Evaluation of postoperative antibiotics after non-perforated appendectomy

OBJECTIVE

To evaluate the role of postoperative antibiotics in reducing surgical site infections after appendectomy for non-perforated appendicitis.

METHODS

The randomised controlled trial was conducted at Khyber Teaching Hospital, Peshawar, Pakistan, from November 11, 2012, to May 30, 2014, and comprised patients of emergency appendectomy for non-perforated appendicitis who were divided into groups A and B. Group A received a single dose of cefuroxime sodium and metronidazole half-an-hour before induction, while Group B received one more dose of the same antibiotics postoperatively. Both groups were followed for 6 weeks. SPSS 20 was used for statistical analysis.

RESULTS

Of the 390 patients in the study, 192(49.2%) were in Group A and 198(50.7%) in Group B. Number of surgical site infections was 15(7.8%) in Group A and 18(9.1%) in Group B (p=0.65). Mean hospital stay of 3.32±0.4 days and 3.59±0.46 days was observed for Group A and B, respectively, (p<0.001).

CONCLUSIONS

A single pre-operative dose of cefuroxime and metronidazole had the same efficacy in preventing surgical site infections in cases of non-perforated appendicitis as when the same regimen was repeated post-operatively.

Successful reimplantation of extruded long bone segments in open fractures of lower limb--a report of 3 cases

Extruded bone segments are rare complication of high energy open fractures. Routinely these fractures are treated by debridement followed by bone loss management in the form of either bone transport or free fibula transfer. There are very few reports in the literature about reimplantation of extruded segments of bone and there are no clear guidelines regarding timing of reimplantation, bone stabilisation and sterilisation techniques. Reimplantation of extruded bone is a risky procedure due to high chances of infection which determines the final outcome and can result in secondary amputations. We present two cases of successful reimplantation of extruded diaphyseal segment of femur and one case of reimplantation of extruded segment of tibia.

Antimicrobial prophylaxis in patients with colorectal lesions undergoing endoscopic resection

AIM: To investigate the effect of prophylaxis with antibiotics on clinical adverse events in patients who underwent endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) for colorectal lesions.

METHODS: From June 2011 to December 2013, a total of 428 patients were enrolled into the study, of which 214 patients admitted to hospital underwent EMR or ESD procedures. These patients were randomized to an antibiotic group, in which patients were given cefuroxime 1.5 g iv half an hour before and 6 h after surgery respectively, and a control group, in which patients were not given any antibiotic. A further 214 outpatients with small polyps treated by polypectomy were compared with controls that were matched by age and gender, and operations were performed as outpatient surgery. Recorded patient parameters were demographics, characteristics of lesions and treatment modality, and the size of the wound area. The primary outcome measures were clinical adverse events, including abdominal pain, diarrhea, hemotachezia, and fever. Secondary outcome measures were white blood cell count, C-reactive protein and blood culture. Additionlly, the relationship between the size of the wound area and clinical adverse events was analyzed.

RESULTS: A total of 409 patients were enrolled in this study, with 107 patients in the control group, 107 patients in the antibiotic group, and another 195 cases in the follow-up outpatient group. The patients’ demographic characteristics, including age, gender, characteristics of lesions, treatment modality, and the size of the wound area were similar between the 2 groups. The rates of adverse events in the antibiotic group were significantly lower than in the control group: abdominal pain (2.8% vs 14.9%, P < 0.01), diarrhea (2.0% vs 9.3%, P < 0.05), and fever (0.9% vs 8.4%, P < 0.05) respectively. The levels of inflammatory markers also decreased significantly in the antibiotic group compared with the control group: leukocytosis (2.0% vs 11.2%, P < 0.01), and C-reactive protein (2.0% vs 10.7%, P < 0.05). Additionally, clinical adverse events were related to the size of the surgical wound area. When the surgical wound area was larger than 10 mm × 10 mm, there were more clinical adverse events.

CONCLUSION: Clinical adverse events are not uncommon after EMR or ESD procedures. Prophylactic antibiotics can reduce the incidence of clinical adverse events. This should be further explored.

[Keratitis after laser in situ keratomileusis (LASIK). A different entity and treatment management]

Keratitis after laser in situ keratomileusis (LASIK) is rare and challenging as patients may present with mild symptoms and initial management differs significantly. Post-LASIK keratitis is usually due to gram-positive bacteria or opportunistic/atypical microorganisms located beneath the corneal flap. Due to relative protective interface location it is necessary to lift the corneal flap for cultures and antibiotic irrigation. The case report demonstrates that post-LASIK keratitis requires prompt referral to ophthalmology department as correct initial management is pivotal for good visual outcome.

The management of acute mastoiditis in children with cochlear implants: saving the device

OBJECTIVE

Early treatment of profound bilateral sensorineural hearing loss with cochlear implantation has become routine, resulting in an increased proportion of children implanted at younger ages. These children are at a relatively high risk for acute otitis media (AOM), and are more likely to develop mastoiditis in the implanted ear. Despite the significant risks associated with mastoiditis, including compromise of the implant, there are no specific guidelines on the management of this population. We propose a treatment algorithm emphasizing early but conservative operative intervention.

METHODS

A retrospective chart review included eight patients, who experienced mastoiditis, in the context of cochlear implantation at our center from August 2005 to November 2012. During this period 806 implant surgeries were completed.

RESULTS

The median age at which mastoiditis occurred was 37 months, and the mean time from implantation to mastoiditis was 9.56 months. All patients underwent drainage of the middle ear in conjunction with intravenous antibiotics, and two additionally underwent post-auricular incision and drainage.

DISCUSSION

Recent mastoidectomy may be a risk factor for the development of a post-auricular abscess in children, who develop AOM following cochlear implantation. A treatment algorithm was developed, which emphasizes early operative drainage in conjunction with aggressive antibiotic therapy. Conclusions A consistent approach to the management of mastoiditis in children with cochlear implants has not been established. Rapid initiation of aggressive antibiotic therapy and a low threshold for conservative operative intervention results in effective resolution of infection while allowing preservation of the implant.

Clinical Efficacy and Safety of a Short Regimen of Azithromycin Sequential Therapy vs Standard Cefuroxime Sequential Therapy in the Treatment of Community-Acquired Pneumonia: An International, Randomized, Open-Label Study

An international, randomized, open-label, comparative study was undertaken in order to assess the efficacy and safety of azithromycin and cefuroxime, short sequential vs standard sequential therapy, respectively, in the treatment of patients with community-acquired pneumonia (CAP). 180 adult patients were included in the study. 89 patients received azithromycin 500 mg intravenously (i.v.) once daily for 1-4 days followed by azithromycin 500 mg orally once daily for 3 days. 91 patients received cefuroxime 1.5 g i.v. three times daily for 1-4 days followed by cefuroxime axetil 500 mg orally twice daily for 7 days. Clinical efficacy was achieved in 67/82 (81.7%) patients treated with azithromycin, and in 73/89 (82.0%) patients treated with cefuroxime. The mean duration of total (i.v. and oral) therapy was significantly shorter for the azithromycin group than for the cefuroxime group (6.2 days vs 10.1 days). Adverse events were recorded in 38.2% of patients treated with azithromycin, and in 29.7% of patients treated with cefuroxime (p = 0.20). Shorter sequential i.v.-to-oral azithromycin therapy of patients with CAP was as effective as standard sequential i.v.-to-oral cefuroxime therapy.

Evaluation of an institutional guideline for the treatment of cerebrospinal fluid shunt-associated infections

BACKGROUND

Cerebrospinal fluid (CSF) shunt-associated infection is one of the most frequent complications of CSF shunt surgery. We evaluated our institutional guideline for the treatment of shunt-associated infections.

METHODS

We retrospectively analysed all 92 episodes of shunt-associated infections in 78 patients treated in our institution from 2002 to 2008. All patients underwent urgent surgery, i.e. removal of the complete shunt hardware or externalisation of the distal tubing in cases with an infection restricted to the distal shunt (10 %), placement of an external ventricular drainage as necessary and antibiotic therapy. Standard empirical first-line antibiotic treatment consisted of a combination of flucloxacillin and cefuroxime.

RESULTS

We observed 38 % early (<1 month after shunt surgery) and 20 % late infections (> 1 year after shunt placement). Coagulase-negative staphylococci (CoNS) were isolated in 38 %. In 38 % no pathogens could be isolated. Of cases with a first shunt infection, 58 % were initially treated with flucloxacillin/cefuroxime. Only 53 % of all infections were treated successfully with the first course of antibiotics. Only 51 % of bacterial isolates were sensitive to empirical first-line antibiotics. Twenty percent of infections caused by sensitive bacterial isolates nevertheless required second-line antibiotic therapy.

CONCLUSIONS

Urgent surgery for shunt removal and antibiotic therapy will usually cure a shunt-associated infection. The choice of antibiotics should reflect the spectrum of pathogens seen at one's institution, paying particular attention to the role of CoNS isolates, and in vitro sensitivity testing results.

Cefuroxime-impregnated cement and systemic cefazolin for 1 week in primary total knee arthroplasty: an evaluation of 2700 knees

BACKGROUND

Infection is one of the most devastating complications after primary total knee arthroplasty (TKA). Antibiotics-impregnated cement has been used and proven effective in preventing deep infection. This study was to evaluate the long-term results of using cefuroxime-impregnated cement and systemic cefazolin for one week to assess their efficacy in preventing infection of primary TKA.

METHODS

From 1999 to 2007, 2700 cases of primary TKA were performed with cemented fixation of all patellar, tibial, and femoral components. Cefuroxime-impregnated cement for fixation and systemic cefazolin for one week were selected in all cases. The average follow-up period was 89 months (range, 40-140). The effects of this selected regime in the periprosthetic infection were evaluated.

RESULTS

A total of eight infections occurred after primary TKA, including five deep infections (0.19%) and three superficial infections (0.11%) in the 2700 knees. No loosening or osteolysis was noted.

CONCLUSION

Comparable with other measurements, cefuroxime-impregnated cement, accompany by systemic cefazolin for 1 week was shown to control postoperative deep infection to 0.19% (after primary TKA was performed in an operative setting without lamina flow and body exhaust suit).

Thrombotic thrombocytopenic purpura after prophylactic cefuroxime axetil administered in relation to a liposuction procedure

Thrombotic thrombocytopenic purpura (TTP) or Moschcowitz's syndrome is characterized by platelet and von Willebrand factor (vWF) deposition in arterioles and capillaries throughout the body, which results in organ ischemia. The diagnostic pentad characterizing TTP consists of thrombocytopenia, microangiopathic hemolytic anemia (MAHA), fever, neurologic manifestations, and renal insufficiency. In terms of type, TTP can be either idiopathic or secondary. The causes of secondary TTP include pregnancy, infections, pancreatitis, collagen vascular disease, cancer, bone marrow transplantation, and drugs (including cephalosporins). Postoperative TTP has been reported after vascular surgery, renal and liver transplantations, and orthopedic, urologic, and abdominal surgical procedures. Therapeutic plasma exchange (TPE) therapy has reduced the mortality rates, but sometimes patients may have to receive immunosuppressive drugs including vincristine (VCR). This report describes a 42-year-old woman with TTP after prophylactic usage of cefuroxime axetil in relation to a liposuction procedure who was treated successfully with plasma exchange and VCR. The patient fully recovered after 17 TPEs and three doses of VCR. At this writing, her TTP still is in remission after 6 months of follow-up evaluation. To the authors' knowledge, this is the first report in the literature describing a patient with TTP after cefuroxime axetil administered in relation to a surgical procedure who was treated successfully with TPE and VCR.

Single versus 3-dose antibiotic prophylaxis in clean and clean contaminated operations

BACKGROUND

Infection is a great problem in surgery and is encountered by all surgeons by nature of their craft; they invariably impair the first line of host defence. Bacteria may enter the wound during or after the operation and may be of endogenous or exogenous origin. The objective of this study was to determine the effectiveness of preoperative antibiotic prophylaxis in reduction of postoperative wound infection in clean and clean contaminated procedures and to compare the cost of antibiotic prophylaxis in both groups.

METHOD

This was a prospective study done on patients in General Surgery Department, Al-Noor Specialist Hospital, Holly Makkah, Saudi Arabia from 1st April 2006 to 30th March 2007. Total 400 patients were divided into 2 groups of 200 patients each: Group-A received single dose antibiotic prophylaxis, and Group-B received 3 doses of antibiotic therapy. Only clean and clean contaminated procedures were included and results were compared.

RESULTS

In Group A, clean procedures (Group-Al) were 110, and clean contaminated (Group-A2) were 90 patients. In clean procedure, rate of infection was 5 out of 110 (4.54%) and in clean contaminated procedures it was 3 out of 90 (3.33%). In Group B, in clean procedures (Group-B1), rate of infection was 7 out of 90 (7.77%), while in clean contaminated procedures (Group-B2) it was 9 out of 110 (8.18%) patients. Over all wound infection rate after single dose antibiotic prophylaxis was 4% in both procedures and 8% after 3-dose antibiotic therapy.

CONCLUSION

Single dose antibiotic prophylaxis is as effective as 3-dose therapy in clean and clean contaminated procedures to prevent wound infection and is cost-effective.

Do augmentin or cefuroxime reach effective levels in lumbar vertebral discs when used prophylactically for discectomy? A preliminary report

The incidence of discitis following discectomy is reported at between 0.75% and 3.0%. We believe this rate could be reduced if an antibiotic that penetrated the disc tissue with an appropriate spectrum were to be given prophylactically to cover surgery. A prospective study of 20 patients undergoing routine lumbar discectomy was performed. Ten patients received Augmentin 1.2 g and ten received cefuroxime 1.5 g pre-operatively. In eight patients sequestrated disc fragments were analysed, and the majority were found to have drug levels higher than in the attached disc material; the reasons for this are discussed. We conclude that Augmentin penetrates damaged disc material to a limited extent, but cefuroxime achieves levels effective against the most commonly implicated pathogens in discitis tissue and is a rational choice of antibiotic for prophylaxis during lumbar discectomy.

Comparative bioavailability of cefuroxime axetil suspension formulations administered with food in healthy subjects

OBJECTIVE

To assess the comparative bioavailability of two formulations (250 mg/5 mL suspension) of cefuroxime axetil (CAS 64544-07-6), administered with food, in healthy volunteers of both sexes.

METHODS

The study was conducted using an open, randomized, two-period crossover design with a 1-week washout interval. Plasma samples were obtained for up to 12 h post dose. Plasma cefuroxime axetil concentrations were analyzed by liquid chromatography coupled with tandem mass spectrometry (LC-MS-MS) with negative ion electrospray ionization using multiple reactions monitoring (MRM). From the cefuroxime axetil plasma concentration vs. time curves, the following pharmacokinetic parameters were obtained: AUClast and Cmax.

RESULTS

The limit of quantification was 0.1 microg/mL for plasma cefuroxime axetil analysis. The geometric mean and 90% confidence interval CI of test/reference product percent ratios were: 106.1% (100.8%-111.8%) for Cmax, 109.4% (104.8%-114.2%) for AUClast.

CONCLUSION

Since the 90% CI for AUClast and Cmax ratios were within the 80-125% interval proposed by the US FDA, it was concluded that cefuroxime axetil (test formulation, 250 mg/5 mL suspension) was bioequivalent to a reference formulation under fed conditions, for both the rate and extent of absorption.

[Prophylaxis of postoperative endophthalmitis with intracameral cefuroxime: a five years' experience]

PURPOSE

To present the outcomes of prophylaxis of postoperative endophthalmitis following cataract surgery with intracameral Cefuroxime.

METHOD

A retrospective study was done on 4281 eyes that underwent cataract surgery from October 2003 to September 2008. All patients underwent phacoemulsification cataract surgery. All cases received an injection of 0.1 ml intracameral Cefuroxime (1 mg) at the end of surgery except those patients allergic to penicillin and cephalosporin until September 2007 and thereafter only those with demonstrated allergy to cefuroxime.

RESULTS

The rate of postoperative endophthalmitis was 0.11% (5 cases). Four of them had a positive culture. We found no evidence of clinical ocular toxicity.

CONCLUSIONS

Intracameral cefuroxime works very well for reducing the incidence of postoperative endophthalmitis. It appears safe to use and is easy to prepare.

[Streptococcus pyogenes infection with tonsillar focus as possible cause of septic shock]

Streptococcus pyogenes (SP) is a common bacterial pathogen. For the past two decades, several studies have reported an increase in the severity and the incidence of SP infections.

CASE

a 60-year-old female admitted to the hospital with tonsillitis acuta verified by strep-A test was initially treated with V-penicillin, but developed septic shock and disseminated intravascular coagulation (DIC), and treatment was changed to cefuroxime and clindamycin. She recovered fully. This case combined with other studies illustrates that SP infections have become more severe. Clindamycin should be added to penicillin for the treatment of invasive SP infections.

[Use of systemic antibacterial agents at a university emergency clinic in Bucharest, in the year 2008]

OBJECTIVE

use of ATC/DDD (Anatomic Therapeutic Classification/Daily Defined Dose) methodology promoted by World Health Organization for calculating and analysis of systemic antimicrobial agents' annual rates of usage among the adult patients hospitalized in Bucharest municipality.

METHODS

descriptive retrospective study conducted in the main university clinic for medical emergencies from Bucharest municipality. Consumption of systemic antimicrobial agents, taken from the clinic pharmacy's records, regarding the 2008 year, has been transformed in defined daily doses and aggregated by ATC subgroups. The number of patient days from 2008 was obtained from clinic administrative service. Antimicrobial agents' usage was expressed as consumption density rate by dividing the defined daily doses counts to the correspondent number of patient days. Analysis of consumption rates has been performed both by whole clinic and also stratified by departments of medical specialties: surgery, internal medicine and intensive care.

RESULTS

In the year 2008, the patients carried in the clinic totalized 255,600 days of hospitalization; during the respective time in clinic there were used 36 of individual antibacterial agents that made up 184,857 defined daily doses. At the level of entire clinic the consumption rate of all systemic antimicrobial agents was 72.6 defined daily doses per 100 de patient days (DDD/PD); by medical specialties the indicator's values were 61.2 DDD/100 PD in the department of internal medicine specialties, 62.8 DDD/100 PD in the departament of surgical specialties and 126 DDD/100 PD in the medical/surgical intensive care unit, respectively. Almost 70% of the defined daily doses' total included five antimicrobial agents: co-amoxiclav, cefuroxim, cefoperazone + sulbactam, ciprofloxacine si metronidazol. By ATC subgroups, the top three consumption rates included penicillin plus beta-lactamase inhibitors, 2nd generation cefalosporines and fluorochinolons, respectively. Comparing the own rate with the distributions of NNIS (National Nosocomial Infection Surveillance) system form USA, demonstrated that the usage was into the expected limits for the majority of antimicrobial agents groups considered, excess usage being detected only in the case of 2nd generation cefalosporins (in non-intensive care sector) and in the case of carbapenems in the intensive care units, respectively.

CONCLUSIONS

At the whole clinic level, the study detected a rate of systemic antimicrobial agents' usage similar with the correspondent values recently reported even from the South European states or form USA. Excessive usage (against the NNIS standard) might be mitigated through augmentation of the compliance with guidelines for prudent utilization of antimicrobial agents.

[Factors influencing the use of systemic antibiotics in hospitalized pediatric patients in Bucharest, Romania]

BACKGROUND

Formulation of effective strategies for prudent usage of antibacterial agents involves knowing of the factors that are modulating the variability of usage rate.

OBJECTIVE

analysis of the factors what modulate the usage rate's variability of antimicrobials prescribed to hospitalized children from Bucharest municipality.

METHODS

A statistically representative sample (n=895) has been extracted from the cohort of children discharged during October 2008 from the Bucharest's main pediatric university clinic. Demographic, clinic and pharmacological relevant data, captured by reviewing the subjects' medical charts were entered in an Epi Info database. For each enrolled subject the density rate of antimicrobial consumption has been calculated by dividing the pooled number of hospital days in which the subject received at least one dose of each individual antimicrobial agent, by the number of days of hospitalization. For the analysis of antimicrobials usage rate's variability, a rate higher the value calculated at 75 percentile has been defined as overuse. Personal, clinical and prescription characteristics significantly associated, in univariate analysis, with overuse status, were analyzed lately for independent association, by unconditional logistic regression.

RESULTS

to the sample's subjects up to 31 individual antimicrobials owning to the J01 group (antimicrobials for systemic use) of the ATC (Anatomical Therapeutic Chemical) classification promoted by World Health Organization were prescribed. In total, in the sample a number of 2607 days of antimicrobial therapy was cumulated, in 60% of these 5 antimicrobials agents were administered: ceftriaxone, gentamicine, cefoperazone, cefazolin and cefuroxime. Antimicrobials overuse was observed in 37% of subjects. By univariate analysis the overuse was significantly associated (p < 0,05) with the following characteristics of the subjects: age under one, with a trip in ICU, diagnosed with LRTI, with a hospitalization longer than 5 days, exposed to more than two antimicrobials agents during the same hospitalization episode and treated with 3rd generation cephalosporins. However, by multivariate analysis, only factors related to antimicrobials prescribing style remained independently associated with overuse status.

CONCLUSIONS

In children hospitalized in Bucharest, the antimicrobial agents' consumption is modulated by factors which are specific for this category of patients, factors broadly internationally recognized. Particularly, through multivariate analysis, we found that the factors related with antimicrobials prescription's style explained with the most fidelity the variation of usage density rate in the child hospitalized in Bucharest. The analysis of the modulators of the usage rate's variability is essential for issuing and evaluation of effective interventions focused on antimicrobials' prudent use.

[Toxic megacolon secondary to Clostridium difficile-associated pseudomembranous colitis]

A 78-year-old male without pre-existing comorbidity who underwent revision of a hip arthroplasty developed abdominal pain and distension, diarrhoeas, pyrexia and leucocytosis after only 5 days' postoperative treatment with cefuroxime and gentamycine. Abdominal computed tomography demonstrated severe colonic dilation, inflammation and oedema consistent with toxic megacolon. Stool samples were positive for Clostridium difficile. Oral vancomycine treatment and colonic decompression were inefficient. Subtotal colectomy was performed after which the condition improved.

[Comparative study on the efficacy of cefuroxime, amoxycillin/clavulanic acid and fosfomycin in prophylaxis of nosocomial infections in oncologic patients after surgical operations]

Rational antibiotic prophylaxis and antibacterial therapy of nosocomial infections is an actual problem in surgery. Improvement of antimicrobial chemotherapy and prophylaxis of nosocomial infections is of special importance in urgent cases in oncologic units. Data on the design of rational schemes for antibacterial prophylaxis of nosocomial infections developing during the postoperative period in patients with cancer of the urinary bladder as one of the unfavourable complications of the main disease treatment are presented. The use of fosfomycin in the schemes of the antibiotic prophylaxis was shown to be more efficient vs. the use of the traditional beta-lactam antibiotics.