Aim. In private healthcare facilities, the access to a specialized infectious disease (ID) advice is difficult. More, the lack of traceability is problematic and harmful for treatment and follow-up. We have tested an information technology (IT) application to improve medical transmission and evaluate an interdisciplinary ID activity. Methods. In November 2015, three ID physicians (IDP) created an interdisciplinary activity, visiting patients and giving phone advices among ten private healthcare facilities. They are members of the complex bone and joint infection unit of the community hospital where they are attached. Since September 2016, each advice was prospectively recorded on a protected online information system. These data are available for consultation and modification by the three IDP. It is the first descriptive analysis of this database. Results. From September 2016 to February 2017, 887 advices from 573 inpatients were collected. Median age was 69 years old and 56% of patients were male (n=320). Comorbidity was notified in 329 patients (57%): presence of a medical device (n=154), active neoplasia (n=76), mellitus diabetes (n=38) and renal failure (n=38) were the most common. Patients were hospitalized in a surgery unit in 49% of cases and of which 69% was the orthopaedic unit. By frequency, type of infection was prosthetic joint (n=111) and osteosynthesis device infection (n=67), urinary tract infection (n=57), skin infection (n=44), and catheter device infection (n=43). The presence of multidrug resistant bacteria was notified in 63 patients. Antibiotics were already administered before the first advice in 62% of patients. Advices were given after a medical consultation in the clinic in 353 cases (40%) and after a phone call with the physician in charge of the patient in 523 cases (60%). Antibiotics were disrupted or not introduced for 126 advices (14%), introduced for 133 advices (15%), modified in 337 advices (38%) and maintained unchanged in 291 advices (33%). New evaluation was effective for 171 patients (30%). Multidisciplinary meeting was requested for 54 patients. Conclusion. Use of an information system for interdisciplinary and multisite ID activity has permitted with a better traceability to improve management of these septic patients, facilitate storage and transmission of medical information. It is a first overview of ID activity in private healthcare facilities and these tools appear essential in the development of such activity and for public health policy

Aim. This study aimed to evaluate the impact on length of hospital stay from dedicated infectious diseases input for orthopaedic infection patients compared to sporadic infection specialist input. Method. We conducted an observational cohort study of 157 adults with orthopaedic infections at a teaching hospital in the UK. The orthopaedic infections included were: osteomyelitis, septic arthritis, infected metalwork and prosthetic joint infections, and adults were aged 18 years or more. Prior to August 2016, advice on orthopaedic infection patients was adhoc with input principally from the on-call infectious diseases registrar and phone calls to microbiology whereas after August 2016 these patients received regular input from dedicated infectious diseases doctor(s). The dedicated input involved bedside reviews, medical management, correct antimicrobial prescribing, managing adverse drug reactions, increased use of outpatient parenteral antimicrobial therapy (OPAT) services especially self-administration of intravenous antibiotics and shared decision-making for treatment failure, whilst remaining under orthopaedic team care. Orthopaedic patients operated on for management of their infection between 29/8/16 and 15/3/17 were prospectively identified and orthopaedic operation records were used to retrospectively identified patients between 29/8/15 and 15/3/16. The length of stay was compared between the 2 groups. Results. There were 83 patients in the dedicated infectious diseases input group (dedicated group) and 74 patients in the sporadic infection specialist input group (sporadic group). The dedicated group were significantly younger: median 58 years versus 69years (p<0.001), and there was a trend to significant differences in the breakdown of diagnosis (p=0.06), but no significant sex difference. The median length of stay for the sporadic group was 20 days (interquartile range (IQR) 13–29 days) compared to 14 days (IQR 9–27 days) for the dedicated group, with a trend to significance (p=0.06) but no effect from age or diagnosis. Our hospital values one day in hospital at £864, therefore over the 6.5 months trial period of the dedicated infectious diseases input there was a cost saving of £430,272 (£864 × 6 days × 83 patients). Conclusions. Dedicated infectious diseases input would be expected to improve patient care but by additionally reducing median length of stay for orthopaedic infection patients, this encourages investment to achieve both. In this era of increased scrutiny of health budgets demonstrating value for money, not just improved quality of patient care, is essential

The second wave of COVID-19 infections in 2021 resulting from the delta strain had a significantly larger impact on the state of New South Wales, Australia and with it the government implemented harsher restrictions. This retrospective cohort study aims to explore how the increased restrictions affected hand trauma presentations and their treatment. Retrospective analysis was performed on patients who underwent hand surgery from the period of June 23 – August 31 in 2020 and 2021 at a level one trauma centre in Western Sydney. During the second-wave lockdown there was an 18.9% decrease in all hand trauma presentations. Despite widespread restrictions placed on the manufacturing, wholesale, retail and construction industries, there was an insignificant difference in work injuries. Stay-at-home orders and reduced availability of professional tradespersons likely contributed to an increase in DIY injuries. Significant reductions in metacarpal and phalangeal fractures coincided with significantly curtailed sporting seasons. The findings from this study can assist in predicting the case-mix of hand trauma presentations and resource allocation in the setting of future waves of COVID-19 and other infectious diseases

Aims. Trained immunity confers non-specific protection against various types of infectious diseases, including bone and joint infection. Platelets are active participants in the immune response to pathogens and foreign substances, but their role in trained immunity remains elusive. Methods. We first trained the innate immune system of C57BL/6 mice via intravenous injection of two toll-like receptor agonists (zymosan and lipopolysaccharide). Two, four, and eight weeks later, we isolated platelets from immunity-trained and control mice, and then assessed whether immunity training altered platelet releasate. To better understand the role of immunity-trained platelets in bone and joint infection development, we transfused platelets from immunity-trained mice into naïve mice, and then challenged the recipient mice with Staphylococcus aureus or Escherichia coli. Results. After immunity training, the levels of pro-inflammatory cytokines (tumour necrosis factor alpha (TNF-α), interleukin (IL)-17A) and chemokines (CCL5, CXCL4, CXCL5, CXCL7, CXCL12) increased significantly in platelet releasate, while the levels of anti-inflammatory cytokines (IL-4, IL-13) decreased. Other platelet-secreted factors (e.g. platelet-derived growth factor (PDGF)-AA, PDGF-AB, PDGF-BB, cathepsin D, serotonin, and histamine) were statistically indistinguishable between the two groups. Transfusion of platelets from trained mice into naïve mice reduced infection risk and bacterial burden after local or systemic challenge with either S. aureus or E. coli. Conclusion. Immunity training altered platelet releasate by increasing the levels of inflammatory cytokines/chemokines and decreasing the levels of anti-inflammatory cytokines. Transfusion of platelets from immunity-trained mice conferred protection against bone and joint infection, suggesting that alteration of platelet releasate might be an important mechanism underlying trained immunity and may have clinical implications. Cite this article: Bone Joint Res 2022;11(2):73–81

Prosthetic joint infections (PJI) are one of the most devastating complications of joint replacement surgery. They are associated with significant patient morbidity and carry a significant economic cost to treat. The management of PJI varies from antibiotic suppression, debridement, antibiotics, and implant retention (DAIR) procedures through to single/multiple stage revision procedures. Concerns have been raised recently in relation to the rising number of revision arthroplasty procedures that are being undertaken in relation to infection. This database aims to collect data on all PJIs that have been managed in the Australian Capital Territory (ACT) region. This will allow us to investigate the microbial trends, outcomes of surgical intervention and patient outcomes within our local population. This database will incorporate diagnostic, demographic, microbiological and treatment information in relation to local PJI cases. The data will be collated from the local infectious diseases database, hospital medical records, and where available the Australian Orthopaedic Association National Joint Replacement Registry Data. The first 100 cases of PJI were assessed. 76% were defined as being acute. 56% of the patients received antibiotics prior to their diagnosis however only 3% were culture negative. 89% were monomicrobial and 11% polymicrobial. The intended management strategy was a DAIR in 38% of patients and a 2-stage revision in 12% of cases. The intended management strategy was successful in 46% of the patients. The ACT is uniquely placed to analyze and create a local PJI database. This will allow us to guide further treatment and local guidelines in terms of management of these complex patients

Aims. To explore the of age of onset distribution for Perthes’ disease of the hip, with particular reference to gender, laterality and conformity to the lognormal distribution. Patients and Methods. A total of 1082 patients were identified from the Liverpool Perthes’ Disease Register between 1976 and 2010, of which 992 had the date of diagnosis recorded. In total, 682 patients came from the geographical area exclusively served by Alder Hey Hospital, of which 673 had a date of diagnosis. Age of onset curves were analysed, with respect to the predefined subgroups. Results. The age of onset demonstrated a positive skew with a median of 5.8 years (interquartile range 4.6 to 7.5). Disease onset was a mean five months earlier in girls (p = 0.01) and one year earlier in those who went on to develop bilateral disease (p < 0.001). There was no difference in the age of onset between geographical districts with differing incidence rates. The entire dataset (n = 992) conformed to a lognormal distribution graphically and with the chi-squared test of normality (p = 0.10), but not using the Shapiro-Wilk test (p = 0.01). The distribution for the predefined geographical subgroup (n = 673) conformed well to a lognormal distribution (chi-squared p = 0.16, Shapiro-Wilk p = 0.08). Given the observed lognormal distribution it was assumed that Perthes’ disease followed on incubation period consistent with a point-source disease exposure. The incubation period was further examined using Hirayama’s method, which suggested that the disease exposure may act in the prenatal period. Conclusion. The age of onset in Perthes’ disease conforms to a lognormal distribution, which allows comparisons with infectious disease epidemiology. Earlier onset in girls and those who develop bilateral disease may offer clues to understanding the aetiological determinants of the disease. The analysis suggests that an antenatal aetiological determinant may be responsible for disease. Take home message: Perthes’ disease age of onset conforms to a lognormal model, which is most typical of infectious diseases. The shape of the distribution suggests that an aetiological trigger in the pre-natal period may be an important determinant of disease. Cite this article: Bone Joint J 2016;98-B:710–14

Aim. Bone and joint infection requires antimicrobial treatment for 6 to 12 weeks. When patients are well prepared and instructed regarding their therapy, they are more likely to have less side effects and improved compliance. Although side effects are common, this coaching is often not routinely performed when oral treatment is given. We developed a monitoring and guidance program for our outpatients who are on long term antimicrobial therapy, in which we can early signal side effects and treatment failure and coach the patients in their journey of infection treatment. Method. In our tertiary referral centre for orthopaedic infections, we started the outpatient monitoring of antimicrobial treatment (OMAT)- team for patients who will receive antimicrobial therapy for >2 weeks. Before discharge, our trained nurse gives instruction to the patient. Within 3 days after hospital discharge the patient is contacted by phone to, if necessary, clarify ambiguities in monitoring set up. During this contact, the nurse checks for side effects, addresses logistic problems regarding laboratory monitoring or future appointments and coaches patients for other questions. The patient is instructed how to recognize and who to contact in case of red flags and problems possibly related to the treatment. This is repeated after every laboratory check-up. Supervision is performed by an infectious disease specialist in close collaboration with the patient's surgeon. Results. The OMAT-team started in October 2020 and consists of 3 trained nurses and 3 ID specialist. In one year, 453 patients were proactively monitored for a mean of 11 weeks. Routinely, laboratory measurements were performed 1 week after the start of therapy and every 3–4 weeks thereafter, which resulted in 2711 contacts per year. In total, 64% of the patients reported side effects and 13% needed one or more extra laboratory measurement. This led to 40 additional outpatient consultations by the ID specialist because of complications of treatment and a switch of the antimicrobial agent in 31% of the patients. Conclusions. OMAT seems to improve the early signalling of complications regarding treatment, which is likely to improve compliance. The OMAT-team serves as a easy to access team to discuss any problem regarding antimicrobial therapy. Being proactive, the OMAT-team intervenes in an early stage of problems regarding side effects, logistics of the treatment and possible treatment failure. Future analysis of our data will show to what extend this will lead to prevention of re-hospitalization and improvement of success rate

Aims. To investigate the experience and emotional impact of prosthetic joint infection (PJI) on orthopaedic surgeons and identify holistic strategies to improve the management of PJI and protect surgeons’ wellbeing. Methods. In total, 18 prosthetic joint surgeons in Sweden were recruited using a purposive sampling strategy. Content analysis was performed on transcripts of individual in-person interviews conducted between December 2017 and February 2018. Results. PJI had a negative emotional impact on Swedish surgeons. Many felt guilt, stress, and a sense of failure, and several aspects of PJI management were associated with psychosocial challenges. Peer support was reported as the most important coping strategy as was collaborating with infectious disease specialists. Conclusion. Our study affirms that there is a negative emotional impact of PJI on surgeons which can be minimized by improved peer support and working in multidisciplinary teams. Based on the surgeons’ experiences we have identified desired improvements that may facilitate the management of PJI. These may also be applicable within other surgical specialties dealing with postoperative infections, but need to be evaluated for their efficacy. Cite this article: Bone Joint J 2020;102-B(6):736–743

Aims. Metagenomic next-generation sequencing (mNGS) is useful in the diagnosis of infectious disease. However, while it is highly sensitive at identifying bacteria, it does not provide information on the sensitivity of the organisms to antibiotics. The purpose of this study was to determine whether the results of mNGS can be used to guide optimization of culture methods to improve the sensitivity of culture from intraoperative samples. Methods. Between July 2014 and October 2019, patients with suspected joint infection (JI) from whom synovial fluid (SF) was obtained preoperatively were enrolled. Preoperative aspirated SF was analyzed by conventional microbial culture and mNGS. In addition to samples taken for conventional microbial culture, some samples were taken for intraoperative culture to optimize the culture method according to the preoperative mNGS results. The demographic characteristics, medical history, laboratory examination, mNGS, and culture results of the patients were recorded, and the possibility of the optimized culture methods improving diagnostic efficiency was evaluated. Results. A total of 56 cases were included in this study. There were 35 cases of JI and 21 cases of non-joint infection (NJI). The sensitivity, specificity, and accuracy of intraoperative microbial culture after optimization of the culture method were 94.29%, 76.19%, and 87.5%, respectively, while those of the conventional microbial culture method were 60%, 80.95%, and 67.86%, respectively. Conclusion. Preoperative aspirated SF detected via mNGS can provide more aetiological information than preoperative culture, which can guide the optimization and improve the sensitivity of intraoperative culture. Cite this article: Bone Joint J 2021;103-B(1):39–45

Aim. The B.A.C.H. system is a new classification for long bone osteomyelitis. It uses the four key inter-disciplinary components of osteomyelitis, namely, bone involvement, anti-microbial options, soft tissue status and host status. This study aims to assess the inter-user reliability of using the B.A.C.H. classification system. Method. We identified 20 patients who had a diagnosis of long bone osteomyelitis using a previously validated composite protocol. For each patient, osteomyelitis history, past-medical history, clinical imaging (including radiology report), photographs of the affected limb and microbiology were presented to clinical observers on an online form. Thirty observers, varying in clinical experience (training grades and consultants, with a variety of exposure to osteomyelitis) and specialty (orthopaedic surgery, infectious diseases and plastic surgery) were asked to rate the twenty cases of osteomyelitis. Before rating, an explanation of how to use the classification system was given to the observers, in a structured ‘user key’. The responses were assessed by accuracy against a reference value and Fleiss' kappa value (Fκ). Results. The 30 users individually classified all 20 cases. The observers comprised 14 orthopaedic surgeons, 13 physicians (either microbiology, infectious diseases or anesthetists) and 3 plastic surgeons. The users had a variety of exposure to osteomyelitis ranging from less than one case per month to greater than one case per week. The accuracy across all variables was 86.2% (95% CI 83.9% – 88.6%, SD 6.2%), with the ‘C’ variable scoring the highest at 92.5% (95% CI 88.5% – 95.6%, SD 8.2%) and the ‘B’ variable scoring the lowest at 77.0% (95% CI 71.2% – 82.8%, SD 15.5%). The variable with the highest agreement between users was the anti-microbial options with a Fκ of 0.815 (95% CI 0.811 – 0.819) which correlated to an ‘almost perfect agreement’. Despite this, the classification of the more complex isolates proved problematic. The most variability was seen in the bone involvement variable with an Fκ of 0.479 (95% CI 0.475 – 0.483) which correlated to a ‘fair agreement’. Conclusions. The B.A.C.H. classification system for long bone osteomyelitis demonstrated a substantial agreement between observers according to the Fκ value. This was supported by a high level of accuracy of classification within each of the variables. The bone involvement category had a moderate agreement amongst users. This could be due to the nature of the 2-D presentation of cases within the online form. The Fκ was not influenced by clinical experience or clinical specialty, suggesting that B.A.C.H. is applicable by all levels. Further work is required to assess and optimise the descriptions of the bone involvement and anti-microbial options variables

Aim. Our hospital is a referral center for Bone and Joint Infection (BJI) with a 15-bed orthopedic unit. Patients benefit from a multidisciplinary team management (surgeons, anesthetists, infectious disease physicians, microbiologists, dietician etc.). Computerized drug prescriptions are performed by anesthetists, surgical residents, surgeons and infectious disease physicians. Since 2015, a pharmacist has been included in ward rounds and in weekly multidisciplinary consultative meetings, where antibiotic treatment strategies are decided for hospitalized patients. This work aimed to assess the impact of a pharmacist in this unit to limit prescription errors. Method. Prospective monocentric study of all pharmacist's advice or interventions during 15 weeks in 2016 and 2017. A complete pharmaceutical analysis of prescriptions is performed twice a week at least. This analysis is based on doses control and drug interactions, but also takes into account biological and clinical data of patients (patient history, renal function, symptoms, adverse effects…). In case of a prescription error, a computerized message and/or a phone call is sent to the prescriber. Each pharmacist's intervention is recorded and classified according to the French Society of Clinical Pharmacy. The pharmacist collected the number of pharmaceutical advice (when spontaneously solicited by any member of the multidisciplinary team), the different types of prescription errors, the pharmacological class associated to these errors, the types of pharmacist's interventions and their impact on prescriptions. Results. During ward rounds, 24 pharmaceutical advices were asked spontaneously by physicians about drug treatment optimization, predominantly about preparation and administration of injectable antibiotics or about doses adaptation. Regarding medication problems detected by the pharmacist, there were 145 prescription errors: inappropriate dose (38/145), too long-duration treatment (24/145), drug omission (18/145), drug overlap (13/145), inappropriate route (13/145), drug interaction (10/145), non-adherence to guidelines (15/145), omission of specific monitoring (4/145), other (10/145). The main pharmacist's interventions were drug discontinuations (53/145, 37%) and dose adjustments (37/145, 26%). In this specific BJI unit, 67/145 (46%) pharmacist's interventions were related to antibiotic drugs, 29/145 (20%) to drugs for digestive disorders and 16/145 (11%) to cardiovascular drugs. Most of pharmacist's interventions were accepted by prescribers (123/145, 85%), with immediate correction of prescriptions. Conclusions. Most prescription errors concerned doses and durations of treatments. Antibiotic prescriptions were often susceptible to errors. The involvement of a pharmacist in this bone and joint infection unit allows a better medication safety

Introduction. Pulmonary Tuberculosis (TB) can be detected by sputum cultures. However, Extra Pulmonary Spinal Tuberculosis (EPSTB), diagnosis is challenging as it relies on retrieving a sample. It is usually discovered in the late stages of presentation due to its slow onset and vague early presentation. Difficulty in detecting Mycobacterium Tuberculosis bacteria from specimens is well documented and therefore often leads to culture negative results. Diagnostic imaging is helpful to initiate empirical therapy, but growing incidence of multidrug resistant TB adds further challenges. Methods. A retrospective analysis of cases from the Infectious Disease (ID) database with Extra Pulmonary Tuberculosis (EPTB) between 1. st. of January 2015 to 31. st. of January. Two groups were compared 1) Culture Negative TB (CNTB) and 2) Culture Positive TB (CPTB). Audit number was. Results. 31 cases were identified with EPSTB. 68% (n=21) were male. 55% (n=17) patients were Asian, (19% (n=6) were black and 16% (n=5) were of white ethnicity. 90.4% (n=28) patients presented with isolated spinal TB symptoms. No patient had evidence of HBV/HCV/HIV infections. CPTB Group was 51.6% (n=16) compared to CNTB Group with 48.4% (n=15) 48% (15) lumbar involvement, 42% (13) thoracic and 10% (3) cervical. 38.7% (12) patients presented with late neurology, equally in both groups. 56% CPTB patients showed signs of vertebral involvement on plain radiograph compared to 13.3% in CNTB patients. 68.7% CPTB patients had pathological changes or paraspinal collections seen on CT scan compared to 53.3% of CNTB patients. 81% of CPTB showed positive MRI findings compared to 86% in CNTB. Both groups were treated with Anti-TB medications according to local guidelines. 83% patients were followed up till the end of the treatment course. 22.5% (n=7) patients had Ultrasound guided aspiration. 29% (n=9) patients underwent surgical intervention. 3 patients had Laminectomy for decompression. 6 patients underwent Spinal Decompression and Fixation due to extensive bone destruction. No mortality occurred. Conclusion. TB continues to be a growing problem in the developed world with high numbers of patients travelling from endemic regions. 75% of our cases were from Asian or Black ethnicity. The thoracolumbar region was most commonly effected (90%). Approximately 50% of cases of extrapulmonary spinal TB were culture negative. Neurological deficit occurred in 40% patients and 30% of patients required surgery. Standard anti-TB treatment was however effective in all cases with no significant drug resistant variants noted. MRI and CT imaging remain the superior diagnostic tests in the presence of high CN EPSTB

Periprosthetic joint infections (PJI) continue to be a diagnostic challenge for orthopedic surgeons. Chronic PJI are sometimes difficult to diagnose and occasionally present in a subclinical fashion with normal CRP/ESR and/or normal joint aspiration. Some institutions advocate for routine use of intraoperative culture swabs at the time of all revision surgeries to definitively rule out infection. The purpose of this study is to determine whether routine intraoperative cultures is an appropriate and cost effective method of diagnosing subclinical chronic PJI in revision joint replacement patients with a low clinical suspicion for infection. We performed a retrospective chart review and identified 33 patients that underwent revision hip or knee replacement from a single surgeon over a five-month period. The AAOS guidelines for preoperative PJI workup were followed. 13 patients were diagnosed preoperatively with infection and excluded from the study. 20 patients underwent revision joint replacement and three separate cultures swabs were taken for each patient to help in determining true-positive cultures. Infectious Disease was consulted for all patients with any positive culture. Culture results were reviewed. At our hospital, the cost billed to insurance for a single culture is $1,458.58. We did not calculate the cost of the consultant fee. Three (15%) of the 20 revision arthroplasty patients had a single positive culture. Infectious Disease consultants diagnosed all three of these positive cultures as contaminants. None of the patients had a true-positive intraoperative culture. The total cost billed by the hospital to obtain these cultures in all 20 patients was $87,514.80. In our study, obtaining a set of three intraoperative cultures for those patients with a negative preoperative infection workup was not only cost prohibitive but did not diagnose a single subclinical infection. Studies to find other more reliable, accurate, and cost effective alternatives to diagnose PJI are warranted. In patients undergoing revision hip or knee arthroplasty with a low preoperative clinical suspicion for infection, it does not seem that routine intraoperative culture swabs are necessary or cost effective method for diagnosing subclinical periprosthetic joint infection

Aim. Calcaneal osteomyelitis is an uncommon and challenging condition. In this systemic review we aim to analyse the concomitant use of bone debridement and soft tissue management for patients diagnosed with calcaneal osteomyelitis. Method. A complete computerised and comprehensive literature search of Pubmed and Cochrane database was undertaken from January 2000 to October 2018. During the review, studies were screened for information about the surgical and antimicrobial treatment, the complications, the reinfection rate and the functional outcome of patients with calcaneal osteomyelitis. Results. Of the 20 studies included, seven (35%) described bone treatment only, six (30%) soft tissue treatment only, five (25%) soft tissue and bone treatment, and two (10%) focused on prognostic factors and differences in outcomes between diabetic and non-diabetic patients. In the studies with bone treatment only, infection recurrence ranged from 0 to 35% and the amputation rate from 0 to 29%. If soft tissue coverage was also needed, both the reinfection rate and amputation rate ranged from 0 to 24%. Studies presenting the functional status showed preservation or even improvement of the preoperative ambulatory status. Conclusions. Calcaneal osteomyelitis is difficult to treat. A multidisciplinary approach involving orthopaedic surgeons, plastic surgeons and infectious disease physicians is necessary for treatment success. Based on the localisation and size of the bone and soft tissue defect, decision for surgical treatment should be made

The purpose of this study was to evaluate the use of spinal rehabilitation services in Gauteng Province. During the period November 2001 to March 2002 we sent a questionnaire to all hospitals under the control of the Gauteng Health Department. Identified individuals in each hospital completed the questionnaires. The results were analysed statistically. A mean 153 patients were admitted every month. On average, traumatic penetrating injuries accounted for 64 patients, fractures for 52, infectious diseases for 14, tumours for eight, vascular compromise for one, miscellaneous causes for five and readmissions for nine. On average, four patients died after admission. The majority (61%) of readmissions were because of pressure sores. Every month a mean 24 patients were discharged. Neurological levels were as follows: incomplete paraplegia 19%, complete paraplegia 45%, complete quadriplegia 19%, incomplete quadriplegia 17%. The mean length of stay was 44 days. Traumatic penetrating injury called for a mean stay of 63 days, fracture 81 days, infectious diseases 56 days, tumours 49 days, vascular problems six days and other causes eight days. Only 53% of patients were admitted to a spinal unit, while 36% were treated in general wards and 11% were admitted to ‘rehabilitation beds’. We believe that spinal rehabilitation needs to be recognised as a specialised field. More rehabilitation beds are needed. Referral routes to dedicated spinal units need to be improved and available facilities optimally used and distributed

Aims. Current antibiotic treatment strategies for prosthetic joint infection (PJI) are based mostly on observational retrospective studies. High-quality data from prospective cohorts using identical treatment strategies may improve current clinical practice. We developed a regional network of collaborating hospitals and established a uniform treatment protocol. Data from all patients diagnosed with a PJI are prospectively registered in a an online database. With this quality registry we aim to study the outcome of antibiotic and surgical strategies while adhering to a pre-established treatment protocol. Methods. A working group of orthopaedic surgeons, infectious disease specialists and microbiologists was established. The working group reached consensus on definition of PJI and a uniform treatment protocol, based on current guidelines and expert-based clinical experience. A website was built to communicate information to colleagues and patients (. www.protheseinfectie.nl. ). In each participating hospital weekly multidisciplinary meetings were started to discuss all PJI cases. All patients are included in an online quality registry and followed for at least two years. We aim to enroll >600 patients with a knee or hip PJI. Research will focus on the duration of antibiotic treatment, antibiotic suppressive therapy and comparison of different oral antibiotic treatment strategies in relation to successful treatment outcomes. Results. Currently, four regional hospitals are included in the partnership. Multidisciplinary meetings have lowered the threshold to discuss patients, and the adherence to the PJI treatment protocol has improved steadily. Complicated cases are discussed between colleagues from collaborating centers. The collaboration has been perceived as very successful by the participating hospitals. Since 2015, over 300 patients have been included, of whom 52% were male. In 26%, PJI occurred after revision surgery. Staphylococcus aureus was involved in 25% of cases, coagulase-negative Staphylococci in 23%, Streptococci in 13% and Gram-negative micro-organisms in 15%. Conclusions. In this project, collaboration between different medical specialties through multidisciplinary meetings was the key to the improvement of patient care The regional collaborative project led to the implementation of a uniform treatment protocol for PJI. With this prospective project we aim to improve patient care by providing evidence for optimal antibiotic and surgical strategies for PJI. Ideally, countries should have hospital networks and a uniform method of data collection to make it easy to share data for scientific research

Aim. Over the past three years, roughly 100,000 hip and knee replacements have been performed by the Brazilian Public Healthcare System. Prosthetic joint infection (PJI) is expected to range between 1% to 10% after primary and revisions joint arthroplasties, respectively. So far, there have been no published national PJI data which would be helpful at developing local preventive strategies and guide surgeons and clinicians. We aimed at describing the epidemiological, clinical and microbiological PJI results of a national and collaboration study among infectious diseases specialists and orthopaedic surgeons, including academic, public and private institutions. Method. We prospectively enrolled patients with PJI in a national cohort study among 12 hospitals from 6 different States to describe host, pathogens, diagnosis, surgery strategies adopted (according to the standard hospital-based guideline) and outcome after 1- and 2-years follow-up. PJI was defined using the IDSA criteria (Osmon D, et al. Clin Infect Dis. 2013). Patients were enrolled from July 2013 to December 2015. Results. Overall, 234 patients undergoing hip, knee and shoulder (n=3) arthroplasty were eligible; 35 were excluded: did not fulfil the inclusion criteria (n=14), withdrawal informed consent (n=11) and early lost to follow-up (n=10). A total of 199 were available for analysis. Twenty-two (11%) patients died during the follow-up, most of which (95%) occurred within 1 year of PJI diagnosis. In the one-year (12 patients lost to follow-up) and two-year (18 patients lost to follow-up) post-diagnosis analysis, overall treatment failure occurred in 13.3% (n=22/166), and 17% (n=25/147). Knee and hip rate failure in the 1- and 2-year follow up were 12.2% (n=9/74), 15.4% (n=14/91), and 16.2% (n=11/68), 18.2% (n=14/77), respectively. Debridement with implant retention (DAIR), one-stage exchange, two-stage exchange, and arthrodesis was performed in 44.7%, 25.4%, 22.3%, 7.6% respectively. Failure rates for DAIR, one-stage exchange, two-stage exchange, and arthrodesis after 1- and 2-year follow-up were 24.2% (n=16/66), 4.3% (n=2/46), 9.8% (4/41), 0% (n=0/15), and 28.6% (n=16/56), 4.8% (n=2/42), 15.8% (n=6/38), 0% (n=0/15), respectively. Microbial diagnosis yielded positive culture in 71.7%. Staphylococcus aureus (34%), coagulase-negative staphylococci (28%), Pseudomonas aeruginosa (17%) were more prevalent. Polymicrobial PJI were diagnosed in 32.8%. Conclusions. This is so far the largest Brazilian cohort of patients with PJI showing an overall 2-years failure-free survival rate of 83%, in which DAIR is the most frequent and less successful strategy, single-stage exchange seems to be a growing surgical option. Polymicrobial and non-fermenting Gram-negative bacilli and Enterobacteriacae is frequent

Severe acute respiratory syndrome (SARS) is a newly described infectious disease caused by the SARS coronavirus which attacks the immune system and pulmonary epithelium. It is treated with regular high doses of corticosteroids. Our aim was to determine the relationship between the dosage of steroids and the number and distribution of osteonecrotic lesions in patients treated with steroids during the SARS epidemic in Beijing, China in 2003. We identified 114 patients for inclusion in the study. Of these, 43 with osteonecrosis received a significantly higher cumulative and peak methylprednisolone-equivalent dose than 71 patients with no osteonecrosis identified by MRI. We confirmed that the number of osteonecrotic lesions was directly related to the dosage of steroids and that a very high dose, a peak dose of more than 200 mg or a cumulative methylprednisolone-equivalent dose of more than 4000 mg, is a significant risk factor for multifocal osteonecrosis with both epiphyseal and diaphyseal lesions. Patients with diaphyseal osteonecrosis received a significantly higher cumulative methylprednisolone-equivalent dose than those with epiphyseal osteonecrosis. Multifocal osteonecrosis should be suspected if a patient is diagnosed with osteonecrosis in the shaft of a long bone

Aim. The aim of our study was to identify pathogens involved in septic knee arthritis after ACLR and to describe clinical features, treatment and outcome of infected patients. Methods. We conducted a retrospective observational study including all patients with ACLR infection in 3 orthopedic centers sharing the same infectious disease specialists. Results. During a seven-year period (2011–2017) we identified 74 infected patients among 9858 patients who had ACLR (incidence rate = 0.0075). Fourteen patients had polymicrobial infection. We identified 89 pathogens. Twenty four patients (34.4 %) were infected with S. aureus (27% of all isolates)(only one oxacillin-resistant strain). C. acnes was the second most frequent pathogen, identified in 14 patients (18.9%) (15.7% of all isolates). S. lugdunensis was identified in 9 patients (12.2%) (10.1% of all isolates). S. caprae was as frequent as S. epidermidis identified in 8 patients each (10.8%) (9 % of all isolates for each). No strain of S. lugdunensis and S. caprae was resistant to oxacillin, levofloxacin or rifampicin. Ten patients infected by C. acnes, 8 infected by S. lugdunensis, and 7 infected by S. caprae had an early acute infection. In all cases but one an arthroscopic lavage was performed, in 14 cases two lavages were required and in 4, 3 lavages. All patients infected by a strain susceptible to levofloxacin and rifampicin, including those with C. acnes, S. caprae and S. lugdunensis infection, were treated with an oral combination of levofloxacin and rifampicin, after a couple of days of IV empirical treatment with vancomycin and a broad spectrum beta-lactam. The median duration of treatment was 6 weeks. Seventy one patients were considered cured. Conclusions. To our knowledge this is the largest reported series of infection after ACLR. S. aureus is the main pathogen (27% of all strains). C. acnes, S. lugdunensis and S. caprae accounted for almost 35% of pathogens and 38% of infections. A conservative strategy consisting in arthroscopic lavage(s) and a 6-week treatment with levofloxacin and rifampicin was effective