Introducing intrauterine antibiotic infusion as a novel approach in effectively treating chronic endometritis and restoring reproductive dynamics: a randomized pilot study

The chronic nature of Chronic Endometritis (CE) along with the challenging management and infertility entailed, call for cutting-edge therapeutic approaches. This study introduces the novel treatment of intrauterine antibiotic infusion (IAI) combined with oral antibiotic administration (OAA), and it assesses respective performance against the gold standard treatment of OAA. Data sourced herein reports on treatment efficiency and fertility restoration for both patients aiming to conceive naturally or via In Vitro fertilization. Eighty CE patients, 40 presenting with recurrent implantation failure, and 40 with recurrent pregnancy loss, were enrolled in the IVF and the natural conception arm respectively. Treatment was subjected to randomization. Effectively treated patients proceeded with either a single IVF cycle or were invited to conceive naturally over a 6-month period. Combination of IAI and OAA provided a statistically significant enhanced effectiveness treatment rate (RR 1.40; 95%CI 1.07–1.82; p = 0.01). No statistically significant difference was observed regarding the side-effects rate (RR 1.33; 95%CI 0.80–2.22; p = 0.52). No statistically significant difference was observed for either arm regarding live-birth rate. Following an intention-to-treat analysis, employment of IAI corresponds to improved clinical pregnancy rate-albeit not reaching statistical significance. In conclusion, complimentary implementation of IAI could provide a statistically significant enhanced clinical treatment outcome.

Debridement, antibiotics, and implant retention combined with direct intra-articular antibiotic infusion in patients with acute hematogenous periprosthetic joint infection of the knee

Background Debridement, antibiotics, and implant retention (DAIR) is the recommended treatment for acute hematogenous periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). However, DAIR is associated with a high percentage of unsuccessful outcomes. Since 2007, direct intra-articular antibiotic infusion, which can provide a high concentration of intra-articular antibiotic, has been used in combination with DAIR to improve treatment outcomes among patients in our institution. This study aimed to assess the outcomes of DAIR combined with direct intra-articular antibiotic infusion in patients who presented with acute hematogenous PJI after TKA. Methods We reviewed the data of all patients diagnosed with acute hematogenous PJI after primary TKA (from 2008 to 2015) who received DAIR combined with direct intra-articular antibiotic infusion. Results In total, 15 knees in 12 patients were semi-urgently treated with this method. The mean follow-up time was 93.3 (minimum: 56) months, and the longest follow-up time was 11 years. Two patients (n = 3 knees) had a well-functioning, non-infected prosthesis 6 and 10 years after the procedure. Two patients (n = 2 knees) had re-infection 2 and 5 years after surgery, and they required two-stage revision. None of the patients were lost to follow-up. Finally, 13 (86.6%) of 15 infected knees were successfully treated with this method. Conclusions DAIR combined with direct intra-articular antibiotic infusion is an effective treatment for acute hematogenous PJI after TKA.

Clinical effectiveness of flucloxacillin delivery using an elastomeric device for outpatient parenteral antimicrobial therapy

There has been a surging interest in using elastomeric infusion devices to deliver outpatient parenteral antimicrobial therapy (OPAT), which is more cost-effective than standard antibiotic administration, which requires multiple daily home visits. This has been particularly important since the outbreak of the coronavirus pandemic, because reducing patient contact can also help to minimise transmission of COVID-19 to outpatients who are at a high risk of COVID-19-triggered complications. In this retrospective study, the clinical effectiveness of intravenous (IV) infusion of flucloxacillin using an elastomeric device was explored in a convenience sample of patients. Patients with three primary infective diagnoses—bloodstream infection, non-vertebral osteomyelitis and vertebral osteomyelitis—were included in the analyses. In non-vertebral osteomyelitis patients, Accufuser antibiotic infusion shortened the course of OPAT care relative to standard antibiotic administration (p<.05). In contrast, in vertebral osteomyelitis patients, it prolonged the course of OPAT care relative to standard administration (p<.05). In patients with bloodstream infections, no significant difference was found between the treatment modes (p=.93). Thus, the clinical effectiveness of Accufuser antibiotic infusion varies among patients with different infective diagnoses, and there seems to be a complex relationship between the method of antibiotic delivery and the patient's condition.

Optimizing Antibiotic Treatment Strategies for Neonates and Children: Does Implementing Extended or Prolonged Infusion Provide any Advantage?

Optimizing the use of antibiotics has become mandatory, particularly for the pediatric population where limited options are currently available. Selecting the dosing strategy may improve overall outcomes and limit the further development of antimicrobial resistance. Time-dependent antibiotics optimize their free concentration above the minimal inhibitory concentration (MIC) when administered by continuous infusion, however evidences from literature are still insufficient to recommend its widespread adoption. The aim of this review is to assess the state-of-the-art of intermittent versus prolonged intravenous administration of antibiotics in children and neonates with bacterial infections. We identified and reviewed relevant literature by searching PubMed, from 1 January 1 2000 to 15 April 2020. We included studies comparing intermittent versus prolonged/continuous antibiotic infusion, among the pediatric population. Nine relevant articles were selected, including RCTs, prospective and retrospective studies focusing on different infusion strategies of vancomycin, piperacillin/tazobactam, ceftazidime, cefepime and meropenem in the pediatric population. Prolonged and continuous infusions of antibiotics showed a greater probability of target attainment as compared to intermittent infusion regimens, with generally good clinical outcomes and safety profiles, however its impact in terms on efficacy, feasibility and toxicity is still open, with few studies led on children and adult data not being fully extendable.

Treatment of acute hematogenous infection after total knee arthroplasty with open arthrotomy debridement and polyethylene exchange combined with direct intra-articular antibiotic infusion: a midterm result with mean follow up of 75 months

Background: Standard management of acute hematogenous infection after total knee arthroplasty consisted of open arthrotomy debridement and polyethylene exchange. However, the efficacy of this method was inconsistent with successful retention could be less than 50%. Direct intra-articular antibiotic infusion could be a potential adjuvant for this complicated problem. Objective: To report our results of open arthrotomy debridement and polyethylene exchange combined with direct intra-articular antibiotic for the treatment of acute hematogenous infection after TKA. Materials and Methods: We retrospectively review data from 16 knees (13 patients) with this type of infection and being treated by open arthrotomy debridement and polyethylene exchange combined with direct intra-articular antibiotic (IA-ATB) with our protocol since 2009. Results: all cases were diagnoses with acute hematogenous PJI and treated with semi-urgent basis and underwent open arthrotomy debridement and PE exchange combined with IA-ATB with our protocol were included in this study. 2 cases (2 knees) were loss to follow up after the infection were eradicated at 7 months and 48 months. 2 cases (3 knees) passed away with intact prosthesis at 6 years. 2 cases (2 knees) were reinfected with at 2 years and 5 years after operation and later need to do 2 stage revision. The longest follow up was 11 years with average follow up of 75 months. Therefore, 12 out of 14 infected knees were successful treated with this technique. Conclusions: Open arthrotomy debridement and polyethylene exchange combined with direct intra-articular antibiotic infusion is an effective method for the treatment of acute hematogenous infection after total knee arthroplasty.

Effective treatment of single-stage revision using intra-articular antibiotic infusion for culture-negative prosthetic joint infection

Aims In the absence of an identified organism, single-stage revision is contraindicated in prosthetic joint infection (PJI). However, no studies have examined the use of intra-articular antibiotics in combination with single-stage revision in these cases. In this study, we present the results of single-stage revision using intra-articular antibiotic infusion for treating culture-negative (CN) PJI. Methods A retrospective analysis between 2009 and 2016 included 51 patients with CN PJI who underwent single-stage revision using intra-articular antibiotic infusion; these were compared with 192 culture-positive (CP) patients. CN patients were treated according to a protocol including intravenous vancomycin and a direct intra-articular infusion of imipenem and vancomycin alternately used in the morning and afternoon. In the CP patients, pathogen-sensitive intravenous (IV) antibiotics were administered for a mean of 16 days (12 to 21), and for resistant cases, additional intra-articular antibiotics were used. The infection healing rate, Harris Hip Score (HHS), and Hospital for Special Surgery (HSS) knee score were compared between CN and CP groups. Results Of 51 CN patients, 46 (90.2%) required no additional medical treatment for recurrent infection at a mean of 53.2 months (24 to 72) of follow-up. Impaired kidney function occurred in two patients, and one patient had a local skin rash. No significant difference in the infection control rate was observed between CN and CP PJIs (90.2% (46/51) versus 94.3% (181/192); p = 0.297). The HHS of the CN group showed no substantial difference from that of CP cases (79 versus 81; p = 0.359). However, the CN group showed a mean HSS inferior to that of the CP group (76 versus 80; p = 0.027). Conclusion Single-stage revision with direct intra-articular antibiotic infusion can be effective in treating CN PJI, and can achieve an infection control rate similar to that in CP patients. However, in view of systemic toxicity, local adverse reactions, and higher costs, additional strong evidence is needed to verify these treatment regimens. Cite this article: Bone Joint J 2020;102-B(3):336–344