Case Report: Living on the Edge—Transcatheter Mitral Valve Repair Related Infective Endocarditis

Background: Infective endocarditis (IE) following mitral valve edge-to-edge repair is a rare complication with high mortality.Case summary: A 91-year-old male patient was admitted to intensive care unit with sepsis due to urinary tract infection after insertion of a urinary catheter by the outpatient urologist. Two weeks ago, the patient was discharged from hospital after successful transcatheter edge-to-edge mitral valve repair (TEER) using a PASCAL Ace device. The initially withdrawn blood revealed repeatedly Proteus mirabilis bacteremia as causal for the sepsis due to urinary tract infection. An antibiotic regime with Ampicillin/Sulbactam was initiated and discontinued after 7 days. During the clinical course the patient again developed fever and blood cultures again revealed P. mirabilis. In transesophageal echocardiography (TOE), IE of the PASCAL Ace device was confirmed by a vegetation accompanied by a mild to moderate mitral regurgitation. While the patient was stable at this time and deemed not suitable for cardiac surgery, the endocarditis team made a decision toward a prolonged 6-week antibiotic regime with an antibiotic combination of Ampicillin 2 g qds and Ciprofloxacin 750 mg td. Due to posterior leaflet perforation severe mitral regurgitation developed while PASCAL Ace vegetations were significantly reduced by the antibiotic therapy. Therefore, the patient underwent successful endoscopic mitral valve replacement. Another 4 weeks of antibiotic treatment with Ampicillin 2 g qds followed before the patient was discharged.Discussion:P. mirabilis is able to form biofilms, resulting in a high risk for endocarditis following transcatheter mitral valve repair especially when device endothelization is incomplete. Endoscopic mitral valve replacement could serve as a bailout strategy in refractory Clip-endocarditis.

1247 Fusobacterium Necrophorum - A Rare Thyroglossal Cyst Habitat That Can Be Lethal

Thyroglossal cyst is the most frequent developmental cervical anomaly with a prevalence of 7% in the population. Infection and abscess formation are common complications. Isolation of Fusobacterium Necrophorum (F. Necrophorum) made the management of this case challenging. An 18-year-old male presented to the emergency department with a 3-day history of a neck mass, sore throat, cachexia, dysphagia and fever. Clinical examination revealed an erythematous 4 x 5 fluctuant swelling in the midline of the neck with evident lymphadenopathy on level II on the left-hand side. A CT neck that was undertaken nine months ago was suggestive of a thyroglossal cyst and the patient was placed in the waiting list for surgical excision under general anaesthesia. He reported three episodes of midline neck swelling since then. Upon admission, ultrasound guided drainage was arranged, and a pus sample obtained. The presence of F. Necrophorum was reported by microbiology with instructions of urgent admission and strict antibiotic regime. Excision of the cyst was scheduled after the completion of the antibiotic course. Fusobacterium Necrophorum is a rare microorganism with increased virulence and a significant mortality rate. It has been involved in oropharyngeal infections complicated by Lemierre’s syndrome, necrobacillosis, post anginal sepsis and septic jugular thrombophlebitis making this case of particular interest.

PREVENTION OF POST OPERATIVE INFECTIONS IN EMERGENCY CAESAREAN SECTIONS: ROLE OF SURGICAL BUNDLE AND VAGINAL CLEANING

Introduction: Caesarean section (CS) is one of the commonest surgical procedures performed in obstetrics. Postoperative infectious complications including surgical site infections (SSI) are a cause of significant morbidity after CS as compared to vaginal delivery. Aim: To assess the role of application of surgical bundle and vaginal cleaning before caesarean section in preventing postoperative infectious complications. Design: Prospective randomised interventional study. Place and duration of study: Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College and hospital,Aligarh from November 2016 to October 2018. Methodology: Total of 216 patients undergoing emergency CS in the hospital was enrolled in the study. Patients were kept in 2 groups. In group 1, women undergoing emergency C-Section whom conventional preoperative preparation was done using savlon-povidone iodine as skin antiseptic and a 7 day postop prophylactic antibiotic regime was administered.In group 2,surgical bundle and vaginal cleaning was done but postop prophylactic antibiotic regime was reduced to 3 day Results:Overall,SSIs were most common infectious morbidity in both groups with highest incidence in group 1(14.7%) and lower in group 2(7.01%), and the difference was statistically significant. Rates of endometritis, UTI and URTI were similar among 2 groups.Duration of hospital stay was lower for group 2 (6.43+_3.29days).No Significant association was noted between haemoglobin levels <8g/dl and number of >4 vaginal examinations with risk of development of SSI (p<0.05). Conclusion:Bundled approach including vaginal cleaning has decreased the incidence of SSIs after emergency CS but larger clinical studies are needed to prove the definite role

Thalamic abscess in a patient with hereditary hemorrhagic telangiectasia successfully treated with an empiric antibiotic regime: case report and review of the literature

Background Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease associated with neurological complications, including cerebral abscesses (CA). They tend to be unique, supratentorial and lobar. While the surgical intervention is a rule of thumb when treating and diagnosing the etiology of these lesions, this is not always possible due to dangerous or inaccessible locations. We report the case of a patient solely treated with empiric antibiotics without stereotaxic intervention and satisfactory results. Case presentation We present the case of a 21-year-old patient with a right thalamic abscess due to HHT and pulmonary arteriovenous malformations, previously embolized, treated solely with antibiotics. At first, we contemplated the possibility of a stereotaxic biopsy, but the high-risk location and the fact that our patient received a previous full course of antibiotic treatment (in another center), made us discard this intervention because of the low diagnostic yield. We started an empiric antibiotic regime. We followed up very closely the clinical and radiological evaluation the next weeks, adjusting our antibiotic treatment when necessary. The results were favorable from both the radiological and clinical aspects and 6 months after the diagnosis the images show its almost complete disappearance. Conclusion Carefully tailored antibiotic-only regime and vigilance of its adverse effects and close radiological following is a good treatment approach when surgery is not an option.

Retrospective Study on the Microbial Drug Resistance Profile and Predictive Risk Factors in Early Infection of Open Fractures

Introduction: This study was conducted to evaluate the susceptibility of microorganisms involved in early infection of open fractures in orthopaedics to current prophylactic antibiotics practice and determine the association of various parameters related to the causative organism, patient, injury and management to the resistance of such microorganisms. Methods: This is a retrospective study that reviewed cases collected from the surgical operations record from January 2015 to December 2017 in Hospital Tengku Ampuan Afzan, Kuantan. A total of 179 cases were collected with 110 cases fulfilling the proposed inclusion / exclusion criteria. They all underwent routine debridement followed by culture and sensitivity. Previous clinical records were traced to identify the various risk factors for infection and evaluate these against the resistance of the microorganisms to prophylactic antimicrobial drugs. Results: Admission to the intensive care unit, blood transfusion, antibiotic regime and duration, fracture grade, injury severity score and duration of admission were all significantly associated with resistance of microorganism. The study also demonstrated the predominance of Gram-negative microorganisms constituting 65.9% of isolates. Gramnegative microorganisms were seen more in higher fracture grades and Injury Severity Scale, and longer duration of admission and antibiotic treatment. The overall susceptibility of microorganisms to antibiotics was also demonstrated with up to 68.6% resistance to cefuroxime and 36.9% to Gentamicin. Staphylococcus aureus and MRSA were the commonest Gram-positive organisms while Pseudomonas and Acinetobacter spp. the commonest Gram-negatives. Conclusion: Admission to Intensive Care Unit, blood transfusion, antibiotic regime and duration, fracture grade, injury severity score and duration of antibiotics have a significant positive predictive value to the development of resistance of microorganisms. The shift to predominantly Gram-negative microorganisms indicate an urgency to modify management of open fracture to achieve optimal results. This will also prevent the emergence of new multi-drug resistance microorganism which is already a worldwide public health problem.

Spondylitis Presenting With Cauda Equina Syndrome in a 12 Year Old Boy

A 12-year-old boy presented with a 2-week history of low back pain and 10-day history of weakness of the lower limbs,5-day history of inability to pass urine. An MRI scan of the lumbar spine showed dehiscent lamina of L5,S1 and an epidural abscess. He was admitted to hospital and treated with a high dose of IV antibiotics followed by radical surgical excision of the lesion. Histopathology showed features of abscess. He eventually recovered bowel and bladder control and regained muscle power in the lower limbs. Infection is not a common cause of cauda equina syndrome. Aggressive surgical treatment combined with a prolonged antibiotic regime is recommended to achieve a satisfactory result. J Dhaka Medical College, Vol. 28, No.1, April, 2019, Page 119-122

Hundred and Eleven Cases of Subfascial Breast Augmentation in Trans Women—A Single-Center Experience

Hundred and eleven patients of breast augmentation in trans women operated between January 2004 and September 2019 are presented. Two surgeons conducted the study with a slightly different antibiotic regime. Only round implants were used. Till December 2017, 72 implants used were textured. Thereafter, we switched over smooth silicone gel implants more for reasons of availability than others. It was used in 39 patients. We did not notice any difference in results. Our postoperative regimes consisted of antibiotics (usually amoxicillin + clavulanic acid) for 10 days, restricted shoulder movements for 3 weeks, use of an inner brassiere and outer sports vest for 2 months. Routes of implantation were either periareolar or inframammary, former being selected as per choice of the patient, provided the hemicircumference of the areola was 4.5 cm or more. We never used transaxillary route. The implants were always placed in a subfascial pocket. Routine irrigation of the pocket with 5% povidone iodine was done before insertion of implant. From 3 weeks postoperatively, routine massage of breasts for a period of 6 to 8 weeks were advised. Complications included delayed minor wound healing problems usually in periareolar technique requiring secondary suture under local anesthesia. This was negligible with inframammary technique. Capsular contracture was found in 12 patients. Two of these merited intervention but one of them refused operation. In one patient, implant had to be extracted due to severe suppurative infection resulting from a separate incidence of traumatic injury with hematoma formation 2 weeks post operatively. Poor scarring including one keloid were noticed in 11 patients.

Reducing Surgical Site Infection in Pediatric Scoliosis Surgery: A Multidisciplinary Improvement Program and Prospective 4-Year Audit

Study Design: Single-center prospective cohort. Objectives: To evaluate a multidisciplinary led, structured protocol for reducing surgical site infections (SSIs) in pediatric scoliosis surgery. Methods: Following a spike to 8.6% in local annual infection rate, a multidisciplinary team was convened to identify interventions. The team consisted of spinal surgeons, infectious diseases consultants, physiotherapists, specialist nurses, and theatre managers. A protocol was initiated, including preoperative skin decontamination; standardized operative site prepreparation; betadine-soaked swabs sutured to wound edges; blood loss minimization; 3 L0.9% saline pulsed-lavage; defined protocol of glove changes; antibiotic regime of preoperative gentamicin, intraoperative subfascial vancomycin powder, 48-hour cefuroxime; and intraoperative normothermia. A 4-year audit was initiated of all patients aged ≤18 years undergoing corrective spinal deformity surgery. Institutional board review was not required. Results: Between January 1, 2014 and January 1, 2018, 414 operations were performed on 355 patients: male:female = 1:2.2, mean age 13.7 years (range 2.5-17.9), 233 idiopathic (mean operated vertebral levels 12), 122 neuromuscular (mean operated vertebral levels 14), 66 growing rod procedures, 41 multistage procedures. The mean number of operated vertebral levels both overall and in infected cases was 13 (range 2-17). Nine SSIs occurred in 8 patients at 3 months (4 neuromuscular), resulting in an overall SSI per operation of 2.2%. Conclusion: A multidisciplinary approach with standardized measures significantly reduced SSIs in the unit’s pediatric scoliosis surgery.