Biomedical subjects

Paul D Holtom

Publications and source records attributed to Paul D Holtom.

11 recordsLinked to original sources

PubMed2006

Septic arthritis in patients with human immunodeficiency virus.

The literature contains few descriptions of the infective organisms and diagnostic issues associated with musculoskeletal infections in patients with HIV. We retrospectively reviewed 19 patients with HIV treated at our musculoskeletal infection ward for septic arthritis. The mean CD4 count was 154/mm (range, 7-482/mm), and 11 patients had a CD4 count < 200/mm and were diagnosed with AIDS. The most common pathogen (six patients) was oxacillin-resistant Staphylococcus aureus. Mycobacterial infections occurred in three patients but no fungal pathogens were identified. Septic arthritis was monoarticular in 14 patients and involved the knee in eight patients, the hip in three patients, and the wrist in three patients. Five patients presented with polyarticular septic arthritis. All mycobacterial infections and four of the five polyarticular infections occurred in patients with a CD4 count < 200/mm. Patients with CD4 count < 200/mm had a lower joint fluid WBC count compared to patients with a CD4 count > 200/mm (40,500 vs 69,000/mm). Oxacillin-resistant Staphylococcus aureus was the most common pathogen. A high index of suspicion for Mycobacterium. tuberculosis arthritis and polyarticular septic arthritis is necessary in patients with HIV and a CD4 count < 200/mm.

AIDS-Related Opportunistic Infections↗

PubMed2006

Recalcitrant septic knee arthritis due to adjacent osteomyelitis in adults.

We asked whether adjacent osteomyelitis with acute septic knee arthritis explained a lack of response to initial management, and whether patient comorbidities predisposed to the nonresponsiveness. From 147 adult patients (151 knees) with septic arthritis, we identified 29 patients (33 knees) who had persistence or recurrence of symptoms after surgical drainage. Adjacent osteomyelitis was present in 31 (94%) of the 33 knees (27 of 29 patients) with poor response to treatment. Patients with adjacent osteomyelitis had more comorbid conditions (23 of 27 patients, 85%) than patients without osteomyelitis (64 of 120, 53%). The most common comorbid conditions in patients with adjacent osteomyelitis were diabetes mellitus (10 patients, 37%) and intravenous drug use (eight patients, 30%). We identified Staphylococcus aureus in 19 of 31 knees (61%) with osteomyelitis, eight (26% of total cases) of which were methicillin-resistant. Persistence of clinical signs of infection after surgical management of septic knee arthritis in adults should raise the suspicion of adjacent osteomyelitis, especially in patients with comorbid conditions. Additional imaging studies may be necessary to evaluate the distal femur and proximal tibia.

Adult↗

PubMed2006

Antibiotic prophylaxis: current recommendations.

Antibiotic prophylaxis consists of a brief course of antibiotics initiated preoperatively in order to decrease the risk of postoperative wound infection in the patient with a clean wound. The antibiotic should be started within 60 minutes before skin incision and continued for not more than 24 hours. Antibiotic therapy is indicated for the contaminated or dirty wound. In open fractures, antibiotics should be started as soon as possible after injury and continued for 3 days (type I and II fractures) or 5 days (type III). This treatment should be combined with local therapy consisting of antibiotic-impregnated polymethylmethacrylate beads. Although the utility of antibiotics in low-velocity gunshot wounds is controversial, high-velocity gunshot wounds should be treated with 48 to 72 hours of antibiotic therapy.

Anti-Bacterial Agents↗

PubMed2005

Management of open fractures.

Open fractures are high-energy injuries that require a principle-based approach, starting with detailed evaluation of patient status and injury severity. Early, systemic, wide-spectrum antibiotic therapy should cover gram-positive and gram-negative organisms, and a common regimen is a 3-day administration of a first-generation cephalosporin and an aminoglycoside, supplemented with ampicillin or penicillin to cover anaerobes in farm or vascular injuries. Local antibiotic delivery with the bead pouch technique increases the local concentration of antibiotics, minimizes systemic toxicity, and prevents secondary wound contamination. Thorough irrigation and surgical debridement is critical for prevention of infection. Primary wound closure remains controversial because of concerns for gas gangrene. Partial wound closure is an alternative, with delayed wound closure within 3 to 7 days. In the presence of extensive soft tissue damage, local or free muscle flaps should be transferred to achieve coverage. Stable fracture fixation should be achieved with a method suitable for the bone and soft tissue characteristics. Early bone grafting is indicated for bone defects, unstable fractures treated with external fixation, and delayed union. A management plan guided by the above principles will achieve the goals of prevention of infection, fracture healing, and restoration of function in most of these challenging injuries.

Adult↗

PubMed2005

Microbiology of osteomyelitis in patients infected with the human immunodeficiency virus.

Osteomyelitis rarely develops in patients infected with the human immunodeficiency virus despite their immunosuppressed state. In the limited literature available on this subset of patients, the role of opportunistic micro-organisms is controversial. Our purpose is to describe the microbiologic features of osteomyelitis. This is a retrospective review of 20 patients infected with the human immunodeficiency virus who were admitted to our musculoskeletal infection ward with the diagnosis of osteomyelitis. Eleven patients (55%) were intravenous drug users. Medical comorbidities were present in 14 of 20 patients (70%), including tuberculosis in five patients and hepatitis C in three patients. The mean CD4 count was 269/mm (range, 20-539/mm). Osteomyelitis was monomicrobial in 10 patients (50%) and polymicrobial in seven patients (35%) whereas in three patients no organism was cultured. The most common pathogen was Staphylococcus aureus, present in 10 patients (50%). No mycobacterial or fungal pathogens were identified. Infection recurred in 3 of 14 patients (21%) that were available for followup. Despite their immunocompromised status, patients infected with the human immunodeficiency virus did not develop osseous infections with opportunistic pathogens. Staphylococcus aureus was the most common pathogen found; however, a considerable proportion of infections were polymicrobial.

AIDS-Related Opportunistic Infections↗

PubMed2005

Spinal epidural abscess: early clinical outcome in patients treated medically.

Treatment of spinal epidural abscess has been based on surgical debridement. Medical treatment with antibiotics has been proposed as an alternative, but data on its efficacy are limited. The purpose of this study was to determine the early clinical outcome of medical treatment. This is a retrospective review of 52 patients with a spinal epidural abscess who were treated at our institution. Medical treatment was selected if no systemic sepsis was present and the neurologic examination was normal or stable (radiculopathy or signs of partial cord compression present for more than 72 hours before admission without deterioration). Twenty-nine patients had medical treatment and 23 patients were treated surgically. Medical treatment resulted in good or excellent early neurologic outcome in 24 of 29 patients (83%) at a median followup of 2 months. Three patients (11%) had failed medical treatment and required surgery and one patient (3%) who had severe comorbidities died. Staphylococcus aureus was the most common infectious pathogen, isolated in 28 of 36 positive cultures (78%). Medical treatment is a viable alternative to surgery for selected patients with a spinal epidural abscess. However, close clinical followup is essential and surgical decompression should be done when neurologic deterioration or development of systemic sepsis is observed.

Adult↗

PubMed2004

Porcine small intestine submucosa does not show antimicrobial properties.

The goal of this study is to examine whether porcine small intestine submucosa (SIS) exhibits antimicrobial properties in a standard in vitro system, without pretreatment with acetic acid or extraction of soluble proteins. Previous animal studies suggest that porcine SIS may have inherent antibiotic properties. Using the guidelines for disk diffusion susceptibility testing by Bauer, 17/64-inch diameter disks made of porcine small intestine submucosa and of gortex were compared with standard antibiotic-impregnated disks against six organisms. The zone of inhibition was measured after 24 hours and minimum bacterial concentrations were determined by serial dilutions of a solution in which porcine small intestine submucosa was allowed to elute for 24 hours. Neither porcine SIS or gortex discs caused inhibition of the growth of any organism. The porcine small intestine submucosa discs showed bacterial growth on top of the discs whereas the gortex did not. Neither the dilutional concentrations of the porcine small intestine submucosa eluent nor the gortex eluent inhibited the growth of any organism. These findings suggest that the porcine small intestine submucosa does not have intrinsic antimicrobial properties. The growth of bacteria on top of the porcine small intestine submucosa suggests that porcine small intestine submucosa itself may provide a favorable environment for the growth of bacteria. More research is necessary to decide what role porcine small intestine submucosa plays in the treatment of infected surgical sites.

Animals↗

PubMed2003

Laboratory monitoring in pediatric acute osteomyelitis and septic arthritis.

The purpose of the current study was to determine the usefulness of erythrocyte sedimentation rate and C-reactive protein in pediatric bone and joint infections treated with and without surgery. The medical records of 50 patients admitted for acute osteomyelitis, septic arthritis, or both were reviewed retrospectively. There were 22 patients with septic arthritis, 20 with osteomyelitis, and eight with osteomyelitis with adjacent septic arthritis. There were 25 patients each in the surgical and nonsurgical groups. There was a statistically significant difference between the two groups regarding mean days to peak and normalization of erythrocyte sedimentation rate values and normalization of C-reactive protein values. Statistically significant differences were revealed for the mean days to normalization of erythrocyte sedimentation rate and C-reactive protein values among the patients with a diagnosis of osteomyelitis, septic arthritis, or both. The mean days to peak and normalization for erythrocyte sedimentation rate and C-reactive protein were twice as long in the surgical group as compared with the nonsurgical group. Complete recovery was achieved by all patients. This information should help the clinician in the diagnosis and treatment of children having surgery for acute osteomyelitis and septic arthritis.

Acute Disease↗

PubMed2003

Negative pressure dressings as an alternative technique for the treatment of infected wounds.

Coverage of wounds caused by infection and subsequent treatment often are variable because of the location of the wound and wound size. Although much research has been done to expand the indications of negative pressure wound treatment systems, little investigation has been done to quantify the reduction of wound size for vacuum-assisted closure treatment in the presence of infection. In this series, 14 patients who had wounds caused by infections were treated with the vacuum-assisted wound closure system. All wounds were greater than 20 cm2. The duration of treatment averaged 10 days (range, 2-27 days), and the initial wound size averaged 70 cm2 (range, 22.5-288 cm2). After the course of treatment, the final wound size averaged 39 cm2 (range, 10-147 cm2). The average wound size reduction was 43%. This method seems to enhance the rapidity of wound reduction, and because it is a closed system of treatment, it has the added benefit of minimizing exposure of staff and other patients to communicable diseases. Vacuum-assisted wound closure systems add another option in the care of musculoskeletal infections.

Adult↗

PubMed2003

Newer methods of antimicrobial delivery for bone and joint infections.

The advantages of systemic therapy include the ability to deliver antibiotics to areas that cannot be reached with topical therapy, the choice of a large selection of agents directed against the pathogens encountered in orthopaedic infections, and arrest or eradication of infection in most cases (in conjunction with adequate débridement). Disadvantages include the potential for toxicity from systemic agents, difficulty in achieving high concentrations of antimicrobial agents at the site of infection, and problems with compliance. To combat these disadvantages, newer methods for the delivery of antimicrobial agents have been investigated. Some of these newer methods include new formulations of antimicrobial agents to decrease systemic toxicity and improved methods for delivering local antimicrobial therapy.

Absorbable Implants↗

PubMed2002

Osteomyelitis attributable to vancomycin-resistant enterococci.

Vancomycin-resistant enterococcus first was described in 1988, and has become a major problem in nosocomial infections. This is a retrospective review of 10 patients, seen at the authors' hospital during a 2-year period, with confirmed vancomycin-resistant enterococcal osteomyelitis: four patients had total joint arthroplasty infections, one patient had an infected tibial nail, three patients had infections associated with external fixators, and two patients had osteomyelitis of the femur. Four of the 10 patients had underlying medical illnesses (diabetes mellitus, systemic lupus erythematosus, human immunodeficiency virus infection); four of the 10 patients were intravenous drug users. Two patients had vancomycin-resistant enterococci on admission, and the other eight patients were admitted to the hospital for a mean of 21.3 days (range, 3-73 days) before vancomycin-resistant enterococci were identified in the bone. Eight of the 10 patients had monomicrobial infections with vancomycin-resistant enterococci. Patients were treated by surgical debridement, removal of hardware, and antibiotics (chloramphenicol in eight patients, quinupristin and dalfopristin (Synercid) in two patients). All patients initially improved with therapy, but one patient had a recurrence of vancomycin-resistant enterococcal osteomyelitis and died of bacteremia. Bone infections with vancomycin-resistant enterococcus still may be uncommon, but with time and selective antibiotic pressures, vancomycin-resistant enterococci may become a more prominent entity in orthopaedic infections.

Adult↗