Original Citation:Prevention of pin track infection in external fixation with silver coated pins: clinical and microbiological results.
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Bone penetration of both glycopeptides ranged from poor (<15%) to satisfactory (15-30%) in the cortical compartment, while it was far higher into the highly vascularized cancellous tissue. Vancomycin bone penetration was slightly higher than with teicoplanin, but the difference was not statistically significant. Higher bone concentrations were observed with higher inflammatory markers, possibly as a result of increased vascularization and vascular permeability under inflammatory conditions. Bone concentrations over the MIC and AUC/MIC ratios suggested that both glycopeptides achieve a satisfactory pharmacokinetic exposure in the cancellous bone, as far as Gram-positive pathogens are concerned. On the other hand, cortical bone exposure was suboptimal in most patients. Furthermore, as antimicrobial penetration may be affected by impaired blood supply, the role of radical surgical removal of purulent and necrotic tissues appears to be essential in order to shorten treatment duration and to reduce the risk of treatment failure.
We report a case of osteomyelitis caused by Enterobacter cancerogenus resistant to aminopenicillins in a 56-year-old male who had a motorcycle accident and suffered from multiple bone fractures with abundant environmental exposure. E. cancerogenus has rarely been associated with human infections, and its clinical significance remains unclear.
CASE REPORTA previously healthy 56-year-old lawyer had a severe motorcycle accident, in which he was thrown onto the ground. He suffered from an open fracture of the proximal third of the right leg, a right acromioclavicular (AC) luxation and multiple fractures in other body parts.He immediately underwent surgery with reduction and external fixation of the open tibial fracture. A single dose of cefamandole (2 g) given intravenously (i.v.) was administered as prophylaxis at the time of anesthesia. Empirical therapy with amoxicillin-clavulanic acid (2.2 g given i.v. every 8 h) and metronidazole (500 mg given i.v. every 8 h) was introduced, starting from the day following the intervention. A week later, another surgery was performed in order to reduce the AC luxation and to insert an external fixator on the right ulna. Metronidazole therapy was stopped after 2 weeks.Four weeks after admission, while on continued antibiotic treatment with amoxicillin-clavulanic acid, the patient started complaining of increasing leg pain, with concomitant appearance of spontaneous purulent drainage from the wound on the anterior tibial side. The patient remained apyretic with normal white blood cells, an erythrocyte sedimentation rate of 38 mm/h, C-reactive protein level of 8.2 mg/liter (normal values, 0 to 5 mg/liter), and fibrinogen level of 445 mg/dl. An X-ray of the right leg showed that the fracture had not healed.
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