if present it is linked to the presence of shunt or concomitant left sided IE. Clinical presentation A 35-years old gentleman with history of heroin intravenous drug abuse (IV), presented with a history of unexplained fever for two weeks along with exertional dyspnea, productive cough, chest pain and severe left hypochondria pain. On examination he had a blood pressure of 130/80 mmHg, a heart rate of 130 bpm, a temperature of 40oC, elevated jugular venous pressure and a harsh pansystolic murmur over the lower left sternal border. Laboratory results revealed anaemia, leukocytosis elevated ESR and CRP and blood cultures were positive for methicillin-resistant staphylococcus aureus (MRSA), electrocardiography showed sinus tachycardia and abdomen computed tomography scan revealed multiple splenic infarctions. Methods and results 2D&3DTrans-Thoracic Echocardiography (TTE) revealed the presence of an echogenic elongated highly mobile mass measures 2.0 cm in maximum dimension attached to the atrial surface of the anterior tricuspid valve leaflet a long with severe valvular regurgitation. Patent foramen ovale (PFO) was visualized by Color Doppler and right to left shunt was confirmed by contrast study with a complete opacification of the left side. The left ventricle dimensions were normal , there was an evidence of hyokinesis of inter-ventricular septum (IVS) and inferior wall and function was reduced, estimated LVEF = 45%. Hence, coronary angiography was done and revealed normal coronaries. 3D Trans-esophageal Echocardiography(TEE) was done for better visualization of the interatrial septum (IAS), vegetation and to rule out complications. The study confirmed the presence of PFO, there was no concomitant IAS defects, the vegetation is highly mobile and facing the IAS. Accordingly, patient was diagnosed with tricuspid infective endocarditis complicated with paradoxical embolization, anti-biotics were commenced and patient underwent successful tricuspid valve replacement and PFO closure. Discussion Tricuspid valve endocarditis has been linked to IV drug abuse and staphylococcus aureus has been recognized as the most commonly implicated organism. While systemic emboli are rare in right sided IE, our patient represent this uncommon complication. He had multiple splenic infractions and TTE contrast study showed PFO with a high degree of right to left shunt. Coronary embolization was a suspect in our patient as well given the presence of regional wall motion abnormalities involving the left ventricle inferior wall and IVS. Conclusion Echocardiography is a crucial imaging modality in patient with long standing fever and history of IV drug abuse to rule out infective endocarditis. 3D-TEE is of added value along with TTE in better definition of vegetations and detection of infective endocarditis complication. Abstract P1299 Figure. Tricuspid valve infective endocarditis

Routine screening for hepatitis C viral infection in patients undergoing elective cranial neurosurgery

OBJECTIVEUndiagnosed hepatitis C virus (HCV) and HIV in patients present risks of transmission of bloodborne infections to surgeons intraoperatively. Presurgical screening has been suggested as a protocol to protect surgical staff from these pathogens. The authors sought to determine the incidence of HCV and HIV infection in elective craniotomy patients and analyze the cost-effectiveness of universal and risk factor–specific screening for protection of the surgical staff.METHODSAll patients undergoing elective craniotomy between July 2009 and July 2016 at the National Brain Aneurysm Center who did not refuse screening were included in this study. The authors utilized rapid HCV and HIV tests to screen patients prior to elective surgery, and for each patient who tested positive using the rapid HCV or HIV test, qualitative nucleic acid testing was used to confirm active viral load, and risk factor information was collected. Patients scheduled for nonurgent surgery who were found to be HCV positive were referred to a hepatologist for preoperative treatment. The authors compared risk factors between patients who tested positive on rapid tests, patients with active viral loads, and a random sample of patients who tested negative. The authors also tracked the clinical and material costs of HCV and HIV rapid test screening per patient for cost-effectiveness analysis and calculated the cost per positive result of screening all patients and of screening based on all patient risk factors that differed significantly between patients with and those without positive HCV test results.RESULTSThe study population of patients scheduled for elective craniotomy included 1461 patients, of whom 22 (1.5%) refused the screening. Of the 1439 patients screened, 15 (1.0%) tested positive for HCV using rapid HCV screening; 9 (60%) of these patients had active viral loads. No patient (0%) tested positive for HIV. Seven (77.8%) of the 9 patients with active viral loads underwent treatment with a hepatologist and were referred back for surgery 3–6 months after sustained virologic response to treatment, but the remaining 2 patients (22.2%) required urgent surgery. Of the 9 patients with active viral loads, 1 patient (11%) had a history of both intravenous drug abuse and tattoos. Two of the 9 patients (22%) had tattoos, and 3 (33%) were born within the age-screening bracket (born 1945–1965) recommended by the Centers for Disease Control and Prevention. Rates of smoking differed significantly (p < 0.001) between patients who had active viral loads of HCV and patients who were HCV negative, and rates of smoking (p < 0.001) and IV drug abuse (p < 0.01) differed significantly between patients who were HCV rapid-test positive and those who were HCV negative. Total screening costs (95% CI) per positive result were $3,877.33 ($2,348.05–$11,119.28) for all patients undergoing HCV rapid screening, $226.29 ($93.54–$312.68) for patients with a history of smoking, and $72.00 ($29.15–$619.39) for patients with a history of IV drug abuse.CONCLUSIONSThe rate of undiagnosed HCV infection in this patient population was commensurate with national levels. While the cost of universal screening was considerable, screening patients based on a history of smoking or IV drug abuse would likely reduce costs per positive result greatly and potentially provide cost-effective identification and treatment of HCV patients and surgical staff protection. HIV screening found no infected patients and was not cost-effective.

A Rare Culprit of Infective Endocarditis in an IV Drug User: Burkholderia cepacia

Infective endocarditis (IE) is an infection of the cardiac native or prosthetic valves typically caused by Staphylococcus aureus, viridans streptococci group, and coagulase-negative staphylococci. Risk factors include congenital heart disease, structural and valvular heart disease, implantation of prosthetic heart valves, and intravenous (IV) drug abuse. IE caused by organisms such as Burkholderia cepacia is rarely seen. We herein present a case of a patient with a history of IV drug abuse previously treated for Staphylococcus aureus IE with newly diagnosed IE secondary to B. cepacia. He was taken to the operating room for mitral valve replacement after an echocardiogram revealed severe mitral regurgitation. He was successfully treated with antibiotics. After 2 months, at follow-up, the patient remained free from mechanical valve-related events, had no new occurrences of fever, and had no other symptoms of infection. He reported good exercise tolerance.

Unusual Case of Osteomyelitis and Discitis in a Drug User with a Background of Chronic Back Pain: Do Not Miss the Serious Etiologies

Chronic back pain is a common presenting complaint that is frequently encountered by clinicians. The challenge for clinicians is identifying the relatively few patients with a significant probability of a more serious problem that requires further evaluation. Such individuals require further evaluation for possible occult malignancy, infection, or fracture. We present a case of a 50-year-old male with a past medical history of chronic back pain and IV drug abuse who presented with acute back pain and in whom a diagnosis of vertebral osteomyelitis was missed during multiple visits to the emergency room.

PSEUDOANEURYSMS IN INTRAVENOUS DRUG ABUSERS

Background: Intravenous drug abuse can lead to vascular complications, most frequent of which is pseudoaneurysm. Thesepseudoaneurysms (false aneurysms) are prone to rupture, leading to profuse hemorrhage and death. Objective: To evaluatepseudoaneurysms in intravenous drug addicts for the site, mode of presentation, management and outcome. Design: Descriptive study.Place and duration of study: Surgical unit I, Combined Military Hospital, Rawalpindi. Surgical unit 2, Combined Military Hospital, Lahore.January 2006 to September 2010. Subjects and methods: All cases of pseudoaneurysms in intravenous drug addicts who presented to asingle vascular surgeon, between 1st January 2006 and 30th September 2010, were evaluated for site, mode of presentation, treatment andthe outcome. Surgical procedures included excision of pseudoaneurysm with interpositioning of graft, repair of vascular rent, ligation of vesseland debridement. All cases were referred to psychiatrist for management of drug addiction. Results: Total 12 cases of pseudoaneurysms dueto IV drug abuse were included in our study. Arteries affected included 9(75%) common femoral arteries (CFA). In 3(25%) cases, both commonfemoral artery and vein were involved with arteriovenous fistula between them. There was 1(8.3%) pseudoaneurysm each of external iliacartery, superficial femoral artery and brachial artery. Nine cases (75%) presented with recurrent hemorrhage from a swelling while in 3(25%)cases there was swelling with no history of hemorrhage. In 7(58.3%) cases, repair/grafting, while in 5(41.6%) cases ligation and debridementwas done. There was seroma formation in 1(8.3%) case after excision and grafting. In none of the cases, in which artery was ligated, critical limbischaemia occurred. Conclusions: Common femoral artery is the most frequent site of pseudoaneurysms in IV drug abuse. In those caseswhere vascular reconstruction is not possible due to extensive skin necrosis or infection, ligation of affected vessel is not only a life savingprocedure but a safe option also.

Demographic characteristics of IV drug abusers commencing treatment in opiate detoxification centers in Iran

IntroductionIV drug abuse is a medical and social problem in countries all over the world including IranObjectivesKnowing about the characteristics of drug abuser could help policy makers to have more precise plan of action for prevention and management of addictionAimsThis study was designed to investigate the demographic characteristics of IV drug abusers in Iran and determining the risk factors for shifting to IV drug abuse.Methods150 intravenous drug addicts (147 males and 3 females) aged 19–61 referred to opiate detoxification centers in Yazd city in autumn 2008 were randomly enrolled to this descriptive cross sectional study. Data collection was undertaken through a structured interview, a questionnaire for demographic data and written documents at detoxification centers. Analysis of data was done with SPSS software (version 13).ResultsThere was positive family history of addiction in 56.7%, known psychiatric illness in 43.3%, known physical disease in 32% and history of psychotropic medication abuse in 58% of participants. The mean age of onset in opium and its derivatives abusers was 19.12, heroin abusers 23.5 and IV bupropion abusers 27.2 years. The most common injecting drug at the time of study was heroin (65.2%).ConclusionFamily history of addiction, psychiatric disease, physical illness and low education could all be risk factors for exacerbating an addiction. Identification of these risk factors could lead to the development of interventions to reduce the burden of addiction. Further research about this subject is required to determine if this is true.