Abstract Objective Research and identification of Cutibacterium acnes (C. acnes) and other microorganisms in deeptissue samples collected in clean shoulder surgeries of patients who did not undergo any previous invasive joint procedure and who had no clinical history of infection. Methods We analyzed the results of cultures of intraoperative deep tissue samples from 84 patients submitted to primary clean shoulder surgery. Tubes containing culture medium were used for storage and transport of anaerobic agents, prolonged incubation time, and mass spectrometer for diagnosis of bacterial agents. Results Bacteria growth was evidenced in 34 patients (40.4%) of the 84 included in the study. Of these, 23 had growth of C. acnes in at least one sample of deep tissue collected, corresponding to 27.3% of the total patients. The second most common agent was Staphylococcus epidermidis, present in 7.2% of the total individuals included. We showed a higher relationship between sample positivity and males, a lower mean age, absence of diabetes mellitus, ASA I score, and antibiotic prophylaxis in anesthetic induction with cefuroxime. Conclusions A high percentage of isolates of different bacteria was found in shoulder tissue samples of patients undergoing clean and primary surgeries, who had no history of previous infection. Identification of C. acnes was high (27.6%), and Staphylococcus epidermidis was the second most frequent agent (7.2%).

Resumo Objetivo Pesquisa e identificação de Cutibacterium acnes (C. acnes) e de outros microrganismos em amostras de tecidos profundos coletados em cirurgias limpas de ombro em pacientes que não foram submetidos a nenhum procedimento invasivo articular prévio e que não possuíam antecedentes clínicos de infecção. Métodos Foram analisados os resultados das culturas de amostras de tecidos profundos intraoperatórias de 84 pacientes submetidos à cirurgia limpa primária do ombro. Foram utilizados tubos contendo meio de cultivo para armazenamento e transporte de agentes anaeróbicos, tempo prolongado de incubação e espectrômetro de massa para diagnósticos de agentes bacterianos. Resultados Foi evidenciado o crescimento de bactérias em 34 pacientes (40,4%) dos 84 incluídos no estudo. Desses, 23 apresentavam crescimento de C. acnes em pelo menos uma amostra de tecido profundo coletada, correspondendo a 27,3% do total de pacientes. O segundo agente mais encontrado foi o Staphylococcus epidermidis, presente em 7,2% do total de indivíduos incluídos. Evidenciamos maior relação da positividade de amostras com o gênero masculino, uma média de idade inferior, a ausência de diabetes mellitus, o escore ASA I e a profilaxia antibiótica na indução anestésica com cefuroxima. Conclusões Verificou-se um elevado percentual de isolados de diferentes bactérias em amostras de tecidos de ombros de pacientes submetidos a cirurgias limpas e primárias e sem histórico de infecção anterior. A identificação de C. acnes foi elevada (27,6%) e o Staphylococcus epidermidis foi o segundo agente mais frequente (7,2%).

ABSTRACT Introduction: cholelithiasis is a highly prevalent disease of the digestive system in the world. In Brazil, it is a routine condition, whose studies suggest a prevalence of around 10% of adults. Colonization of bile and gallstone pathogens can occur when there is bacterial stasis and proliferation. This proliferation is facilitated by the adhesion and biofilm formation capacity of some bacteria. There are also lithogenic processes that involve bacterial participation. Studies have shown changes in the microbiota of the gallbladder of patients undergoing cholecystectomy, which may impact empirical treatment with antibiotics. Methodology: microbiological analyzes of the sonication fluid of the gallstones and of two samples with bile were performed. Identification and antimicrobial susceptibility testing were performed according to a standard routine. Results: of the 34 patients, 76.4% were female. The age group was 48 years +/- 16.61. Acute cholecystitis occurred in 50% of cases. Bactobilia was evidenced in 32.1% of the cases. Klebisiella pneumoniae was noted as the most prevalent pathogen in acute cholecystitis; and Enterobacter sp, in cases of uncomplicated cholelithiasis. Greater sensitivity was obtained in the search for microorganisms in the sonication fluid samples of the stones in relation to the bile samples (p=0.0058). Conclusion: there was a higher prevalence of bactobilia in patients with acute cholecystitis compared to those with uncomplicated cholelithiasis. The use of sonication in bacterial investigation proved to be superior to the conventional method and can be considered.

RESUMO Introdução: a colelitíase é uma doença do sistema digestivo de alta prevalência no mundo. No Brasil, trata-se de uma condição rotineira, cujos estudos sugerem uma prevalência em torno de 10% dos adultos. A colonização de patógenos da bile e do cálculo biliar pode ocorrer quando há estase e proliferação bacteriana. Esta proliferação é facilitada pela capacidade de adesão e de formação de biofilme de algumas bactérias. Também há processos litogênicos que envolvem a participação bacteriana. Estudos evidenciaram mudanças na microbiota da vesícula biliar de pacientes submetidos à colecistectomia, o que pode impactar no tratamento empírico com antibióticos. Metodologia: Realizou-se análises microbiológicas do fluido de sonicação dos cálculos biliares e de duas amostras com bile. A identificação e o teste de sensibilidade aos antimicrobianos foram realizados de acordo com uma rotina padrão. Resultados: Nos 34 pacientes, 76,4% deles foram do sexo feminino. A faixa etária foi de 48 anos +/- 16,61. A colecistite aguda ocorreu em 50% dos casos. A bactobilia foi evidenciada em 32,1% dos casos. Notou-se Klebisiella pneumoniae como o patógeno mais prevalente em quadros de colecistite aguda; e Enterobacter sp, nos casos de colelitíase não complicada. Obteve-se maior sensibilidade na pesquisa de microrganismos nas amostras de fluido de sonicação dos cálculos em relação às de bile (p=0,0058). Conclusão: Houve maior prevalência de bactobilia nos pacientes com colecistite aguda em relação àqueles com colelitíase não complicada. A utilização da sonicação na investigação bacteriana se mostrou superior ao método convencional e pode ser considerada.

ABSTRACT Objective: Evaluating the clinical results of bioactive glass S53P4 putty for the treatment of cavitary chronic osteomyelitis. Methods: Retrospective observational study, including patients of any age with clinical and radiological diagnosis of chronic osteomyelitis, who underwent surgical debridement and implantation of bioactive glass S53P4 putty (BonAlive® Putty, Turku, Finland). Patients who underwent any plastic surgery on the soft tissues of the affected site or had segmental bone lesions or septic arthritis were excluded. Statistical analysis was performed using Excel®. Demographic data, as well as data on the lesion, treatment, and follow-up, were collected. Outcomes were classified as “disease-free survival,” “failure,” or “indefinite.” Results: This study included 31 patients, of which 71% were men and had with a mean age of 53.6 years (SD ± 24.2). In total, 84% were followed-up for at least 12 months and 67.7% had comorbidities. We prescribed combination antibiotic therapy for 64.5% of patients. In 47.1%, Staphylococcus aureus was isolated. Finally, we classified 90.3% of cases as “disease-free survival” and 9.7% as “indefinite.” Conclusion: Bioactive glass S53P4 putty is safe and effective to treat cavitary chronic osteomyelitis, including infections by resistant pathogens, such as methicillin-resistant S. aureus. Level of Evidence IV, Case Series.

RESUMO Objetivo: Avaliar a atividade do vidro bioativo S53P4 em pasta no tratamento de osteomielite crônica. Métodos: Estudo observacional retrospectivo, com inclusão de indivíduos de qualquer idade com diagnóstico clínico e radiológico de osteomielite que realizaram tratamento cirúrgico com limpeza e desbridamento, seguido do preenchimento da cavidade com biovidro S53P4 em pasta (BonAlive ® Putty, Turku, Finland). Foram excluídos pacientes submetidos a procedimentos de cirurgia plástica nos tecidos moles do local afetado, com lesões ósseas segmentares e com presença de artrite séptica. A análise estatística foi realizada em Excel ® . Foram coletados dados demográficos, sobre a lesão, o tratamento e o acompanhamento. O desfecho foi classificado em “sobrevida livre de doença”, “falha” ou “indeterminado”. Resultados: Dos 31 pacientes analisados, 71% eram homens, com idade média de 53,6 anos (DP ± 24,26). Do total, 84% foram acompanhados por no mínimo 12 meses, e 67,7% apresentaram comorbidades. A terapia antibiótica combinada foi realizada em 64,5% dos pacientes, sendo o patógeno mais frequente o Staphylococcus aureus (47,1%). Ao final, 90,3% dos pacientes obtiveram “sobrevida livre de doenças” e 9,7% foram considerados “indeterminados”. Conclusão: O vidro bioativo S53P4 em pasta é seguro e eficaz no tratamento da osteomielite cavitária e de infecções por patógenos resistentes, incluindo o S. aureus multirresistente. Nível de Evidência IV, Série de Casos.

ABSTRACT Objective: To determine the frequency of reoperations in the treatment of adult patients diagnosed with septic arthritis of the knee, the average number of debridements needed to control the infection, the mortality rate, and to assess factors associated with a greater need for reoperation and mortality. Methods: Retrospective cohort study evaluating 38 adult patients diagnosed with septic arthritis who underwent arthrotomy via a medial parapatellar approach for joint cleaning and debridement. Demographic, clinical, surgical, and microbiological variables of the cases were analyzed by review of medical records. Tests for equality of two proportions, chi-square, and multivariate logistic regression analysis were performed, defining a significance level at 0.05, with 95% confidence interval. Results: A total of 50% of the cases underwent reoperation, with an average number of required debridement of 2.02 and a mortality rate of 10.5%. Patients with infection caused by Staphylococcus aureus were more likely to need a reoperation compared to patients with positive cultures for other agents (OR 6.0). Conclusion: In 50% of cases, an average of 2.02 debridements were necessary and the mortality rate was 10.5%. Staphylococcus aureus infection is associated with a 6 times greater chance of additional surgeries. /Level of Evidence IV, Case Series.

RESUMO Objetivo: Determinar a frequência de reabordagens cirúrgicas no tratamento de pacientes adultos com diagnóstico de artrite séptica do joelho, a média de desbridamentos necessários para o controle da infecção e a taxa de mortalidade, assim como avaliar os fatores associados à maior necessidade de reabordagem e mortalidade. Métodos: Estudo retrospectivo tipo coorte que avaliou 38 pacientes adultos com diagnóstico de artrite séptica submetidos à artrotomia por via parapatelar medial para limpeza e desbridamento da articulação. Foram analisadas variáveis demográficas, clínicas, cirúrgicas e microbiológicas dos casos, por revisão de prontuário médico, e realizados testes de igualdade de duas proporções, qui-quadrado e análise multivariada de regressão logística, sendo definido um nível de significância de 0,05, com 95% de confiança estatística. Resultados: 50% dos casos foram submetidos à reabordagem cirúrgica, sendo a média de desbridamentos necessários de 2,02 e a taxa de mortalidade de 10,5%. Pacientes com infecção causada por Staphylococcus aureus apresentaram mais chances de necessitar de reabordagem quando comparados aos pacientes com culturas positivas para outros agentes (OR 6,0). Conclusão: Em 50% dos casos foram necessários, em média, 2,02 desbridamentos e a taxa de mortalidade foi de 10,5%. A infecção por Staphylococcus aureus está associada com seis vezes mais chances de cirurgias adicionais. Nível de Evidência IV, Série de Casos.

RESUMO Objetivo: Avaliar as características epidemiológicas da infecção pós-operatória nas cirurgias com instrumentação da coluna vertebral no nosso serviço, assim como se há correlação entre a taxa de infecção pós-operatória e a etiologia da indicação do procedimento cirúrgico primário. Metodologia: Foi realizada uma busca retrospectiva por meio dos prontuários de pacientes submetidos a cirurgia da coluna vertebral com instrumentação em nosso hospital entre 2015 e 2019, e que evoluíram com infecção pós-operatória aguda ou crônica com necessidade de limpeza cirúrgica para sua resolução. Foram excluídos os casos de cirurgias não instrumentadas, casos de infecção primária da coluna (osteomielite e espondilodiscite) e casos de infecção superficial da ferida operatória sem necessidade de limpeza cirúrgica. Resultados: A taxa de infeção pós-operatória foi de 11,6%. Deste grupo de pacientes que evoluíram com essa complicação a maioria foi submetida a cirurgia primariamente por trauma (38,9%), seguido de doença degenerativa (30,8%), indicação oncológica (19,2%), e deformidade (15,4%). Porém quando analisamos esses pacientes comparando-os com o total de casos de cirurgia na coluna vertebral com instrumentação realizadas no período, obtivemos uma prevalência maior de infecção em pacientes operados por deformidade (17,6%), seguido de doença degenerativa (13%), doença oncológica (11,4%) e trauma (9,9%). Essa diferença não mostrou ser estatisticamente significativa (p=0,79), assim como a correlação com sexo e idade. Conclusão: Em nosso estudo, proporcionalmente, houve diferença na prevalência de infecção pós-operatória de acordo com a indicação etiológica, sendo maior nos casos operados por deformidade, principalmente em decorrência de doença neuromuscular. Nível de evidência IV; Estudo terapêutico de série de casos.

ABSTRACT Objective: To evaluate the epidemiological characteristics of postoperative infection in surgeries of the spine with instrumentation in our service, and whether there is a correlation between the rate of postoperative infection and the etiology of the indication for the primary surgical procedure. Methodology: A retrospective search through medical records of patients who underwent spinal surgery with instrumentation in our hospital between 2015 and 2019 was performed, and the ones that evolved with acute or chronic postoperative infection with need for surgical cleaning to resolve it were selected. Cases of non-instrumented surgery, primary infection of the spine (osteomyelitis and spondylodiscitis) and superficial infection of the surgical wound without the need for surgical cleaning were excluded. Results: The rate of postoperative infection was 11.6%. In this group of patients who evolved with this complication, most were submitted to surgery primarily for trauma (38.9%), followed by degenerative disease (30.8%), neoplasm (19.2%), and deformity (15, 4%). However, when we analyzed these patients comparing them with the total number of cases of spinal surgery with instrumentation performed in the period, we obtained a higher prevalence of infection in patients operated for deformity (17.6%), followed by degenerative disease (13%), neoplasm (11.4%) and trauma (9.9%). This difference did not prove to be statistically significant (p = 0.79), nor the correlation with sex and age. Conclusion: In our study, proportionally, there was a difference in the prevalence of postoperative infection according to the etiological indication, being higher in cases operated for deformity, mainly due to neuromuscular disease. Level of evidence IV; A case series therapeutic study.

RESUMEN Objetivo: evaluar las características epidemiológicas de la infección postoperatoria en cirugías de columna con instrumentación en nuestro servicio, así como si existe una correlación entre la tasa de infección postoperatoria y la etiología de la indicación para el procedimiento quirúrgico primario. Metodología: se realizó una búsqueda retrospectiva a través de los registros médicos de pacientes que se sometieron a cirugía de columna con instrumentación en nuestro hospital entre 2015 y 2019, y que evolucionaron con infección postoperatoria aguda o crónica con necesidad de una limpieza quirúrgica para resolverlo. Se excluyeron los casos de cirugía no instrumentada, infección primaria de la columna (osteomielitis y espondilodiscitis) y infección superficial de la herida quirúrgica sin necesidad de limpieza. Resultados: la tasa de infección postoperatoria fue del 11,6%. De este grupo de pacientes que evolucionaron con esta complicación, la mayoría fueron sometidos a cirugía principalmente por trauma (38.9%), seguidos de enfermedad degenerativa (30.8%), neoplasia (19.2%) y deformidad (15, 4%). Sin embargo, cuando analizamos a estos pacientes comparándolos con el número total de casos de cirugía de columna con instrumentación realizada en el período, obtuvimos una mayor prevalencia de infección en pacientes operados por deformidad (17,6%), seguido de enfermedad degenerativa (13%), neoplasia (11.4%) y trauma (9.9%). Esta diferencia no resultó ser estadísticamente significativa (p = 0,79), así como la correlación con el sexo y la edad. Conclusión: En nuestro estudio, proporcionalmente, hubo una diferencia en la prevalencia de infección postoperatoria según la indicación etiológica, siendo mayor en los casos operados por deformidad, principalmente debido a enfermedad neuromuscular. Nivel de evidencia IV; Estudio terapéutico de serie de casos.

RESUMO Objetivo: A tuberculose (TB) é uma das dez principais causas de morte no mundo. O início insidioso e os sintomas inespecíficos geralmente resultam em atraso do diagnóstico. O objetivo é avaliar as características dos pacientes com espondilodiscite tuberculosa em acompanhamento, em um hospital de referência sul-americano. Método: Avaliação retrospectiva de dados de prontuários, diagnóstico de tuberculose da coluna vertebral entre 2009 e 2018, de ambos os sexos, entre 0 e 80 anos de idade. As variáveis foram analisadas com base em grupos: epidemiológicas, clínicas, laboratoriais, microbiológicas, exames de imagem e tratamento. Resultados: Total de 26 casos, cerca de 80,8% do sexo masculino, média de idade de 41,6 ± 22,46 anos. A dor axial foi o sintoma mais prevalente (84,6%), o escore da EVA foi de 6,85 ± 2,87. A média de tempo entre o início dos sintomas e o diagnóstico foi de 23,8 ± 24,1 semanas (4-96). A região mais acometida foi a coluna torácica (50% dos casos). A maioria (61,4%) dos participantes apresentou função neurológica inalterada (Frankel D e E) no início do tratamento e 6 meses depois, sendo que 84,5% obtiveram melhora. No tratamento, 34,6% necessitaram de cirurgia, e a principal indicação foi déficit neurológico isolado (55,5%). O procedimento mais realizado foi descompressão e artrodese (55,5%). O tempo médio até a cura foi de 12,0 ± 8,8 meses (8-48). Conclusão: Doença de início insidioso, sintomas inespecíficos, grande frequência de exames microbiológicos negativos em casos com a doença. A menor parte dos casos necessitou de tratamento cirúrgico e a maioria apresentou boa recuperação neurológica. Nível de evidência IV; Série de casos.

ABSTRACT Objective: Tuberculosis (TB) represents one of the top ten causes of death in the world. Its insidious onset and nonspecific symptoms usually result in delayed diagnosis. The objective is to evaluate the characteristics of patients with tuberculous spondylodiscitis in follow-up at a South American reference hospital. Method: Retrospective evaluation of the medical records of patients of both sexes and between 0 and 80 years of age diagnosed with tuberculosis of the spine between 2009 and 2018. The variables were analyzed based on groups: epidemiological, clinical, laboratorial, microbiological, imaging tests and treatment. Results: Total of 26 cases, about 80.8% male, mean age 41.6 ± 22.46 years. Axial pain was the most prevalent symptom (84.6%), the VAS score was 6.85 ± 2.87. The mean time between symptom onset and diagnosis was 23.8 ± 24.1 weeks (4-96). The most affected region was the thoracic spine (50% of the cases). Most participants (61.4%) had no change in neurological function (Frankel D and E) at the beginning of treatment and after 6 months, and 84.5% improved. During treatment 34.6% required surgery and the main indication was isolated neurological deficit (55.5%). The most frequently performed procedure was decompression and arthrodesis (55.5%). The average time to cure was 12.0 ± 8.8 months (8-48). Conclusion: Disease with insidious onset, nonspecific symptoms, high frequency of negative microbiological tests in cases with the disease. A small number of the cases required surgical treatment and most of them achieved good neurological recovery. Level of evidence IV; Case series.

RESUMEN Objetivo: La tuberculosis (TB) es una de las diez principales causas de muerte en el mundo. El inicio insidioso y los síntomas inespecíficos generalmente resultan en atraso del diagnóstico. El objetivo es evaluar las características de los pacientes con espondilodiscitis tuberculosa en acompañamiento en un hospital de referencia sudamericano. Método: Evaluación retrospectiva de datos de historiales clínicos, diagnóstico de tuberculosis de la columna vertebral entre 2009 y 2018, de ambos sexos, entre 0 y 80 años de edad. Las variables fueron analizadas con base en grupos: epidemiológicas, clínicas, de laboratorio, microbiológicas, exámenes de imagen y tratamiento. Resultados: Total de 26 casos, cerca de 80,8% del sexo masculino, promedio de edad de 41,6 ± 22,46 años. El dolor axial fue el síntoma más prevalente (84,6%). El puntaje de la EVA fue de 6,85 ± 2,87. El promedio de tiempo entre el inicio de los síntomas y el diagnóstico fue de 23,8 ± 24,1 semanas (4-96). La región más acometida fue la columna torácica (50% de los casos). La mayoría (61,4%) de los participantes presentó función neurológica inalterada (Frankel D y E) al inicio del tratamiento y seis meses después, siendo que 84,5% obtuvo mejora. En el tratamiento, 34,6% precisó cirugía, y la principal indicación fue déficit neurológico aislado, (55,5%). El procedimiento más realizado fue descompresión y artrodesis (55,5%). El tiempo promedio hasta la cura fue de 12,0 ± 8,8 meses (8-48). Conclusión: Enfermedad de inicio insidioso, síntomas inespecíficos, alta frecuencia de exámenes microbiológicos negativos en casos con la enfermedad. La menor parte de los casos requirió tratamiento quirúrgico y la mayoría presentó buena recuperación neurológica. Nivel de evidencia IV; Serie de casos.

ABSTRACT Background: Community-genotype methicillin-resistant Staphylococcus aureus (CG-MRSA) emerged in the 1990s as a global community pathogen primarily involved in skin and soft tissue infections (SSTIs) and pneumonia. To date, the CG-MRSA SSTI burden in Latin America (LA) has not been assessed. Objective: The main objective of this study was to report the rate and genotypes of community-genotype methicillin-resistant Staphylococcus aureus (CG-MRSA) causing community-onset skin and soft tissue infections (CO-SSTIs) in LA over the last two decades. In addition, this research determined relevant data related to SSTIs due to CG-MRSA, including risk factors, other invasive diseases, and mortality. Data sources: Relevant literature was searched and extracted from five major databases: Embase, PubMed, LILACS, SciELO, and Web of Science. Methods: A systematic review was performed, and a narrative review was constructed. Results: An analysis of 11 studies identified epidemiological data across LA, with Argentina presenting the highest percentage of SSTIs caused by CG-MRSA (88%). Other countries had rates of CG-MRSA infection ranging from 0 to 51%. Brazil had one of the lowest rates of CG-MRSA SSTI (4.5–25%). In Argentina, being younger than 50 years of age and having purulent lesions were predictive factors for CG-MRSA CO-SSTIs. In addition, the predominant genetic lineages in LA belonged to sequence types 8, 30, and 5 (ST8, ST30, and ST5). Conclusion: There are significant regional differences in the rates of CG-MRSA causing CO-SSTIs. It is not possible to conclude whether or not CG-MRSA CO-SSTIs resulted in more severe SSTI presentations or in a higher mortality rate.

RESUMO Objetivo Descrever as características epidemiológicas e clínicas de pacientes com espondilodiscite piogênica tratados em um hospital brasileiro. Métodos Trata-se de estudo retrospectivo de pacientes com diagnóstico de espondilodiscite inespecífica. Foram incluídos pacientes de ambos os sexos, acima de 18 anos, com tempo de seguimento mínimo de seis meses. Foram analisados dados epidemiológicos, laboratoriais e clínicos. Resultados Nove pacientes foram incluídos. A média de idade foi de 64 anos, sendo sete homens (77,7%) e duas mulheres (22,2%). Todos os pacientes avaliados tinham dorsalgia. O local mais acometido foi a coluna lombar (44,4%). Apenas três pacientes (33,3%) apresentaram febre e cinco (55%), sintomas constitucionais. O tempo médio de sintomas antes do diagnóstico foi de 2,5 (± 1,5) semanas. Apenas quatro pacientes (44,4%) tiveram culturas positivas. Cinco pacientes (55,5%) apresentaram alteração neurológica. Ao término do tratamento, dois pacientes melhoraram um nível no escore de Frankel, dois pacientes melhoraram dois níveis. A principal indicação para cirurgia foi déficit neurológico (55,5%). Dois pacientes avaliados foram a óbito em decorrência do quadro infeccioso. Conclusões Menos da metade dos pacientes com espondilodiscite piogênica tiveram febre ou sintomas constitucionais. A dorsalgia estava presente em todos os casos. Em menos da metade dos pacientes foi possível isolar o microrganismo responsável. A maioria dos pacientes foi submetida a tratamento cirúrgico, embora nem todos tiveram melhora do déficit neurológico. Nível de evidência II; Estudo Retrospectivo.

ABSTRACT Objective To describe the epidemiological and clinical characteristics of patients with pyogenic spondylodiscitis treated in a Brazilian hospital. Methods This is a retrospective study of patients diagnosed with nonspecific spondylodiscitis. Patients of both sexes, above 18 years of age with a minimum follow-up time of 6 months were included. Epidemiological, laboratory, and clinical data were analyzed. Results Nine patients were included. The mean age was 64 years, with seven men (77.7%) and two women (22.2%). All patients evaluated had back pain. The most affected location was the lumbar spine (44.4%). Only three patients (33.3%) had fever and five (55%) had constitutional symptoms. The mean duration of symptoms before diagnosis was 2.5 (± 1.5) weeks. Only four patients (44.4%) had positive cultures. As for neurological status, five patients (55.5%) presented neurological change. At the end of treatment, two patients improved one level in the Frankel score and two patients improved two levels. The main indication for surgery was neurological deficit (55.5%). Two of the patients evaluated died as a result of an infectious condition. Conclusions Less than half of the patients with pyogenic spondylodiscitis had fever or constitutional symptoms. Back pain was present in all cases. In less than half of the patients it was possible to isolate the responsible microorganism. Most patients underwent surgical treatment, although not all improved from the neurological deficit. Level of evidence II; Retrospective study.

RESUMEN Objetivo Describir las características epidemiológicas y clínicas de pacientes con espondilodiscitis piógena tratados en un hospital brasileño. Métodos Se trata de un estudio retrospectivo de pacientes con diagnóstico de espondilodiscitis inespecífica. Fueron incluidos pacientes de ambos sexos, mayores de 18 años, con tiempo de seguimiento mínimo de seis meses. Fueron analizados datos epidemiológicos, de laboratorio y clínicos. Resultados Se incluyeron nueve pacientes. El promedio de edad fue de 64 años, siendo siete hombres (77,7%) y dos mujeres (22,2%). Todos los pacientes evaluados tenían dolor de espalda. El local más acometido fue la columna lumbar (44,4%). Sólo tres pacientes (33,3%) presentaron fiebre y cinco (55%) síntomas constitucionales. El tiempo promedio de síntomas antes del diagnóstico fue de 2,5 (± 1,5) semanas. Sólo cuatro pacientes (44,4%) tuvieron cultivos positivos. Cinco pacientes (55,5%) presentaron alteración neurológica. Al término del tratamiento, dos pacientes mejoraron un nivel en la escala de Frankel, dos pacientes mejoraron dos niveles. La principal indicación para cirugía fue el déficit neurológico (55,5%). Dos pacientes evaluados fueron a óbito como consecuencia del cuadro infeccioso. Conclusiones Menos de la mitad de los pacientes con espondilodiscitis piógena tuvieron fiebre o síntomas constitucionales. El dolor de espalda estuvo presente en todos los casos. En menos de la mitad de los pacientes fue posible aislar el microorganismo responsable. La mayoría de los pacientes fue sometida a tratamiento quirúrgico, aunque no todos tuvieron mejora del déficit neurológico. Nivel de evidencia II; Estudio retrospectivo.

ABSTRACT Purposes: Shoulder arthroplasty (SA) has been performed by many years for the treatment of several conditions, including osteoarthritis and proximal humeral fractures following trauma. Surgical site infection (SSI) following Shoulder arthroplasty remains a challenge, contributing to increased morbidity and costs. Identification of risk factors may help implementing adequate strategies to prevent infection. We aimed to identify pre- and intra-operative risk factors associated with deep infections after Shoulder arthroplasty. Methods: An unmatched case-control study was conducted to describe the prevalence, clinical and microbiological findings, and to evaluate patient and surgical risk factors for prosthetic shoulder infection (PSI), among 158 patients who underwent SA due to any reason, at a tertiary public university institution. Risk factors for PSI was assessed by uni- and multivariate analyses using multiple logistic regression. Results: 168 SA from 158 patients were analyzed, with an overall infection rate of 9.5% (16/168 cases). Subjects undergoing SA with American Society of Anesthesiologists (ASA) grade III or higher (odds ratio [OR] = 5.30, 95% confidence interval [CI] = 1.58-17.79, p < 0.013) and presenting local hematoma after surgery (odds ratio [OR] = 7.10, 95% confidence interval [CI] = 1.09-46.09, p = 0.04) had higher risk for PSI on univariate analysis. However, only ASA score grade III or higher remained significant on multivariate analysis (OR = 4.74, 95% CI = 1.33-16.92, p = 0.016). Gram-positive cocci and Gram-negative bacilli were equally isolated in 50% of cases; however, the most commonly detected bacterium was Pseudomonas aeruginosa (18.7%). Conclusion: This study provides evidence suggesting that patient-related known factors such as higher ASA score predisposes to shoulder arthroplasty-associated infection. Furthermore, unusual pathogens associated with PSI were identified.

Abstract Objectives To compare cultured microorganisms identified on endotracheal tubes biofilms through sonication technique with traditional tracheal aspirate collected at extubation of pediatric intensive care unit patients. Methods Demographic and epidemiological data were analyzed to identify factors possibly related with the microbiological profile of the two collection methods. Associations between categorical and continuous variables were analyzed using the chi-square or Fisher's exact test, or Student's t test. p-Value <0.05 were considered significant. Results Thirty endotracheal tubes and tracheal aspirates samples from 27 subjects were analyzed. Only one patient presented the clinical diagnosis of ventilator-associated pneumonia. Overall, 50% of bacteria were Gram-negative bacilli, followed by Gram-positive bacteria in 37%, and fungi in 10%. No statistically significant difference on the distribution of Gram-positive or Gram-negative bacteria (p = 0.996), and fungi (p = 0.985) were observed between the collection methods. Pseudomonas spp. was the most frequent microorganism identified (23.8%), followed by Streptococcus spp. (18.5%), Acinetobacter spp. (15.9%), coagulase-negative staphylococci (11.2%), and Klebsiella spp. (8.6%). Concordant results between methods amounted to 83.3%. Pseudomonas aeruginosa and Acinetobacter baumannii showed carbapenem resistance in 50% and 43.7% of the isolates, respectively. In general, cultures after endotracheal tubes sonication (non-centrifuged sonication fluid and centrifuged sonication fluid) yielded bacteria with higher rates of antimicrobial resistance compared to tracheal aspirates cultures. Additionally, in 12 subjects (40%), we observed discrepancies regarding microbiologic profiles of cultures performed using the collection methods. Conclusions Our study demonstrated that sonication technique can be applied to ET biofilms to identify microorganisms attached to their surface with a great variety of species identified. However, we did not find significant differences in comparison with the traditional tracheal aspirate culture approach.

Objectives:To identify and compare the rate of success of therapeutic modalities applied in surgeries for the treatment of infections associated with total knee arthroplasty (TKA), and to evaluate the functional outcome and pain in different therapeutic modalities by means of quality of life scores.Methods:We evaluated all patients who developed periprosthetic infection after TKA for primary or secondary osteoarthritis, in the period from January 1st, 2008 to December 31st, 2010.Results:In the study period, 29 patients with TKA had infection, and 12 of these underwent debridement and retention of the prosthesis (D+R), seven received two-stage and six one-stage exchange arthroplasties, and four patients were treated with suppressive antibiotic therapy because they could not undergo another surgical procedure.Conclusion:The D+R, one-stage revision and two-stage revision success rates were 75%, 83.3%, and 100%, respectively. The best results of quality of life (QoL) and function occur in patients undergoing D+R. In contrast, the worst QoL and functional results were obtained in patients treated with two-stage revision arthroplasty. Level of Evidence II, Prognostic Studies - Investigating the Effect of a Patient Characteristic on the Outcome of Disease.

Candida infections account for 80% of all fungal infections in the hospital environment, including bloodstream, urinary tract and surgical site infections. Bloodstream infections are now a major challenge for tertiary hospitals worldwide due to their high prevalence and mortality rates. The incidence of candidemia in tertiary public hospitals in Brazil is approximately 2.5 cases per 1000 hospital admissions. Due to the importance of this infection, the authors provide a review of the diversity of the genus Candida and its clinical relevance, the therapeutic options and discuss the treatment of major infections caused by Candida. Each topography is discussed with regard to epidemiological, clinical and laboratory diagnostic and therapeutic recommendations based on levels of evidence.

OBJETIVOS: Estudar a presença, forma de apresentação e as conseqüências da hipotermia em nosso meio. MÉTODOS: Estudo prospectivo em hipotérmicos atendidos no Serviço de Emergência de Clínica Médica da Santa Casa de São Paulo, com 212 pacientes com hipotermia leve, moderada e grave, entre 1987 a 2001, a maioria constituída por alcoólatras crônicos e moradores de rua. Foram analisados os resultados quanto ao sexo, faixa etária, temperatura central, eletrocardiograma, comorbidades e mortalidade. RESULTADOS: A hipotermia predominou no sexo masculino em 75,9%. Quanto à faixa etária prevaleceu a idade entre 30 e 59 anos. Em 70,3% dos pacientes a temperatura central foi inferior a 32ºC, sendo que em 26,4% destes, a temperatura foi menor que 28ºC. A associação com quadros infecciosos ocorreu em 76,8% dos casos. Os pacientes com hipotermia leve responderam melhor à terapêutica (96,8%) quando comparados com os hipotérmicos moderados (72,1%) e graves (87,5%). A onda de Osborn esteve presente em 42,6% dos pacientes. A mortalidade geral foi de 38,2%. CONCLUSÕES: A hipotermia acidental em serviços de emergência de país tropical é fato inegável. O socorrista deve estar atento e treinado para o reconhecimento desta doença de alta morbidade e mortalidade. A mortalidade aumenta com a presença de doenças associadas, particularmente processos infecciosos, desnutrição e alcoolismo crônico.

OBJECTIVE: This paper has by objective to study the hypothermia's presence, presentation form and consequences in our environment. METHODS: A prospective study in hypothermic patients assisted in the Medical Clinic Emergency Service of Santa Casa of São Paulo, with 212 patients with mild, moderate and serious hypothermia from 1987 to 2001, the most part of them constituted by chronic alcoholics and homeless. The results were analyzed in reference to sex, age group, central temperature, electrocardiogram, co-morbidity and mortality. RESULTS: The hypothermia prevailed in the male sex with 75.9%. As age group prevailed the age between 30 and 59 years. In 70.3% of the patients the central temperature went lower than 32°C, and in 26.4% of these, the temperature was lower than 28°C. The association with infectious processes happened in 76.8% of the cases. The patients with mild hypothermia answered better at therapeutics (96.8%) when compared with the moderate hypothermic (72.1%) and serious (87.5%) patients. The Osborn's wave was present in 42.6% of the patients. The general mortality was 38.2%. CONCLUSIONS: The accidental hypothermia in Emergency Services from Tropical Country is an undeniable fact. The paramedic and medics should be alert and trained to recognize this disease of high morbidity and mortality. The mortality increases with the presence of associated diseases, particularly infectious processes, malnutrition and chronic alcoholism.

CONTEXTO: O tromboembolismo pulmonar é a terceira doença cardiovascular aguda mais freqüente como causa de morbidade e mortalidade. A incidência de embolia pulmonar em necropsias não se modificou nas últimas décadas. Doenças cardíacas, neoplasias, traumas, cirurgias recentes e doenças sistêmicas são condições clínicas predisponentes importantes. A relação entre os sexos masculino e feminino é estimada em 1,24. Vários estudos mostram aumento da morbidade no inverno. Há grande dificuldade para o diagnóstico anátomo-patológico preciso quanto a localização dos êmbolos nos vasos pulmonares, havendo preferência por localizarem-se no pulmão direito e lobos inferiores. OBJETIVO: Estudar a incidência de tromboembolismo pulmonar letal e não letal, de acordo com variáveis epidemiológicas e anatômicas. TIPO DE ESTUDO: Estudo retrospectivo realizado através relatórios dos laudos de necropsias. LOCAL: Hospital Universitário de atendimento terciário. AMOSTRA: 16.466 necropsias consecutivas realizadas de janeiro de 1972 a dezembro de 1995. VARIÁVEIS ESTUDADAS: Freqüência de tromboembolismo pulmonar letal e não letal, doenças predisponentes, ocorrência de acordo com as estações do ano e o local de impactação do êmbolo. RESULTADOS: O tromboembolismo pulmonar foi encontrado em 4,7% de todas as necropsias realizadas. Houve predomínio dos casos letais (68,2%). Não houve diferença em relação ao sexo ou estações do ano para a ocorrência desta doença. As doenças cardiovasculares estiveram mais freqüentemente associadas aos fenômenos tromboembólicos. Quanto ao local de impactação do êmbolo, houve maior incidência no comprometimento bilateral de vários segmentos dos pulmões. CONCLUSÃO: Durante o período deste estudo observou-se que houve redução na incidência de tromboembolismo pulmonar, provavelmente pelo aumento de medidas profiláticas nas últimas décadas. Contudo, a freqüência de tromboembolismo letal predominou, provavelmente em função da instalação abrupta do quadro com acometimento de grande área pulmonar, falta de suspeita clínica e portanto do diagnóstico precoce e, demora da instituição de terapêutica fibrinolítica nos casos com repercussão hemodinâmica ou com grande número de segmentos pulmonares afetados.

CONTEXT: Pulmonary thromboembolism is the third most frequent cause of morbidity and mortality among acute cardiovascular diseases. The incidence of pulmonary embolism in necropsies has remained unchanged over the last few decades. Cardiac diseases, neoplasia, trauma, recent surgery and systemic diseases are important predisposing clinical conditions. The relationship between male and female sexes is estimated at 1.24. Various studies have shown an increase in morbidity in spring and autumn. There is great difficulty in precise anatomopathological diagnosis in relation to the localization of the emboli in the pulmonary vessels, although they are preferentially located in the right lung and lower lobes. OBJECTIVE: To study the incidence of lethal and non-lethal pulmonary thromboembolism in relation to epidemiological and anatomical variables. DESIGN: Retrospective study performed via reports on the necropsy findings. SETTING: University hospital providing tertiary-level attendance. SAMPLE: 16,466 consecutive necropsies performed from January 1972 to December 1995. MAIN MEASUREMENTS: Frequency of lethal and non-lethal pulmonary thromboembolism, predisposing diseases, occurrence in relation to the seasons of the year, and location where the embolus is lodged. RESULTS: Pulmonary thromboembolism was found in 4.7% of all the necropsies performed. There was a predominance of lethal cases (68.2%). There was no difference in relation to sex or seasons of the year for the occurrence of this disease. Cardiovascular diseases were more frequently associated with thromboembolic phenomena. With regard to the location where the embolus was lodged, various lung segments showed greater incidence of being bilaterally compromised. CONCLUSION: Over the period of this study, it was observed that there was a reduction in the incidence of pulmonary thromboembolism, which was probably due to the increase in prophylactic measures over the last few decades. Nonetheless, lethal thromboembolism predominated in frequency, probably because of the abrupt onset of a condition of attack across a large area of the lung, lack of clinical suspicions and consequently a lack of early diagnosis, and delay in instituting fibrinolytic therapy in the cases with hemodynamic repercussions or a large number of lung segments affected.