{"id":1320,"date":"2017-09-28T13:28:32","date_gmt":"2017-09-28T11:28:32","guid":{"rendered":"http:\/\/www.newslab.sk\/2017\/09\/28\/infekcie-bedrovych-endoprotez\/"},"modified":"2017-10-04T14:16:29","modified_gmt":"2017-10-04T12:16:29","slug":"infections-of-the-hip-endoprostheses","status":"publish","type":"post","link":"https:\/\/www.newslab.sk\/en\/infections-of-the-hip-endoprostheses\/","title":{"rendered":"Infections of the hip endoprostheses"},"content":{"rendered":"<pre><span style=\"color: #ff0000;\"><strong>*All tables, charts, graphs and pictures that are featured in this article can be found in the .pdf \r\nattachment at the end of the paper. \r\n\r\n<\/strong><\/span><\/pre>\n<p><strong>\u00davod<\/strong><\/p>\n<p>Infekcia bedrovej endoprot\u00e9zy je jedna z troch naj\u010dastej\u00ad\u0161\u00edch komplik\u00e1ci\u00ed, ku ktorej doch\u00e1dza po primoimplant\u00e1cii k\u013a\u00adbovej n\u00e1hrady v r\u00f4znom \u010dasovom odstupe. Nie je naj\u010dastej\u00ad\u0161ia, ale patr\u00ed medzi najob\u00e1vanej\u0161ie a najz\u00e1va\u017enej\u0161ie lok\u00e1lne komplik\u00e1cie<sup>(1<\/sup>&#8216;<sup>2)<\/sup>. Definuje sa ako rast a mno\u017eenie bakt\u00e9ri\u00ed na povrchu implant\u00e1tu alebo v jeho okol\u00ed, \u010do vedie k po\u0161kodeniu periprotetick\u00e9ho tkaniva z\u00e1palovou reakciou a vo v\u00e4\u010d\u0161ine pr\u00edpadov sa kon\u010d\u00ed rejekciou endoprot\u00e9zy<sup>(3)<\/sup>.<\/p>\n<p>Pod\u013ea lokaliz\u00e1cie del\u00edme tieto infekcie na povrchov\u00e9 a hl\u00adbok\u00e9. Z \u010dasov\u00e9ho aspektu sa rozli\u0161uj\u00fa skor\u00e9 infekcie (ak\u00fat\u00adne), mitigovan\u00e9 (resp. chronick\u00e9) a neskor\u00e9 hematog\u00e9nne in\u00adfekcie (Coventry)<sup>(2<\/sup>&#8216;<sup>3)<\/sup>.<\/p>\n<ol>\n<li>typ infekcie je ak\u00fatny, poopera\u010dn\u00fd s manifest\u00e1ciou do 3 mesiacov od oper\u00e1cie. Klinick\u00fd obraz je pr\u00edzna\u010dn\u00fd a diag\u00adnostika nerob\u00ed \u0165a\u017ekosti<sup>(3)<\/sup>.<\/li>\n<li>typ infekcie je chronick\u00fd, od 3 mesiacov do 2 rokov po oper\u00e1cii. Symptomatika je menej \u0161pecifick\u00e1. Podmienkou je trvaj\u00faci mierny diskomfort od oper\u00e1cie. M\u00f4\u017ee pripom\u00edna\u0165 aseptick\u00e9 uvo\u013enenie. Rozhoduj\u00faci je \u010das, ktor\u00fd uplynul od pri\u00admoimplant\u00e1cie. \u010c\u00edm je krat\u0161\u00ed, t\u00fdm je menej pravdepodobn\u00e1 mo\u017enos\u0165 aseptick\u00e9ho uvo\u013enenia endoprot\u00e9zy<sup>(3)<\/sup>.<\/li>\n<li>typ infekcie je hematog\u00e9nny, s rozvojom po viac ne\u017e 2 rokoch od oper\u00e1cie s t\u00fdm, \u017ee nov\u00fd k\u013ab fungoval ist\u00fd \u010das bez probl\u00e9mov. Vznik\u00e1 z pln\u00e9ho zdravia a typick\u00fdm pr\u00edznakom b\u00fdva hor\u00fa\u010dka a boles\u0165 v k\u013abe<sup>(3)<\/sup>.<\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n<p><strong>Etiol\u00f3gia a epidemiol\u00f3gia<\/strong><\/p>\n<p>Vznik a rozvoj periprotetickej infekcie je komplexn\u00fd pro\u00adces. Z\u00e1vis\u00ed od mnoh\u00fdch faktorov, ktor\u00fdch rizikovos\u0165 je ve\u013e\u00admi variabiln\u00e1 a individu\u00e1lna. V s\u00fa\u010dasnosti neexistuj\u00fa \u0161t\u00fadie, ktor\u00e9 by potvrdili kauzalitu a signifikantnos\u0165 medzi vznikom a po\u010dtom periprotetick\u00fdch infekci\u00ed a r\u00f4znymi opera\u010dn\u00fdmi technikami, r\u00f4znymi re\u017eimami profylaxie a sp\u00f4sobmi fix\u00e1cie implant\u00e1tu, resp. dodnes nebola preuk\u00e1zan\u00e1 z\u00e1vislos\u0165 me\u00addzi uveden\u00fdmi javmi a rozvojom periprotetick\u00fdch infekci\u00ed<sup>(1)<\/sup>.<\/p>\n<p><strong>Faktory zvy\u0161uj\u00face riziko vzniku infekcie endoprot\u00e9zy:<\/strong> vy\u0161\u0161\u00ed vek pacienta, oper\u00e1cia trvaj\u00faca viac ne\u017e 3 hodiny, po\u00adruchy hojenia rany, chronick\u00e9 choroby zvy\u0161uj\u00face Charlsonov index (diabetes mellitus, hepatopatie, stavy po infarkte myokardu, hemoglobinopatie, syst\u00e9mov\u00e9 z\u00e1palov\u00e9 choroby, chronick\u00e1 kortikoterapia a imunosupres\u00edva), alkoholiz\u00admus, malnutr\u00edcia, faj\u010denie, osteomyelit\u00eddy a detsk\u00e9 infekcie v anamn\u00e9ze, infek\u010dn\u00e9 lo\u017eisk\u00e1 v tele, nosi\u010dstvo Staphylococ\u00adcus aureus, malignity, obezita, ASA klasifik\u00e1cia 3 a viac, po\u00adhlavie (mu\u017ei maj\u00fa zv\u00fd\u0161en\u00e9 riziko), infekcie v okol\u00ed k\u013abu (reumatoidn\u00e1 artrit\u00edda, erysipel, psori\u00e1za, celulit\u00edda)<sup>(3)<\/sup>.<\/p>\n<p>V\u00fdskyt periprotetick\u00fdch infekci\u00ed bedrov\u00fdch k\u013abov sa v\u0161eobecne uv\u00e1dza pod 2 %<sup>(3)<\/sup>. Revidovanos\u0165, teda mno\u017estvo umel\u00fdch n\u00e1hrad, ktor\u00e9 sa skomplikovali a bolo treba opa\u00adkovane prist\u00fapi\u0165 k oper\u00e1cii, kol\u00ed\u0161e na na\u0161ich ortopedick\u00fdch pracovisk\u00e1ch medzi 7 a\u017e 10 %<sup>(14)<\/sup>. Naj\u010dastej\u0161\u00edm d\u00f4vodom na rev\u00edziu tot\u00e1lnej endoprot\u00e9zy bedrov\u00e9ho k\u013abu je aseptick\u00e9 uvo\u013enenie, nasleduje lux\u00e1cia a infek\u010dn\u00e9 pr\u00ed\u010diny, ktor\u00fdch po\u00addiel na celkovom po\u010dte reoper\u00e1ci\u00ed je okolo 5,5 %&lt;<sup>314<\/sup>&gt;.<\/p>\n<p>V rebr\u00ed\u010dku etiologick\u00fdch agensov s\u00fa na prvom mieste stafylokoky s negat\u00edvnou koagul\u00e1zou, nasleduje Staphylococ\u00adcus aureus a \u010fal\u0161ie grampozit\u00edvne koky, ktor\u00fdch podiel na in\u00adfekci\u00e1ch bedrov\u00fdch endoprot\u00e9z sa pohybuje od 50 do 70 %<sup>(3)<\/sup>. Z gramnegat\u00edvnych bakt\u00e9ri\u00ed s\u00fa \u010dasto izolovan\u00e9 Enterobacteriaceae a Pseudomonas spp. Z anaer\u00f3bov boli izolovan\u00e9 Propionibacterium acnes, Finegoldia magna a Peptostreptococcus spp.<sup>(3)<\/sup>.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Klinick\u00fd obraz<\/strong><\/p>\n<p><em>\u0160k\u00e1la objekt\u00edvnych a subjekt\u00edvnych pr\u00edznakov je ve\u013emi pes\u00adtr\u00e1. Podozrenie na periprotetick\u00fa infekciu vznik\u00e1 v pr\u00edtom\u00adnosti t\u00fdchto faktorov:<\/em><\/p>\n<ul>\n<li>klinick\u00fd obraz a laborat\u00f3rne n\u00e1lezy: lok\u00e1lne a syst\u00e9mo\u00adv\u00e9 zn\u00e1mky infekcie (boles\u0165 v k\u013abe, hor\u00fa\u010dka, dlhodob\u00fd dis\u00adkomfort, hnisav\u00e1 secern\u00e1cia v okol\u00ed k\u013abu, fistula, absces, dehiscencia rany, elev\u00e1cia z\u00e1palov\u00fdch markerov)<sup>(123)<\/sup><\/li>\n<li>porucha funkcie endoprot\u00e9zy, jej uvo\u013enenie (nemus\u00ed sa v\u017edy dostavi\u0165)<\/li>\n<li>pozit\u00edvna kultiv\u00e1cia: identifik\u00e1cia mikroorganizmu z po\u00advrchu implant\u00e1tu alebo z periprotetick\u00fdch tkan\u00edv, absce\u00adsu, pyartr\u00f3zy<\/li>\n<\/ul>\n<p><em>Doc. Jir\u00ed Gallo z Ortopedickej kliniky na LF UP v Olomouci rozdelil krit\u00e9ri\u00e1 na tri skupiny (2006):<\/em><\/p>\n<ol>\n<li>ve\u013emi siln\u00e9: hnis v k\u013abovej dutine, fistula komunikuj\u00faca s k\u013abom, dehiscencia rany<\/li>\n<li>siln\u00e9 (\u0161tandardn\u00e9): pozit\u00edvna kultiv\u00e1cia, pozit\u00edvna histol\u00f3\u00adgia a cytol\u00f3gia z punkcie k\u013abovej dutiny, typick\u00fd status lo\u00adcalis ex inflammatione, pozit\u00edvny rontgenov\u00fd obraz<\/li>\n<li>slab\u00e9 (podporn\u00e9): pozit\u00edvna anamn\u00e9za, FW nad 35 mm\/h, CRP nad 10 mg\/l, elev\u00e1cia IL-6, pozit\u00edvne PCR a scintigrafia&lt;<sup>3<\/sup>Aio).<\/li>\n<\/ol>\n<p>Na zv\u00fd\u0161enie pravdepodobnosti diagn\u00f3zy infekcie bedro\u00advej endoprot\u00e9zy odpor\u00fa\u010da skupina doc. Galla pr\u00edtomnos\u0165 jedn\u00e9ho ve\u013emi siln\u00e9ho krit\u00e9ria alebo dvoch siln\u00fdch, pr\u00edpad\u00adne jedn\u00e9ho siln\u00e9ho a aspo\u0148 dvoch slab\u00fdch krit\u00e9ri\u00ed. Na jej po\u00adtvrdenie, presn\u00e9 ur\u010denie mikrobiologickej etiol\u00f3gie, odl\u00ed\u0161enie aseptick\u00e9ho uvo\u013enenia pri ne\u0161pecifick\u00fdch pr\u00edznakoch v r\u00e1m\u00adci diferenci\u00e1lne diagnostick\u00e9ho procesu sl\u00fa\u017eia zlo\u017eit\u00e9 algo\u00adritmy vych\u00e1dzaj\u00face z odpor\u00fa\u010dan\u00ed AAOS (American Academy of Orthopaedic Surgeons) a ESCMID (European Society of Clinical Microbiology and Infectious Diseases).<\/p>\n<p><strong>Kazuistika 1. Pr\u00edpad povrchovej poopera\u010dnej periprotetickej infekcie<\/strong><\/p>\n<p><strong>Anamn\u00e9za<\/strong><\/p>\n<p>1. osobn\u00e1: \u017eena, vek: 67 rokov, ischemick\u00e1 choroba srdca (ICHS), diabetes mellitus (DM) 2. typu, an\u00e9mia, arteri\u00e1lna hypertenzia 1. st. ESH\/ECH, stav po subtot\u00e1lnej tyreoidekt\u00f3mii pre m. Hashimoto, stav po hysterekt\u00f3mii a adnexekt\u00f3mii, stav po tot\u00e1lnej endoprot\u00e9ze kolena vpravo, chro\u00adnick\u00fd dyspeptick\u00fd syndr\u00f3m, stav po tot\u00e1lnej endoprot\u00e9ze (TEP) bedrov\u00e9ho k\u013abu v\u013eavo<\/p>\n<p>2. teraj\u0161ie ochorenie: 11.2016 operovan\u00e1 na ortopedic\u00adkom oddelen\u00ed v Nemocnici sv. Luk\u00e1\u0161a s poliklinikou v Ga\u00adlante pre prim\u00e1rnu artr\u00f3zu. Od oper\u00e1cie je pr\u00edtomn\u00fd ed\u00e9m v mieste z\u00e1kroku, palpa\u010dn\u00e1 citlivos\u0165 rany a okolia s opako\u00advanou secern\u00e1ciou. Prijat\u00e1 na rev\u00edziu m\u00e4kk\u00fdch tkan\u00edv pre bolesti pri ch\u00f4dzi a subfebrility.<\/p>\n<p><strong>Status praesens generalis:<\/strong> pri plnom vedom\u00ed, orientovan\u00e1 \u010dasom, priestorom, miestom, eupnoick\u00e1, s elev\u00e1ciou BMI me\u00addzi 25-30 (hmotnos\u0165: 83 kg, v\u00fd\u0161ka 168 cm), mobiln\u00e1 za pomo\u00adci barl\u00ed. Ostatn\u00fd n\u00e1lez je v medziach fyziologick\u00fdch noriem.<\/p>\n<p>Status praesens localis: coxa sinistra: eryt\u00e9m v hornej \u010dasti poopera\u010dnej jazvy, obliterovan\u00e1 fistula v jazve s malou ser\u00f3znou secern\u00e1ciou, dorz\u00e1lne subtrochantericky podko\u017e\u00adn\u00e1 fluktuuj\u00faca rezistencia. Akt\u00edvne elevuje doln\u00fa kon\u010datinu do 80 stup\u0148ov, pas\u00edvne do 100 stup\u0148ov, perif\u00e9ria bez patol\u00f3\u00adgie, doln\u00e9 kon\u010datiny s\u00famern\u00e9, bez skr\u00e1tenia a in\u00fdch deform\u00edt.<\/p>\n<p>Pacientka bola hospitalizovan\u00e1 so suspektnou subak\u00fat- nou povrchovou periprotetickou infekciou.<\/p>\n<p>Vy\u0161etrenia, ich v\u00fdsledky a profylaxia<\/p>\n<ul>\n<li>biochemick\u00e9 anal\u00fdzy: CRP 33,5 mg\/l,<\/li>\n<li>hematolologick\u00e9 anal\u00fdzy: krvn\u00fd obraz v norme,<\/li>\n<li>mikrobiologick\u00e1 kultiv\u00e1cia v\u00fdterov z rany: negat\u00edvne,<\/li>\n<li>antibiotick\u00e1 profylaxia pri rev\u00edznom z\u00e1kroku: podan\u00fd cipro- floxac\u00edn 400 mg i. v. pol hodiny pred inc\u00edziou, 200 mg i. v. po z\u00e1kroku<\/li>\n<\/ul>\n<p><strong>Priebeh a terapia<\/strong><\/p>\n<p>Pacientka bola prijat\u00e1 na oddelenie s cie\u013eom opera\u010dnej rev\u00edzie rany. Po predopera\u010dnej pr\u00edprave bol vykonan\u00fd z\u00e1krok. V bl\u00edzkom okol\u00ed jazvy bola pr\u00edtomn\u00e1 drobn\u00e1 s\u00e9romov\u00e1 dutina, lok\u00e1lne o\u0161etren\u00e1 &#8211; debridement a lav\u00e1\u017e roztokom betadinu, zaveden\u00fd Redon dr\u00e9n, indikovan\u00e9 boli pravideln\u00e9 prev\u00e4zy so steriln\u00fdm kryt\u00edm, 7 dn\u00ed bol pod\u00e1van\u00fd klindamyc\u00edn 2x 150 mg \u00e1 8 hod. i. v. Po t\u00fd\u017edni hospitaliz\u00e1cie bola rana pokojn\u00e1, pa\u00adcientka afebriln\u00e1, subjekt\u00edvne bez \u0165a\u017ekost\u00ed, v dobrom stave a kardiopulmon\u00e1lne kompenzovan\u00e1, prepusten\u00e1 do ambu\u00adlantnej starostlivosti. V tomto pr\u00edpade nebolo potrebn\u00e9 pri\u00adst\u00fapi\u0165 k v\u00fdmene bedrovej endoprot\u00e9zy, ke\u010f\u017ee k jej uvo\u013eneniu nedo\u0161lo a m\u00e4kk\u00e9 tkaniv\u00e1 boli v dobrej kond\u00edcii.<\/p>\n<p><strong>Vyhodnotenie a mikrobiologick\u00fd aspekt<\/strong><\/p>\n<p>Diagnostika periprotetickej infekcie vych\u00e1dzala z typick\u00e9\u00adho klinick\u00e9ho obrazu a elev\u00e1cie z\u00e1palov\u00fdch markerov. Kulti\u00adva\u010dn\u00fd n\u00e1lez steru z rany bol negat\u00edvny. Mo\u017en\u00e9 d\u00f4vody, pre ktor\u00e9 sa nepodarilo kultivova\u0165 etiologick\u00fd agens:<\/p>\n<ul>\n<li>odber bol realizovan\u00fd v \u010dase antibiotick\u00e9ho krytia<\/li>\n<li>absentovala po\u017eiadavka na prolong\u00e1ciu kultiv\u00e1cie steru na 14 dn\u00ed<\/li>\n<li>nebol odobrat\u00fd tekut\u00fd materi\u00e1l retinovan\u00fd v okol\u00ed k\u013abu, hmatate\u013en\u00fd ako fluktuuj\u00faca rezistencia na kultiva\u010dn\u00fa anal\u00fdzu<\/li>\n<li>na kultiv\u00e1ciu neboli odobran\u00e9 tkaniv\u00e1 po\u0161koden\u00e9 z\u00e1pa\u00adlom, odstr\u00e1nen\u00e9 debridementom z viacer\u00fdch lokal\u00edt<\/li>\n<\/ul>\n<p><strong>Kazuistika 2. Pr\u00edpad hlbokej hematog\u00e9nnej periprotetickej infekcie<\/strong><\/p>\n<p><strong>Anamn\u00e9za<\/strong><\/p>\n<p>osobn\u00e1: mu\u017e, 71-ro\u010dn\u00fd, stav po TEP coxae I. sin v roku 2010, arteri\u00e1lna hypertenzia, ICHS, DM neguje, obezita b teraj\u0161ie ochorenie: pacient po implant\u00e1cii TEP coxae I. sin v roku 2010. V marci v roku 2016 do\u0161lo k uvo\u013eneniu TEP, ktor\u00e1 bola extrahovan\u00e1. Do\u010dasne bol vlo\u017een\u00fd spacer s an\u00adtibiotikami a s pl\u00e1novanou reimplant\u00e1ciou TEP v druhej f\u00e1\u00adze na september 2016<\/p>\n<p>Status praesens generalis: pri vedom\u00ed, orientovan\u00fd, afebriln\u00fd, eupnoe, mobiln\u00fd s barlami, ostatn\u00fd n\u00e1lez v medziach fyziologick\u00fdch noriem.<\/p>\n<p>Status praesens localis: coxa sinistra bez zn\u00e1mok z\u00e1pa\u00adlu, jazva pokojn\u00e1, nebolestiv\u00e1, dif\u00fazne zv\u00fd\u0161en\u00e1 palpa\u010dn\u00e1 cit\u00adlivos\u0165. Stehn\u00e1 a l\u00fdtka vo\u013en\u00e9, Homans negat. Akt\u00edvne elevuje doln\u00fa kon\u010datinu do 40 stup\u0148ov, pas\u00edvne do 60 stup\u0148ov, vyko\u00adn\u00e1van\u00e9 pohyby s\u00fa bolestiv\u00e9. Doln\u00e9 kon\u010datiny bez skr\u00e1tenia a in\u00fdch deform\u00edt.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Vy\u0161etrenia, ich v\u00fdsledky a profylaxia<\/strong><\/p>\n<ul>\n<li>biochemick\u00e9 anal\u00fdzy: CRP 47 mg\/l v \u010dase uvo\u013enenia (3\/2016),<\/li>\n<li>hematolologick\u00e9 anal\u00fdzy: krvn\u00fd obraz v norme pri prijat\u00ed na reimplant\u00e1ciu,<\/li>\n<li>r\u00e1diologick\u00e9 vy\u0161etrenie: v\u00fdrazn\u00e9 osteol\u00fdzy v okol\u00ed implant\u00e1tu,<\/li>\n<li>mikrobiologick\u00e1 kultiv\u00e1cia steru z povrchu endoprot\u00e9zy: negat\u00edvna,<\/li>\n<li>antibiotick\u00e1 profylaxia pri rev\u00edzii: klindamyc\u00edn i. v. 2x 150 mg podan\u00fd hodinu pred oper\u00e1ciou<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Priebeh<\/strong><\/p>\n<p>Primoimplant\u00e1cia v roku 2010 bola indikovan\u00e1 pre prim\u00e1r\u00adnu artr\u00f3zu bedrov\u00e9ho k\u013abu. V marci roku 2016 pre dlhotrvaj\u00fa\u00adce bolesti v okol\u00ed operovan\u00e9ho k\u013abu bola vykonan\u00e1 extrakcia endoprot\u00e9zy a bol zaveden\u00fd spacer s antibiotikami. V sep\u00adtembri 2016 v celkovej anest\u00e9zii pod antibiotick\u00fdm kryt\u00edm bola vykonan\u00e1 reimplant\u00e1cia. Poopera\u010dn\u00e9 bolesti boli prime\u00adran\u00e9, hojenie rany per primam intentionem, bez secern\u00e1cie. Pacient bol prelo\u017een\u00fd na oddelenie fyziatrie a rehabilit\u00e1cie.<\/p>\n<p>Pri p\u00e1tran\u00ed po mo\u017en\u00fdch zdrojoch v\u00fdznamnej bakteri\u00e9mie ako pr\u00ed\u010diny hlbokej infekcie endoprot\u00e9zy lek\u00e1ri prv\u00e9ho kon\u00adtaktu \u00faspe\u0161n\u00ed neboli. V\u00fdtery z tonz\u00edl a z nosa boli negat\u00edvne. Kultiva\u010dn\u00fd n\u00e1lez v mo\u010di bol tie\u017e negat\u00edvny. Infek\u010dn\u00e9 lo\u017eisk\u00e1 na ko\u017ei pr\u00edtomn\u00e9 neboli.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Terapeutick\u00fd z\u00e1krok<\/strong><\/p>\n<p>Dvojf\u00e1zov\u00e1 oper\u00e1cia TEP coxae sin., v prvej f\u00e1ze extrakcia p\u00f4vodnej TEP, dezinfekcia kostn\u00e9ho l\u00f4\u017eka v\u00fdplachmi a zave\u00addenie spaceru s ATB, v druhej f\u00e1ze po 6 mesiacoch reimplan\u00adt\u00e1cia TEP coxae sin (necementovan\u00e1). Po prepusten\u00ed pacient u\u017e\u00edval per os Dalacin 300 mg 1 &#8211; 1 &#8211; 1, ktor\u00fd bol naordinovan\u00fd na \u010fal\u0161ie 3 t\u00fd\u017edne, analgetik\u00e1 pod\u013ea potreby, prevencia trombembolickej choroby.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Vyhodnotenie a mikrobiologick\u00fd aspekt<\/strong><\/p>\n<p>Diagnostika periprotetickej infekcie bola v tomto pr\u00edpade komplikovanej\u0161ia. Manifest\u00e1cia uvo\u013enenej endoprot\u00e9zy ne\u00adbola v\u00fdrazn\u00e1. Na z\u00e1klade subjekt\u00edvnych pr\u00edznakov pacienta nebolo mo\u017en\u00e9 jednozna\u010dne vyslovi\u0165 podozrenie na infek\u010dn\u00fa etiol\u00f3giu. Laborat\u00f3rne n\u00e1lezy, naopak, poukazovali na prebie\u00adhaj\u00facu z\u00e1palov\u00fa aktivitu. Na rtg. obraze boli n\u00e1padn\u00e9 osteolytick\u00e9 oblasti v okol\u00ed k\u013abovej n\u00e1hrady. Na z\u00e1klade t\u00fdchto objekt\u00edvnych faktorov o\u0161etruj\u00faci lek\u00e1r predpokladal infek\u010dn\u00fa komplik\u00e1ciu<sup>(3)<\/sup>. Kultiv\u00e1cia steru z povrchu extrahovanej endo\u00adprot\u00e9zy v\u0161ak bola negat\u00edvna.<\/p>\n<p><strong>Mo\u017en\u00e9 d\u00f4vody:<\/strong><\/p>\n<ul>\n<li>odber bol vykonan\u00fd v \u010dase antibiotick\u00e9ho krytia<\/li>\n<li>najpravdepodobnej\u0161\u00ed vyvol\u00e1vate\u013e infekcie vytvoril na po\u00advrchu k\u013abovej n\u00e1hrady biofilm. Ani sterom, ani zo\u0161krabnu- t\u00edm nemo\u017eno z\u00edska\u0165 z biofilmu planktonick\u00e9 bunky etiologick\u00e9ho agensu<\/li>\n<li>absentovala po\u017eiadavka o prolong\u00e1ciu kultiv\u00e1cie na 14 dn\u00ed<\/li>\n<li>nebol pou\u017eit\u00fd sonik\u00e1tor na extrahovan\u00e9 komponenty,<\/li>\n<\/ul>\n<p>zvl\u00e1\u0161\u0165 acetabul\u00e1rnu a femor\u00e1lnu, ktor\u00fd by biofilmov\u00fa \u0161truk\u00adt\u00faru rozru\u0161il a uvo\u013enil tak planktonick\u00e9 formy mikroorganiz\u00admu z povrchu endoprot\u00e9zy. Jedine plankt\u00f3n vieme zachyti\u0165 kultiv\u00e1ciou na be\u017ene dostupn\u00fdch agarov\u00fdch p\u00f4dach.<\/p>\n<p><strong>Zv\u00fd\u0161i\u0165 \u00faspe\u0161nos\u0165 pri objas\u0148ovan\u00ed identity mikroorganiz\u00admu, ktor\u00fd sp\u00f4sob\u00ed rozvoj periprotetickej infekcie, by pomohlo, keby sa na mikrobiologick\u00fa anal\u00fdzu odoslali:<\/strong><\/p>\n<ul>\n<li>punkt\u00e1t z k\u013abovej dutiny. Ide o zlat\u00fd \u0161tandard v diagnos\u00adtike hlbok\u00fdch infekci\u00ed k\u013abov\u00fdch endoprot\u00e9z. Senzitivita punkci\u00ed je 94 &#8211; 97 % a \u0161pecificita 88 &#8211; 98 %<sup>(10)<\/sup>.<\/li>\n<li>peropera\u010dn\u00e9 biopsie periprotetick\u00fdch tkan\u00edv z r\u00f4znych lo\u00adkal\u00edt. ESCMID odpor\u00fa\u010da 5 a\u017e 10 k\u00faskov tkan\u00edv z okolia pro\u00adt\u00e9zy, kde prebieha z\u00e1pal<sup>(5)<\/sup>.<\/li>\n<\/ul>\n<p>Pri pou\u017eit\u00ed sonik\u00e1tora sa odpor\u00fa\u010da nastavi\u0165 parametre: n\u00edz\u00adka frekvencia: 40 kHz, energia: 0,25 W\/cm<sup>2<\/sup>. Jednotliv\u00e9 \u010dasti endoprot\u00e9zy vlo\u017e\u00edme do n\u00e1dob s roztokom a umiestnime do pr\u00edstroja. Odpor\u00fa\u010da sa pou\u017eitie Ringerovho roztoku. Endoprot\u00e9zu je nutn\u00e9 o\u0161etrova\u0165 ultrazvukom aspo\u0148 5 a\u017e 6 min\u00fat. Po skon\u010den\u00ed cyklu je predpoklad, \u017ee do\u0161lo k rozru\u0161eniu biofilmu a \u010das\u0165 bakteri\u00e1lnych buniek sa uvo\u013enila do roztoku. Vzniknut\u00fa suspenziu, tzv. sonik\u00e1t, je potrebn\u00e9 vytrepa\u0165 na vortexe s cie\u00ad\u013eom jej homogeniz\u00e1cie minim\u00e1lne 30 sek\u00fand. Na kultiv\u00e1ciu by sa n\u00e1sledne pou\u017eil sonik\u00e1t jeho inokul\u00e1ciou na pr\u00edslu\u0161n\u00e9 agary pre aer\u00f3bnu a anaer\u00f3bnu mikrobiologick\u00fa anal\u00fdzu. Senziti- vita kultiv\u00e1cie sonik\u00e1tu je vy\u0161\u0161ia ako pri steroch z r\u00e1n \u010di povr\u00adchov endoprot\u00e9z, dosahuje a\u017e 80 &#8211; 85 % a \u0161pecificita je okolo 95 %<sup>(4)<\/sup>. Ako sp\u00f4sob transportu sa odpor\u00fa\u010da strieka\u010dka s her\u00admeticky uzavretou ihlou alebo v n\u00e1dob\u00e1ch syst\u00e9mu BACTEC pre aer\u00f3bnu a anaer\u00f3bnu kultiv\u00e1ciu<sup>(3)<\/sup>. (obr\u00e1zok 1)<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Diskusia a odpor\u00fa\u010dania<\/strong><\/p>\n<p>Stery z povrchu endoprot\u00e9z sa dnes neodpor\u00fa\u010daj\u00fa a po\u00adva\u017euj\u00fa sa za najmenej vhodn\u00fd typ vzorky na objasnenie etiologick\u00e9ho agensu periprotetickej infekcie. Potvrdzuje to aj prax vzh\u013eadom na vysok\u00fd podiel kultiva\u010dne negat\u00edvnych sterov. Pr\u00ed\u010dinou je, \u017ee v\u00e4\u010d\u0161inu periprotetick\u00fdch infekci\u00ed sp\u00f4so\u00adbuj\u00fa kmene so schopnos\u0165ou tvori\u0165 biofilm na povrchu endoprot\u00e9zy<sup>(5)<\/sup>.<\/p>\n<p>ESCMID odpor\u00fa\u010da po extrakcii jednotliv\u00fdch komponentov vystavi\u0165 ich \u00fa\u010dinkom ultrazvuku s n\u00edzkou energiou a frekven\u00adciami. Jeho cie\u013eom je dezintegrova\u0165 biofilm na povrchu endoprot\u00e9zy a z\u00edska\u0165 tak planktonick\u00e9 formy mikroorganizmov bez po\u0161kodenia ich buniek.<\/p>\n<p>Ot\u00e1zne je, kde by sa mali sonik\u00e1tory nach\u00e1dza\u0165. \u010ci by ma\u00adli by\u0165 s\u00fa\u010das\u0165ou v\u00fdbavy opera\u010dn\u00fdch s\u00e1l, alebo mikrobiologic\u00adk\u00fdch laborat\u00f3ri\u00ed. V prvom pr\u00edpade by lek\u00e1ri odosielali tekut\u00e9 vzorky, tzv. sonik\u00e1t, do laborat\u00f3ria na spracovanie. V druhom pr\u00edpade by museli posiela\u0165 do laborat\u00f3ri\u00ed jednotliv\u00e9 kompo\u00adnenty v steriln\u00fdch n\u00e1dob\u00e1ch, tzv. kontajneroch, alebo nasu\u00adcho zabalen\u00e9 v steriln\u00fdch rukaviciach.<\/p>\n<p>\u010eal\u0161\u00edm zlat\u00fdm \u0161tandardom s\u00fa biopsie periprotetick\u00e9ho tkaniva po\u0161koden\u00e9ho z\u00e1palom. \u010c\u00edm viac, t\u00fdm lep\u0161ie a z r\u00f4z\u00adnych lokal\u00edt. Je nutn\u00e9 nezab\u00fada\u0165 na po\u017eiadavku prolongovanej kultiv\u00e1cie o jeden a\u017e dva t\u00fd\u017edne. D\u00f4vodom s\u00fa poma\u00adly rast\u00face kmene stafylokokov s negat\u00edvnou koagul\u00e1zou, tzv. small colony variants (SCV), ktor\u00e9 po 24- a\u017e 48-hodinovej kultiv\u00e1cii nedok\u00e1\u017eeme zachyti\u0165 a s\u00fa naj\u010dastej\u0161ou pr\u00ed\u010di\u00adnou mitigovan\u00fdch, chronick\u00fdch infekci\u00ed k\u013abov\u00fdch n\u00e1hrad<sup>(25)<\/sup>.<\/p>\n<p>Pri abscesoch sa odpor\u00fa\u010da odosiela\u0165 na kultiv\u00e1ciu a\u017e posledn\u00fa porciu hnisu, ktor\u00fd vyp\u013a\u0148al dutinu. Dobr\u00e9 je uro\u00adbi\u0165 aj nieko\u013eko sterov zo steny abscesovej dutiny, \u010do najhlb\u00ad\u0161ie ulo\u017eenej, aby sme sa vyhli kontamin\u00e1cii vzorky a dostali sa k miestam, kde prebieha akt\u00edvny z\u00e1pal a granul\u00e1cia nov\u00e9\u00adho tkaniva. Kultiva\u010dn\u00e9 anal\u00fdzy hnisu odobran\u00e9ho inak, ako je tu zaznamenan\u00e9, ved\u00fa k falo\u0161ne negat\u00edvnym n\u00e1lezom, ke\u010f\u00ad\u017ee obsahom hnisu s\u00fa m\u0155tve biele krvinky a rozlo\u017een\u00e9 bakte\u00adri\u00e1lne bunky.<\/p>\n<p>Skupina stafylokokov s negat\u00edvnou koagul\u00e1zou sa ne\u00adust\u00e1le roz\u0161iruje o nov\u00e9 druhy. Preto sa odpor\u00fa\u010da ich presnej\u00ad\u0161ia identifik\u00e1cia hmotnostnou spektrometriou, tzv. met\u00f3dou MALDI-TOF, alebo pri tekut\u00fdch materi\u00e1loch pomocou me\u00adt\u00f3d molekul\u00e1rnej biol\u00f3gie (real-time-PCR). Ak sa z opakova\u00adnej kultiv\u00e1cie viacer\u00fdch vzoriek z r\u00f4znych odberov nepotvrd\u00ed rovnak\u00fd druh stafylokoka s negat\u00edvnou koagul\u00e1zou, je mo\u017e\u00adn\u00e9, \u017ee ide o kontamin\u00e1ciu vzorky z telesn\u00e9ho povrchu. Vyslo\u00advi\u0165 z\u00e1ver, \u017ee identifikovan\u00fd mikroorganizmus je p\u00f4vodcom in\u00adfekcie, m\u00f4\u017eeme na z\u00e1klade kultiva\u010dn\u00e9ho d\u00f4kazu rovnak\u00e9ho druhu so zhodn\u00fdm antibiogramom z viacer\u00fdch vzoriek z r\u00f4z\u00adnych lokal\u00edt (predopera\u010dn\u00fd punkt\u00e1t z\u00edskan\u00fd aspir\u00e1ciou hnisu z k\u013abovej dutiny, peropera\u010dn\u00e9 biopsie periprotetick\u00fdch tkan\u00edv, stery z viacer\u00fdch miest v rane po\u0161kodenej z\u00e1palom).<\/p>\n<p>Obaja pacienti dostali po\u010das prim\u00e1rnych oper\u00e1ci\u00ed pri zav\u00e1\u00addzan\u00ed tot\u00e1lnych endoprot\u00e9z predopera\u010dn\u00fa antibiotick\u00fa pro\u00adfylaxiu cefazolin (Kefzol) 2 g i. v. 30 min\u00fat pred oper\u00e1ciou v s\u00falade s najnov\u0161\u00edmi odpor\u00fa\u010daniami vydan\u00fdmi Minister\u00adstvom zdravotn\u00edctva Slovenskej republiky<sup>(15)<\/sup>. Biologick\u00fd pol\u00ad\u010das cefazolinu s\u00fa 2 hodiny, \u010do sta\u010d\u00ed na profylaktick\u00e9 krytie 3-hodinovej oper\u00e1cie. Pri alergii na betalakt\u00e1mov\u00e9 antibioti\u00adk\u00e1 je alternat\u00edvou klindamyc\u00edn 600 a\u017e 900 mg i. v. podan\u00fd 30 min\u00fat pred prvou inc\u00edziou. Pri rev\u00edznych z\u00e1krokoch sa po\u00add\u00e1va klindamyc\u00edn alebo ciprofloxac\u00edn 400 mg 2 hodiny pred oper\u00e1ciou intraven\u00f3zne<sup>(915)<\/sup>. Klindamyc\u00edn sa preferuje v t\u00fdch\u00adto pr\u00edpadoch hlavne pre jeho dobr\u00fa priepustnos\u0165 do kost\u00ed &#8211; 80 a\u017e 150 % s\u00e9rovej hladiny prenik\u00e1 do kostn\u00e9ho tkaniva<sup>(115)<\/sup>. Ot\u00e1zka poopera\u010dnej profylaxie dodnes nie je vyrie\u0161en\u00e1 v or\u00adtopedickej obci. V\u00fdznam a pr\u00ednos r\u00f4znych sch\u00e9m l\u00ed\u0161iac sa d\u013a\u017ekou a sp\u00f4sobom pod\u00e1vania antibiot\u00edk po oper\u00e1ci\u00ed nie je dodnes podlo\u017een\u00fd \u017eiadnou \u0161t\u00fadiou<sup>(1)<\/sup>.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Z\u00e1ver<\/strong><\/p>\n<p>V \u010dl\u00e1nku op\u00edsan\u00e9 kazuistiky uk\u00e1zali, \u017ee z mikrobiologic\u00adk\u00e9ho h\u013eadiska neboli vyu\u017eit\u00e9 v\u0161etky mo\u017enosti, ktor\u00e9 s\u00fa dnes dostupn\u00e9 pri objas\u0148ovan\u00ed pr\u00ed\u010diny periprotetickej infekcie. Vysok\u00e9 percento falo\u0161ne negat\u00edvnych n\u00e1lezov kultiva\u010dn\u00fdch anal\u00fdz sa pripisuje na vrub n\u00edzkej informovanosti o\u0161etruj\u00fa\u00adcich lek\u00e1rov, \u010do je n\u00e1sledok nedostato\u010dnej spolupr\u00e1ce s le\u00adk\u00e1rmi v mikrobiologickom laborat\u00f3riu. Zv\u00fd\u0161i\u0165 podiel pozit\u00edv\u00adnych kultiv\u00e1ci\u00ed pom\u00f4\u017eu biopsie periprotetick\u00fdch tkan\u00edv, \u010do by mali by\u0165 vzorky prvej vo\u013eby v\u017edy s po\u017eiadavkou na pred\u013a\u017ee\u00adn\u00fa kultiv\u00e1ciu.<\/p>\n<p>Z ka\u017edodennej praxe vid\u00edme, ak\u00e9 nevyhnutn\u00e9 je, aby sa zefekt\u00edvnila komunik\u00e1cia medzi lek\u00e1rom mikrobiol\u00f3gom a le\u00adk\u00e1rmi, ktor\u00ed s\u00fa v prvom kontakte s pacientom. Lek\u00e1r mik\u00adrobiol\u00f3g by mal by\u0165 s\u00fa\u010das\u0165ou t\u00edmu, ktor\u00fd sa star\u00e1 o pacien\u00adtov na oddeleniach s \u0165a\u017ek\u00fdmi infekciami, mal by kontrolova\u0165 spr\u00e1vnos\u0165 preskripcie antibiot\u00edk a br\u00e1ni\u0165 ich nadmern\u00e9mu pou\u017e\u00edvaniu. Podie\u013ea\u0165 by sa mal na informovan\u00ed, ako spr\u00e1vne odobera\u0165 klinick\u00e9 vzorky, ich mno\u017estvo, r\u00f4zne druhy a o sp\u00f4\u00adsoboch ich transportu.<\/p>\n<p>Z\u00e1ujmom ka\u017ed\u00e9ho mikrobiologick\u00e9ho laborat\u00f3ria by mal by\u0165 pokrok a snaha by\u0165 \u010do naju\u017eito\u010dnej\u0161\u00ed pre pacienta. Aj pre\u00adto ver\u00edm, \u017ee u\u017e to nebude dlho trva\u0165 a met\u00f3dy ako sonik\u00e1cia sa \u010doskoro stan\u00fa rutinou aj u n\u00e1s.<\/p>\n<p>&nbsp;<\/p>\n<p>LITERAT\u00daRA<\/p>\n<ol>\n<li>\u010cech O, D\u017eupa V. Rev\u00edzni operace n\u00e1hrad ky\u010deln\u00edho kloubu, Praha, Czech Republic, Galen; 2004; 234 s.<\/li>\n<li>Jahoda D, Sosna A, Ny\u010d O, et al. Infek\u010dn\u00ed komplikace kloubn\u00edch n\u00e1hrad, Praha, Czech Republic, Triton; 2008; 220 s.<\/li>\n<li>Landor I, Vavr\u00edk P, Gallo J, Sosna A. Rev\u00edzni operace tot\u00e1ln\u00edch n\u00e1hrad ky\u010deln\u00edho kloubu, Praha, Czech Republic, Maxdorf; 2012; 398 s.<\/li>\n<li>Rul\u00edk M, Hol\u00e1 V, Ru\u017ei\u010dka F, Votava M, et al. Mikrobi\u00e1ln\u00ed biofilmy, Ol\u00adomouc, Czech Republic, Univerzita Palack\u00e9ho v Olomouci, 2011; 447 s: 151-174.<\/li>\n<li>Hoiby N, Bjarnsholt T, Moser C, et al. for the ESCMID Study Group for Biofilms (ESGP) and Consulting External Expert Werner Zimmerli ESCMID guideline for the diagnosis and treatment of biofilm infections 2014; 25 s.<\/li>\n<li>\u0160vec A. Periprotetick\u00e1 infekcia po implant\u00e1cii tot\u00e1lnej endoprot\u00e9zy bedrov\u00e9ho a kolenn\u00e9ho k\u013abu, 1. Traumatologicko-ortopedick\u00e1 klinika, LF UK, UNB Bratislava, Slovensk\u00e1 republika, Bedeker Zdravia, Ortop\u00e9dia, 2011; 64 s: 4-10.<\/li>\n<li>Murray P et al. Manual of clinical microbiology. 9th edition. Washing\u00adton D.C.: ASM Press; 2007.<\/li>\n<li>Isenberg HD, Clinical microbiology procedures handbook, 2nd ed. Washington D.C.: ASM Press; 2004;<\/li>\n<li>Katzung B.G. Z\u00e1kladn\u00ed a klinick\u00e1 farmakologie, Lange Medical Books, H &amp; H, 2006; 1106 s: 805-819,<\/li>\n<li>Zima T, et al. Laborat\u00f3rn\u00ed diagnostika, Praha, Czech Republic, Gal\u00e9n, 2013; 1146 s: 537-541.<\/li>\n<li>Jahoda D, Ny\u010d O, Pokorn\u00fd D, Landor I, Sosna A. Antibiotika v prevenci infek\u010dn\u00edch komplikac\u00ed u operac\u00ed kloubn\u00edch n\u00e1hrad, ACTA CHIRURGIAE OR- THOPAEDICAE ET TRAUMATOLOGIAE \u010cECHOSL., 73, 2006; p. 108-114.<\/li>\n<li>American Academy of Orthopaedic Surgeon. Guideline on The Di\u00adagnosis of Periprosthetic Joint Infections of the Hip and Knee [on-line] <a href=\"http:\/\/www.aaos.org\/research\/guidelines\/PJIsummary.pdf\">http:\/\/www.aaos.org\/research\/guidelines\/PJIsummary.pdf<\/a> 2010<\/li>\n<li>American Academy of Orthopaedic Surgeon. The diagnosis of peri\u00adprosthetic joint infections of the hip and knee [on-line] <a href=\"http:\/\/www.aaos\">http:\/\/www.aaos<\/a>. org\/research\/guidelines\/PJIguideline.pdf 2010<\/li>\n<li>Ne\u010das L, Katina S, Uhl\u00e1rov\u00e1 J. Anal\u00fdza pre\u017e\u00edvania aloplastick\u00fdch op\u00ader\u00e1ci\u00ed bedrov\u00e9ho a kolenn\u00e9ho k\u013abu. Slovensk\u00fd artroplastick\u00fd register. 2013; 87 s [on-line] <a href=\"http:\/\/sar.mfn.sk\/file\/subory\/V%c3%bdro%c4%8dn%c3%a1%20spr%c3%a1va%20\">http:\/\/sar.mfn.sk\/file\/subory\/V\u00fdro\u010dn\u00e1%20spr\u00e1va%20<\/a> za%20 rok%20 2011 .pdf<\/li>\n<\/ol>\n<p>Odborn\u00e9 usmernenie Ministerstva zdravotn\u00edctva Slovenskej repub\u00adliky pre antibiotick\u00fa profylaxiu chirurgickej ranovej infekcie \u010d. 12372\/2010 OZS z 28. 9. 2010 v s\u00falade s \u00a7 45 ods. 1 p\u00edsm. b) z\u00e1kona \u010d. 576\/2004 Z.z. o zdravotnej starostlivosti, slu\u017eb\u00e1ch s\u00favisiacich s poskytovan\u00edm zdravot\u00adnej starostlivosti a o zmene a doplnen\u00ed niektor\u00fdch z\u00e1konov v znen\u00ed nesko\u00adr\u0161\u00edch predpisov.<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>*All tables, charts, graphs and pictures that are featured in this article can be found in the .pdf attachment at the end of the paper. \u00davod Infekcia bedrovej endoprot\u00e9zy je jedna z troch naj\u010dastej\u00ad\u0161\u00edch komplik\u00e1ci\u00ed, ku ktorej doch\u00e1dza po primoimplant\u00e1cii k\u013a\u00adbovej n\u00e1hrady v r\u00f4znom \u010dasovom odstupe. Nie je naj\u010dastej\u00ad\u0161ia, ale patr\u00ed medzi najob\u00e1vanej\u0161ie a najz\u00e1va\u017enej\u0161ie<\/p>\n","protected":false},"author":7,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_mi_skip_tracking":false,"footnotes":""},"categories":[292],"tags":[590,594,591,595,592,596,593],"class_list":["post-1320","post","type-post","status-publish","format-standard","hentry","category-microbiology","tag-biofilm-en","tag-endoprotection","tag-endoprotetika-en","tag-periprosthetic-infection","tag-periproteticka-infekcia-en","tag-sonication","tag-sonikacia-en","typ_clanku-casuistry"],"acf":{"abstrakt":"<p>Infections of the hip replacements are still a major problem in endoprotection today. Despite various prophy\u00adlactic regimens, surgical techniques, various modifications of the surface of the endoprostheses, and the con\u00adstruction of super sterile surgery rooms, the incidence of these infections is between 1 and 2% of the total num\u00adber of hip replacements per year. The diagnosis of articular replacement infection is a highly serious problem for the patient and his physician.<\/p>\n<p>From a differential diagnostic point of view, the most serious problems are the mitigating infections, appear\u00ading two or three years after the primoimplantation, where the pain caused by the release of endoprostheses is a challenge for orthopaedists to distinguish aseptic release from infectious. The greatest effort is currently be\u00ading concentrated on this area, and the collaboration of orthopaedists with microbiologists will have to be more intensive. In practice, we have many negative findings, and there is no support for orthopedists in the treatment. It will be necessary to gradually introduce microbiological diagnostic methods which will increase cultivation yield, such as the use of sonication.<\/p>\n<p><strong>Key words:<\/strong> endoprotection, periprosthetic infection, biofilm, sonication<\/p>\n","casopis":[{"ID":1223,"post_author":"7","post_date":"2017-09-26 14:15:30","post_date_gmt":"2017-09-26 12:15:30","post_content":"<ul>\r\n \t<li>Fertility disorders: immunological causes and possible curative impact<\/li>\r\n \t<li>The first results of galactose-deficient IgA1 measurement in diagnosis and monitoring of patients with IgA nephropathy<\/li>\r\n \t<li>Application of autovaccines in the treatment of chronic and recurrent colpitises<\/li>\r\n \t<li>Infections of the hip endoprostheses<\/li>\r\n \t<li>Non-invasive markers of liver fibrosis<\/li>\r\n<\/ul>","post_title":"Newslab","post_excerpt":"","post_status":"publish","comment_status":"closed","ping_status":"closed","post_password":"","post_name":"newslab-2017-2","to_ping":"","pinged":"","post_modified":"2017-09-26 14:19:35","post_modified_gmt":"2017-09-26 12:19:35","post_content_filtered":"","post_parent":0,"guid":"http:\/\/www.newslab.sk\/casopis\/newslab-2017-2\/","menu_order":0,"post_type":"casopis","post_mime_type":"","comment_count":"0","filter":"raw"}],"strana":"118","upload_clanok":{"ID":1318,"id":1318,"title":"NEWSLAB 2-2017_Jac\u00e1k","filename":"NEWSLAB-2-2017_Jac\u00e1k.pdf","filesize":695087,"url":"https:\/\/www.newslab.sk\/wp-content\/uploads\/2017\/09\/NEWSLAB-2-2017_Jac\u00e1k.pdf","link":"https:\/\/www.newslab.sk\/en\/infections-of-the-hip-endoprostheses\/newslab-2-2017_jacak-2\/","alt":"","author":"7","description":"","caption":"","name":"newslab-2-2017_jacak-2","status":"inherit","uploaded_to":1320,"date":"2017-09-28 11:13:19","modified":"2017-09-28 11:13:19","menu_order":0,"mime_type":"application\/pdf","type":"application","subtype":"pdf","icon":"https:\/\/www.newslab.sk\/wp-includes\/images\/media\/document.png"}},"_links":{"self":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/posts\/1320","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/comments?post=1320"}],"version-history":[{"count":0,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/posts\/1320\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/media?parent=1320"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/categories?post=1320"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/tags?post=1320"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}