SummaryThe aim of this study was to prospectively evaluate the accuracy of real-time B-mode ultrasonography in the diagnosis of asymptomatic proximal deep vein thrombosis (DVT) in hip surgery patients. Venography was adopted as the gold standard. We studied 100 consecutive patients undergoing hip surgery: 60 patients for hip fracture and 40 patients for elective hip replacement. Bilateral real-time B-mode ultrasonography was performed prior to bilateral venography. The two diagnostic procedures were performed on the same day by different investigators unaware of the assigned prophylatic regimen for DVT Compressibility of the vein segment was adopted as the single criterion for DVT. Venography was performed and judged by radiologists unaware of the ultrasonography results. In 13 limbs venography was either impossible to perform or not adequate for judgement. Ultrasonography and an adequate venography was obtained in 187 limbs. A venography proven DVT was observed in 49 limbs (26.2%) and a proximal DVT in 21 limbs (11.2%). All the patients were asymptomatic for DVT. The sensitivity and specificity of real time B-mode ultrasonography for proximal DVT were 57% (95% confidence interval: C. I. 36–80) and 99% (C. I. 99–100), respectively and the positive and negative predictive values were 93% (C.I. 73–100) and 95% (C.I. 91–97), respectively. The sensitivity and specificity for overall DVT were 25% (C.I. 11–38) and 99% (C.I. 97–100), respectively and the positive and negative predictive values were 92% (C. I. 73–100) and 79% (C.I. 76–85), respectively. Our data indicate that realtime B-mode ultrasonography for its high specificity could make venography unnecessary in patients with positive results. However, because of its low sensitivity it cannot be used for the screening of DVT in asymptomatic patients, nor can it replace venography for outcome measurements in clinical trials on DVT prophylaxis.

Teicoplanin, 200-400 mg (3-6 mg/kg) daily iv or im, was used to treat 71 episodes of infection. The average duration of treatment was 22 days. The 64 evaluable episodes comprised 24 skin/soft tissue, 20 osteoarticular, ten urinary tract and one ventriculo-atrial shunt infections; one case of primary bacteraemia, three of endocarditis, two of pneumonia and three of pleural empyema. Fifty-five episodes were treated with teicoplanin monotherapy and nine with teicoplanin in association to other antibiotics. Overall 61% (39/64) of the evaluable infections were cured, 25% (16/64) improved and 14% (9/64) failed. Staphylococcus aureus was the most frequent pathogen, with 46 isolates. Infections by both methicillin-sensitive and resistant Staph. aureus strains showed favourable clinical and microbiological responses to teicoplanin. Side effects were observed in eight of the 64 episodes (12.5%). Bronchospasm was observed in two other cases at the beginning of therapy and the antibiotic administration was discontinued. Teicoplanin is an effective and well tolerated antibiotic for infections by Gram-positive bacteria, and it is effective against methicillin-resistant staphylococci.

IntroductionProsthetic joint infections are severe complications of joint implants. Further complications arise when polymicrobial and/or multidrug-resistant microorganisms are involved. Currently, there are limited data on the management of these infections and on the tolerability of long-term treatment with daptomycin, ceftazidime and colistin.Case presentationA 55-year-old Caucasian woman who had a right hip prosthesis removed 1 year prior because of infection was admitted for prosthesis reimplantation. On admission at our hospital, anamnesis regarding etiology and management of prosthesis infection was not available. On clinical, laboratory findings and imaging studies infection was not suspected. A hip prosthesis was reimplanted. At surgery, histopathological and microbiological investigations were not taken. Three weeks after reimplantation, surgical site infection due to Enterobacter cloacae was diagnosed and oral ciprofloxacin was prescribed. Four days later, a periprosthesis fluid collection was evidenced and a percutaneous needle aspirate grew Staphylococcus epidermidis and S. haemolyticus. Enterobacter genome was also detected from the same sample. Teicoplanin and meropenem were added to ciprofloxacin without clinical improvement. Moreover, acetabular cup dislocation was documented. She underwent prosthesis explantation, debridement, and positioning of an antimicrobial mixed spacer. From the intraoperatory cultures S. epidermidis and Acinetobacter baumannii were grown. Daptomycin, ceftazidime, colistin and rifampin were administered. Four days later, rifampin was stopped due to a suspected liver toxicity. While undergoing therapy she presented recurrent episodes of wound dehiscence and on the 22nd week of treatment a further surgical debridement was performed, upon which the spacer was removed. At this time, intraoperative cultures resulted negative. Three months later, after a total of 8 months, antimicrobials were interrupted. Subsequently, a femoral transcondylar traction was positioned, and 3 weeks later a new prosthesis was reimplanted. At over 1 year after reimplantation she is well.ConclusionsOur findings suggest that microbiologic investigations are mandatory even when prosthetic joint infection is not suspected. Molecular methods for identification of microorganisms can be used in addition to conventional cultures especially when patients are under antibiotic treatment. Daptomycin, ceftazidime and colistin can be administered for several months without side effects. Guidelines specifically addressing the diagnosis and the management of polymicrobial, multidrug-resistant prosthetic joint infections need to be developed.

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