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Dellinger EP. What Is the Ideal Duration for Surgical Antibiotic Prophylaxis? Surg Infect (Larchmt) 2024; 25:1-6. [PMID: 38150526 DOI: 10.1089/sur.2023.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Background: Surgical antibiotic prophylaxis practice became common in the 1970s and has since become almost universal. The earliest articles used three doses over 12 hours with the first being administered before the start of the operation. Conclusions: The duration of prophylaxis has varied widely in practice over time, but an increasing body of evidence has supported shorter durations, most recently with recommendations in influential guidelines to avoid administration after the incision is closed.
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Affiliation(s)
- E Patchen Dellinger
- Department of Surgery, Division of General Surgery, University of Washington, Seattle, Washington, USA
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2
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Ahmed NJ, Haseeb A, AlQarni A, AlGethamy M, Mahrous AJ, Alshehri AM, Alahmari AK, Almarzoky Abuhussain SS, Mohammed Ashraf Bashawri A, Khan AH. Antibiotics for preventing infection at the surgical site: Single dose vs. multiple doses. Saudi Pharm J 2023; 31:101800. [PMID: 38028220 PMCID: PMC10661588 DOI: 10.1016/j.jsps.2023.101800] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/21/2023] [Indexed: 12/01/2023] Open
Abstract
Background Surgical site infections are common and expensive infections that can cause fatalities or poor patient outcomes. To prevent these infections, antibiotic prophylaxis is used. However, excessive antibiotic use is related to higher costs and the emergence of antimicrobial resistance. Objectives The present meta-analysis aimed to compare the effectiveness of a single dosage versus several doses of antibiotics in preventing the development of surgical site infections. Methods PubMed was used to find clinical trials evaluating the effectiveness of a single dosage versus several doses of antibiotics in avoiding the development of surgical site infections. The study included trials that were published between 1984 and 2022. Seventy-four clinical trials were included in the analysis. Odds ratios were used to compare groups with 95% confidence intervals. The data were displayed using OR to generate a forest plot. Review Manager (RevMan version 5.4) was used to do the meta-analysis. Results Regarding clean operations, there were 389 surgical site infections out of 5,634 patients in a single dose group (6.90%) and 349 surgical site infections out of 5,621 patients in multiple doses group (6.21%) (OR = 1.11, lower CI = 0.95, upper CI = 1.30). Regarding clean-contaminated operations, there were 137 surgical site infections out of 2,715 patients in a single dose group (5.05%) and 137 surgical site infections out of 2,355 patients in multiple doses group (5.82%) (OR = 0.87, lower CI = 0.68, upper CI = 1.11). Regarding contaminated operations, there were 302 surgical site infections out of 3,262 patients in a single dose group (9.26%) and 276 surgical site infections out of 3,212 patients in multiple doses group (8.59%) (OR = 1.11, lower CI = 0.84, upper CI = 1.47). In general, there were 828 surgical site infections out of 11,611 patients in a single dose group (7.13%) and 762 surgical site infections out of 11,188 patients in multiple doses group (6.81%) (OR = 1.05, lower CI = 0.93, upper CI = 1.20). The difference between groups was not significant. Conclusion The present study showed that using a single-dose antimicrobial prophylaxis was equally effective as using multiple doses of antibiotics in decreasing surgical site infections.
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Affiliation(s)
- Nehad J. Ahmed
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Malaysia
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Abdullmoin AlQarni
- Infectious Diseases Department, Alnoor Specialist Hospital, Makkah, Saudi Arabia
| | - Manal AlGethamy
- Department of Infection Prevention & Control Program, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Ahmad J. Mahrous
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Ahmed M. Alshehri
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Abdullah K Alahmari
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | | | | | - Amer H. Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Malaysia
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Nagata K, Yamada K, Shinozaki T, Miyazaki T, Tokimura F, Tajiri Y, Matsumoto T, Yamakawa K, Oka H, Higashikawa A, Sato T, Kawano K, Karita T, Koyama T, Hozumi T, Abe H, Hodohara M, Kohata K, Toyonaga M, Oshima Y, Tanaka S, Okazaki H. Effect of Antimicrobial Prophylaxis Duration on Health Care-Associated Infections After Clean Orthopedic Surgery: A Cluster Randomized Trial. JAMA Netw Open 2022; 5:e226095. [PMID: 35412627 PMCID: PMC9006110 DOI: 10.1001/jamanetworkopen.2022.6095] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Postoperative health care-associated infections are associated with a greater deterioration in patients' general health status and social and economic burden, with at least 1 occurring in approximately 4% of acute care hospital patients. Antimicrobial prophylaxis prevents surgical site infections in various orthopedic procedures; however, its relationship with health care-associated infections remains unknown. OBJECTIVE To examine whether a shorter antimicrobial prophylaxis duration of less than 24 hours after surgery is not inferior to a longer duration in preventing health care-associated infections after clean orthopedic surgery. DESIGN, SETTING, AND PARTICIPANTS This open-label, multicenter, cluster randomized, noninferiority clinical trial was conducted in 5 tertiary referral hospitals in greater Tokyo metropolitan area, Japan, from May to December 2018. Adult patients undergoing clean orthopedic surgery were recruited until the planned number of participants was achieved (500 participants per group). Statistical analysis was conducted from July to December 2019. INTERVENTIONS Antimicrobial prophylaxis was discontinued within 24 hours after surgery in group 24 and 24 to 48 hours after surgery in group 48. Group allocation was switched every 2 or 4 months according to the facility-based cluster rule. Study-group assignments were masked from participants. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of health care-associated infections requiring antibiotic therapies within 30 days after surgery. The noninferiority margin was 4%. RESULTS Of the 1211 participants who underwent cluster allocation, 633 participants were in group 24 (median [IQR] age, 73 [61-80] years; 250 men [39.5%] and 383 women [60.5%]), 578 participants were in group 48 (median [IQR] age, 74 [62-81] years; 204 men [35.3%] and 374 women [64.7%]), and all were eligible for the intention-to-treat analyses. Health care-associated infections occurred in 29 patients (4.6%) in group 24 and 38 patients (6.6%) in group 48. Intention-to-treat analyses showed a risk difference of -1.99 percentage points (95% CI, -5.05 to 1.06 percentage points; P < .001 for noninferiority) between groups, indicating noninferiority. Results of adjusted intention-to-treat, per-protocol, and per designated procedure population analyses supported this result, without a risk of antibiotic resistance and prolonged hospitalization. CONCLUSIONS AND RELEVANCE This cluster randomized trial found noninferiority of a shorter antimicrobial prophylaxis duration in preventing health care-associated infections without an increase in antibiotic resistance risk. These findings lend support to the global movement against antimicrobial resistance and provide additional information on adequate antimicrobial prophylaxis for clean orthopedic surgery. TRIAL REGISTRATION Identifier: UMIN000030929.
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Affiliation(s)
- Kosei Nagata
- Department of Orthopedic Surgery and Spinal Surgery, the University of Tokyo Hospital, Tokyo, Japan
| | - Koji Yamada
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan
| | - Tsuyoshi Miyazaki
- Department of Orthopedic Surgery, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Fumiaki Tokimura
- Department of Orthopedic Surgery, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Yasuhito Tajiri
- Department of Orthopedic Surgery, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Takuya Matsumoto
- Department of Orthopedic Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Kiyofumi Yamakawa
- Department of Orthopedic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Hiroyuki Oka
- Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical and Research Center, Faculty of Medicine, The University of Tokyo, Tokyo, Bunkyo-ku, Japan
| | - Akiro Higashikawa
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan
| | - Toshihide Sato
- Department of Orthopedic Surgery, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Kenichi Kawano
- Department of Orthopedic Surgery, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Tatsuro Karita
- Department of Orthopedic Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Takuya Koyama
- Department of Orthopedic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Takahiro Hozumi
- Department of Orthopedic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Hiroaki Abe
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan
| | - Makoto Hodohara
- Department of Orthopedic Surgery, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Kazuhiro Kohata
- Department of Orthopedic Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Masato Toyonaga
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan
| | - Yasushi Oshima
- Department of Orthopedic Surgery and Spinal Surgery, the University of Tokyo Hospital, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopedic Surgery and Spinal Surgery, the University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Okazaki
- Department of Orthopedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan
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Recomendaciones basadas en la evidencia para la prevención de la infección de herida quirúrgica en cirugía cardiovascular. CIRUGIA CARDIOVASCULAR 2018. [DOI: 10.1016/j.circv.2017.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:5-33. [PMID: 29029110 DOI: 10.1093/ejcts/ezx314] [Citation(s) in RCA: 238] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Järvelä KM, Khan NK, Loisa EL, Sutinen JA, Laurikka JO, Khan JA. Hyperglycemic Episodes Are Associated With Postoperative Infections After Cardiac Surgery. Scand J Surg 2017; 107:138-144. [PMID: 28934890 DOI: 10.1177/1457496917731190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS To describe the incidence of and risk factors for postoperative infections and the correlation between postoperative hyperglycemia despite tight blood glucose control with infectious and other complications after contemporary cardiac surgery. MATERIAL AND METHODS The study comprised 1356 consecutive adult patients who underwent cardiac surgery between January 2013 and December 2014 and were followed up for 6 months. Patients surviving the first 2 days were included in the analysis. Preoperative demographic information, medical history, procedural details, and the postoperative course were recorded. The target range for blood glucose levels was 4-7 mmol/L and repeated arterial blood samples were obtained during the intensive care unit stay. The associations of blood glucose levels during the first postoperative day and the occurrence of postoperative infections and other significant complications were analyzed. RESULTS Of the study cohort, 9.8% developed infectious complications which were classified as major surgical site infections in 2.2%, minor surgical site infections in 1.1%, lung infections in 2.0%, unclear fever or bacteremia in 0.3%, cannula or catheter related in 2.6%, multiple in 1.5%, and other in 0.2%. The incidence of deep sternal wound infection was 2.0%. Repeated hyperglycemia occurred in 39.7% of patients and was associated with increased rates of postoperative infections, 12.1% versus 8.2%, p = 0.019; stroke, 4.9% versus 1.5%, p < 0.001; and mortality, 6.1% versus 2.1%, p < 0.001, when compared to patients with single or no hyperglycemia. CONCLUSION Every 10th patient develops infectious complications after cardiac surgery. Repeated hyperglycemia is associated with increased rates of infectious complications, stroke, and mortality.
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Affiliation(s)
- K M Järvelä
- 1 Department of Cardiothoracic Surgery, TAYS Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - N K Khan
- 2 Department of Vascular Surgery, Tampere University Hospital, Tampere, Finland
| | - E L Loisa
- 3 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - J A Sutinen
- 3 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - J O Laurikka
- 1 Department of Cardiothoracic Surgery, TAYS Heart Hospital, Tampere University Hospital, Tampere, Finland.,3 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - J A Khan
- 1 Department of Cardiothoracic Surgery, TAYS Heart Hospital, Tampere University Hospital, Tampere, Finland
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7
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A prospective randomised trial of isolated pathogens of surgical site infections (SSI). Ann Med Surg (Lond) 2017; 21:25-29. [PMID: 28761643 PMCID: PMC5524225 DOI: 10.1016/j.amsu.2017.07.045] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/16/2017] [Accepted: 07/17/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Every surgical wound is colonized by bacteria, but only a small percentage displays symptoms of infection. The distribution of pathogens isolated in surgical site infections has not significantly changed over the last decades. Staph. Aureus, Coag(-) Staphylococci, Enterococcus spp and E. Coli are the main strains appearing. In addition, a continuously rising proportion of surgical site infections caused by resistant bacterial species (MRSA, C. Albicans) has been reported. METHODS This prospective and randomized clinical study was performed in the 1st Surgical Clinic of Sismanoglion General Hospital of Athens, from February 2009 to February 2015. Patients undergoing elective surgery in the upper or lower digestive system were randomized to receive antimicrobial treatment as chemoprophylaxis. Each patient filled a special monitoring form, recording epidemiological data, surgery related information, surgical site infections (deep and superficial), as well as postoperative morbidity (urinary and respiratory infections included). The monitoring of patients was carried by multiple visits on a daily basis during their hospitalization and continued after they were discharged via phone to postoperative day 30. RESULTS Our overall SSI incidence was 4,3% (31patients out of a whole of 715 patients). Specifically, the incidence of SSIs for scheduled surgery of the upper GI tract was 2,2% (11 out of 500 patients) and for the lower GI tract was 9,3% (20 out of 215 patients). Seven main pathogens were isolated from patients with SSIs: Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Pseudomonas aeruginosa, Bacteroides fragilis, Staphylococcus aureus and Enterococcus faecalis. Their growth rates were respectively: S. Aureus (17,3%), E. faecalis (19,5%), P. aeruginosa (10,5%), B. Fragilis (13,4%) E. coli (20,4%), Enterobacter cloacae (9,1%) and K. Pneumoniae (9,8%). In addition, all the SSIs were found to be multimicrobial. Several studies have already revealed that patient characteristics and coexisting morbidities such as obesity, smoking, heart or renal failure, pre-existing localized infections and patients' age (especially if age exceeds 65) seem to be independent prognostic factors for surgical field infections. Additionally, classification of the surgical wound, surgical operation complexity, preoperative hospitalization, prolongation of surgical time and need for transfusions have been proved to differentiate the incidence of SSIs. CONCLUSIONS In conclusion, surgical site infections are important complications affecting the healthcare services, the cost of hospitalization and the patient himself. Future thorough studies are expected to reveal much more data, regarding predisposing and precautionary patient and hospital characteristics.
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Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, Gomes SM, Gans S, Wallert ED, Wu X, Abbas M, Boermeester MA, Dellinger EP, Egger M, Gastmeier P, Guirao X, Ren J, Pittet D, Solomkin JS. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. THE LANCET. INFECTIOUS DISEASES 2016; 16:e288-e303. [PMID: 27816414 DOI: 10.1016/s1473-3099(16)30402-9] [Citation(s) in RCA: 476] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/28/2016] [Accepted: 09/13/2016] [Indexed: 12/11/2022]
Abstract
Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.
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Affiliation(s)
- Benedetta Allegranzi
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland.
| | - Bassim Zayed
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland
| | - Peter Bischoff
- Institute of Hygiene and Environmental Medicine, Charité-University Medicine, Berlin, Germany
| | - N Zeynep Kubilay
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland
| | - Stijn de Jonge
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Fleur de Vries
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | | | - Sarah Gans
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Elon D Wallert
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Xiuwen Wu
- Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Mohamed Abbas
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marja A Boermeester
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité-University Medicine, Berlin, Germany
| | | | - Jianan Ren
- Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Didier Pittet
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland; WHO Collaborating Centre on Patient Safety (Infection Control and Improving Practices), University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Joseph S Solomkin
- OASIS Global, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Bath S, Lines J, Loeffler AM, Malhotra A, Turner RB. Impact of standardization of antimicrobial prophylaxis duration in pediatric cardiac surgery. J Thorac Cardiovasc Surg 2016; 152:1115-20. [PMID: 27245416 DOI: 10.1016/j.jtcvs.2016.04.091] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 04/20/2016] [Accepted: 04/30/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The optimal duration of antimicrobial prophylaxis following pediatric cardiac surgery is still debated. Adult studies suggest that shorter durations are adequate, but there is a paucity of data on pediatric patients. METHODS This quasi-experimental study reviewed the charts of patients 18 years and younger who underwent cardiac surgery from April 2011 to November 2014 at a single institution. Starting in April 2013, a protocol was implemented to limit antimicrobial prophylaxis to 48 hours following sternal closure. Two analyses were performed: (1) identification of risk factors for surgical site infections from the entire cohort, and (2) comparison of surgical site infection incidence in the pre- and postprotocol groups. RESULTS In the entire cohort, delayed sternal closure (adjusted odds ratio [OR], 5.7; 95% confidence interval [CI], 1.8-17.9) and younger age (adjusted OR, 2.1; 95% CI, 1.1-3.8) were associated with incidence of surgical site infection. Following the protocol change, duration of antimicrobial prophylaxis decreased from 4.2 ± 2.7 to 1.9 ± 1.3 days (P < .0001). After adjusting for age and delayed sternal closure, the postprotocol group had an adjusted OR of 0.98 (95% CI, 0.32-3.00) for occurrence of surgical site infection. Other outcomes were not altered following the protocol change. CONCLUSIONS Restricting antimicrobial prophylaxis to 48 hours following pediatric cardiac surgery did not increase the incidence of surgical site infection at our institution. Further study is needed to validate this finding and to identify practices that reduce surgical site infections in those with delayed sternal closure.
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Affiliation(s)
- Sundeep Bath
- Pacific University, School of Pharmacy, Hillsboro, Ore; Randall Children's Hospital at Legacy Emanuel, Portland, Ore
| | - Jason Lines
- Randall Children's Hospital at Legacy Emanuel, Portland, Ore
| | - Ann M Loeffler
- Randall Children's Hospital at Legacy Emanuel, Portland, Ore
| | | | - R Brigg Turner
- Pacific University, School of Pharmacy, Hillsboro, Ore; Randall Children's Hospital at Legacy Emanuel, Portland, Ore.
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Pourtaheri S, Miller F, Dabney K, Shah SA, Dubowy S, Holmes L. Deep Wound Infections After Pediatric Scoliosis Surgery. Spine Deform 2015; 3:533-540. [PMID: 27927555 DOI: 10.1016/j.jspd.2015.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 03/31/2015] [Accepted: 04/09/2015] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN Retrospective clinical and radiographic review. OBJECTIVE The purpose of this study was to evaluate the characteristics of deep wound infection, as well as the potential factors that correlate to surgical site infection (SSI) in spine deformity surgery. SUMMARY OF BACKGROUND DATA Preventing SSIs in pediatric spinal deformity surgery is a crucial task. Recent data have shown that antibiotic-loaded allograft and properly timed preoperative antibiotic administration decrease SSIs. However, there remain controversies over the appropriate preoperative antibiotic selection. METHODS We reviewed 851 spinal deformity surgeries that took place at a single institution from 2006 to 2010. In particular, preoperative and postoperative characteristics of the deep wound infections were evaluated. RESULTS Twenty-four patients had SSIs. The mean age at surgery in the infected cohort was 14 years, mean length of surgery was 8 hours, and median estimated blood loss was 2,482 mL (%EBV: 66%). Approximately 67% of the infected patients had bowel/bladder incontinence, and 71% had prolonged intravenous access perioperatively. According to culture results, the most effective antibiotic to treat the infections was vancomycin. Preoperative antibiotics were administered within 30 minutes of incision (hospital protocol) in only 12.5% (p = .001) and within 1 hour of incision in 54% of the cases. The wound status within 3 days of surgery is as follows: 38% intact, 29% significant wound drainage, and 33% wound dehiscence. Methicillin-resistant Staphylococcus aureus (MRSA) and oxacillin-resistant Staphylococcus epidermidis were associated with intact wounds, whereas gram-negative pathogens were seen in dehisced or draining wounds (p < .001). CONCLUSIONS The authors showed that their cohort of patients with infection had a high rate of draining wounds, MRSA infections, administration of antibiotics more than 1 hour ahead of incision, and prolonged need for intravenous access after surgery. Efforts to mitigate these associations by using vancomycin prophylactically, doing meticulous wound closure to prevent drainage or dehiscence, and delivering antibiotics at an optimal time ahead of incision may lead to a decrease in infection rates in pediatric spinal surgery. Future prospective studies will be needed to validate this.
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Affiliation(s)
- Sina Pourtaheri
- Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, P.O. Box 269, Wilmington, DE 19899, USA
| | - Freeman Miller
- Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, P.O. Box 269, Wilmington, DE 19899, USA.
| | - Kirk Dabney
- Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, P.O. Box 269, Wilmington, DE 19899, USA
| | - Suken A Shah
- Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, P.O. Box 269, Wilmington, DE 19899, USA
| | - Susan Dubowy
- Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, P.O. Box 269, Wilmington, DE 19899, USA
| | - Laurens Holmes
- Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, P.O. Box 269, Wilmington, DE 19899, USA
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Izquierdo-Blasco J, Campins-Martí M, Soler-Palacín P, Balcells J, Abella R, Gran F, Castillo F, Nuño R, Sanchez-de-Toledo J. Impact of the implementation of an interdisciplinary infection control program to prevent surgical wound infection in pediatric heart surgery. Eur J Pediatr 2015; 174:957-63. [PMID: 25652766 DOI: 10.1007/s00431-015-2493-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 01/11/2015] [Accepted: 01/16/2015] [Indexed: 10/24/2022]
Abstract
UNLABELLED Surgical site infection (SSI) remains a major source of morbidity, mortality, and increased health care costs in children undergoing heart surgery. The aim of this study was to assess the effectiveness of an intervention program designed to reduce the high incidence of SSI observed at our center in pediatric patients. An interdisciplinary infection control program including pre-, intra-, and postoperative measures was introduced for children undergoing heart surgery with cardiopulmonary bypass. We conducted a quasi-experimental interventional study comparing a pre-intervention cohort (June 2009 to March 2010) and a post-intervention cohort (July 2011 to July 2012). A significant drop in SSI incidence from 10.9 % (95 % CI 4.7-18.8) to 1.92 % (95 % CI 0.4-5.52) was observed. Variables significantly associated with infection risk were median age (14 days in infected vs 2.3 years in non-infected patients; p<0.01), hospitalization unit (10.3 % SSI cumulative incidence in the neonatal intensive care unit vs 0 cases in the pediatric intensive care unit; p<0.01), and median preoperative hospital stay (14 days in infected vs 1 day in non-infected patients; p=0.03). CONCLUSIONS The implementation of a new intervention program was associated with an 82 % (95 % CI 34-94) reduction in SSI incidence in children undergoing heart surgery at our center. WHAT IS KNOWN • Surgical site infection (SSI) is associated with significant morbidity and mortality following pediatric cardiac surgery. • Younger patients and longer cardiopulmonary bypass times are associated with higher SSI rates. What is New: • Comprehensive infection control program including preoperative, intraoperative and postoperative nonpharmacologic measures is a key factor for the prevention of SSI. • A significant reduction in SSI rates can be achieve despite a narrower-spectrum antibiotic usage.
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Affiliation(s)
- Jaume Izquierdo-Blasco
- Department of Pediatric Intensive Care Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Hamouda K, Oezkur M, Sinha B, Hain J, Menkel H, Leistner M, Leyh R, Schimmer C. Different duration strategies of perioperative antibiotic prophylaxis in adult patients undergoing cardiac surgery: an observational study. J Cardiothorac Surg 2015; 10:25. [PMID: 25880032 PMCID: PMC4345000 DOI: 10.1186/s13019-015-0225-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 02/10/2015] [Indexed: 11/25/2022] Open
Abstract
Background All international guidelines recommend perioperative antibiotic prophylaxis (PAB) should be routinely administered to patients undergoing cardiac surgery. However, the duration of PAB is heterogeneous and controversial. Methods Between 01.01.2011 and 31.12.2011, 1096 consecutive cardiac surgery patients were assigned to one of two groups receiving PAB with a second-generation cephalosporin for either 56 h (group I) or 32 h (group II). Patients’ characteristics, intraoperative data, and the in-hospital follow-up were analysed. Primary endpoint was the incidence of surgical site infection (deep and superficial sternal wound-, and vein harvesting site infection; DSWI/SSWI/VHSI). Secondary endpoints were the incidence of respiratory-, and urinary tract infection, as well as the mortality rate. Results 615/1096 patients (56,1%) were enrolled (group I: n = 283 versus group II: n = 332). There were no significant differences with regard to patient characteristics, comorbidities, and procedure-related variables. No statistically significant differences were demonstrated concerning primary and secondary endpoints. The incidence of DSWI/SSWI/VHSI were 4/283 (1,4%), 5/283 (1,7%), and 1/283 (0,3%) in group I versus 6/332 (1,8%), 9/332 (2,7%), and 3/332 (0,9%) in group II (p = 0,76/0,59/0,63). In univariate analyses female gender, age, peripheral arterial obstructive disease, operating-time, ICU-duration, transfusion, and respiratory insufficiency were determinants for nosocomial infections (all ≤ 0,05). Subgroup analyses of these high-risk patients did not show any differences between the two regimes (all ≥ 0,05). Conclusions Reducing the duration of PAB from 56 h to 32 h in adult cardiac surgery patients was not associated with an increase of nosocomial infection rate, but contributes to reduce antibiotic resistance and health care costs.
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Affiliation(s)
- Khaled Hamouda
- Department of Cardiothoracic- and Thoracic Vascular Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
| | - Mehmet Oezkur
- Department of Cardiothoracic- and Thoracic Vascular Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
| | - Bhanu Sinha
- Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands.
| | - Johannes Hain
- University of Würzburg, Institute of Mathematics and Informatics, Chair of Mathematics VIII (Statistics), Würzburg, Germany.
| | - Hannah Menkel
- Department of Cardiothoracic- and Thoracic Vascular Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
| | - Marcus Leistner
- Department of Cardiothoracic- and Thoracic Vascular Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
| | - Rainer Leyh
- Department of Cardiothoracic- and Thoracic Vascular Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
| | - Christoph Schimmer
- Department of Cardiothoracic- and Thoracic Vascular Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany.
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Comparison of Vancomycin and Cefuroxime for Infection Prophylaxis in Coronary Artery Bypass Surgery. Infect Control Hosp Epidemiol 2015. [DOI: 10.1017/s0195941700087300] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACTOBJECTIVE: To investigate clinically significant differences between vancomycin and cefuroxime for perioperative infection prophylaxis in coronary artery bypass surgery.DESIGN: A total of 884 patients were randomized prospectively to receive either cefuroxime (444) or van-comycin (440) and were assessed for infectious complications during hospitalization and 1 month postoperatively.SETTING: A university hospital.RESULTS: The overall immediate surgical-site infection rate was 3.2% in the cefuroxime group and 3.5% in the vancomycin group (difference, −0.3; 95% confidence interval, −2.6-2.1).CONCLUSIONS: The data suggest that vancomycin has no clinically significant advantages over cephalosporin in terms of antimicrobial prophylaxis. We suggest that cefuroxime (or first-generation cephalosporins, which were not studied here) is a good choice for infection prophylaxis in connection with coronary artery bypass surgery in institutions without methicillin-resistantStaphylococcus aureusproblems. In addition to the increasing vancomycin-resistant enterococci problem, the easier administration and usually lower price of cefuroxime make it preferable to vancomycin.
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Gorski A, Hamouda K, Özkur M, Leistner M, Sommer SP, Leyh R, Schimmer C. Cardiac surgery antibiotic prophylaxis and calculated empiric antibiotic therapy. Asian Cardiovasc Thorac Ann 2014; 23:282-8. [PMID: 25061221 DOI: 10.1177/0218492314546028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ongoing debate exists concerning the optimal choice and duration of antibiotic prophylaxis as well as the reasonable calculated empiric antibiotic therapy for hospital-acquired infections in critically ill cardiac surgery patients. METHODS A nationwide questionnaire was distributed to all German heart surgery centers concerning antibiotic prophylaxis and the calculated empiric antibiotic therapy. RESULTS The response to the questionnaire was 87.3%. All clinics that responded use antibiotic prophylaxis, 79% perform it not longer than 24 h (single-shot: 23%; 2 doses: 29%; 3 doses: 27%; 4 doses: 13%; and >5 doses: 8%). Cephalosporin was used in 89% of clinics (46% second-generation, 43% first-generation cephalosporin). If sepsis is suspected, the following diagnostics are performed routinely: wound inspection 100%; white blood cell count 100%; radiography 99%; C-reactive protein 97%; microbiological testing of urine 91%, blood 81%, and bronchial secretion 81%; procalcitonin 74%; and echocardiography 75%. The calculated empiric antibiotic therapy (depending on the suspected focus) consists of a multidrug combination with broad-spectrum agents. CONCLUSION This survey shows that existing national guidelines and recommendations concerning perioperative antibiotic prophylaxis and calculated empiric antibiotic therapy are well applied in almost all German heart centers.
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Affiliation(s)
- Armin Gorski
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Khaled Hamouda
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Mehmet Özkur
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Markus Leistner
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Sebastian-Patrick Sommer
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Rainer Leyh
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Christoph Schimmer
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73-156. [PMID: 23461695 DOI: 10.1089/sur.2013.9999] [Citation(s) in RCA: 690] [Impact Index Per Article: 62.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Dale W Bratzler
- College of Public Health, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma 73126-0901, USA.
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. [DOI: 10.2146/ajhp120568] [Citation(s) in RCA: 1364] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Suzuki M, Nishida K, Soen S, Oda H, Inoue H, Kaneko A, Takagishi K, Tanaka T, Matsubara T, Mitsugi N, Mochida Y, Momohara S, Mori T, Suguro T. Risk of postoperative complications in rheumatoid arthritis relevant to treatment with biologic agents: a report from the Committee on Arthritis of the Japanese Orthopaedic Association. J Orthop Sci 2011; 16:778-84. [PMID: 21874335 DOI: 10.1007/s00776-011-0142-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 07/28/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE Since biologic agents were introduced to treat rheumatoid arthritis (RA) in 2003, the number of orthopedic surgical procedures under treatment with biologic agents has been increasing in Japan. However, whether biologic agents cause an increase in the prevalence of postoperative complications is as yet unknown. The Committee on Arthritis of the Japanese Orthopedic Association investigated the prevalence of postoperative complications in patients with RA in teaching hospitals in Japan. METHODS Between January 2004 and November 2008, surveillance forms about medications and surgical procedures in patients with RA were sent to 2,019 teaching hospitals. Data were analyzed by the Rheumatoid Arthritis Committee. RESULTS Biologic agents were administered to RA patients in 632 of 1,245 hospitals (50.8%); 430 of the 1,245 hospitals (34.5%) used surgical intervention under treatment with biologic agents. The number of surgical procedures under treatment with biologic agents was 3,468, and the prevalence of infection was 1.3% (46 cases). The prevalence of infection was 1.0% (567 procedures) in 56,339 procedures under treatment with nonbiologic disease-modifying anti-rheumatic drugs. There were no significant differences between biological and nonbiological treatment groups with respect to the prevalence of infection. In the joint arthroplasty group, the number of procedures under biological and nonbiological treatment was 1,626 and 29,903, and the prevalence of infection was 2.1% (34 procedures) and 1.0% (298 procedures), respectively. There was a significant difference between groups. The odds ratio was 2.12 (95% confidence interval 1.48-3.03, P < 0.0001). CONCLUSION The chance of having biological treatment with joint arthroplasty was more than twofold greater in patients with surgical-site infections compared with those treated with nonbiologic agents. Caution is required for surgical procedure, perioperative course, and obtaining consent for joint arthroplasty for patients with RA undergoing surgery under biological agents.
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Affiliation(s)
- Masahiko Suzuki
- Committee on Arthritis of the Japanese Orthopaedic Association, 2-40-8 Hongo, Bunkyo-ku, Tokyo, 113-8418, Japan.
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18
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Lin MH, Pan SC, Wang JL, Hsu RB, Lin Wu FL, Chen YC, Lin FY, Chang SC. Prospective randomized study of efficacy of 1-day versus 3-day antibiotic prophylaxis for preventing surgical site infection after coronary artery bypass graft. J Formos Med Assoc 2011; 110:619-26. [DOI: 10.1016/j.jfma.2011.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 06/24/2010] [Accepted: 07/05/2010] [Indexed: 10/17/2022] Open
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Does duration of perioperative antibiotic prophylaxis matter in cardiac surgery? A systematic review and meta-analysis. Ann Surg 2011; 254:48-54. [PMID: 21412147 DOI: 10.1097/sla.0b013e318214b7e4] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE We aimed to compare the efficacy of short-term (<24 hours) versus longer-term antibiotic prophylaxis (≥24 hours) in open heart surgery. BACKGROUND The optimal duration of antibiotic prophylaxis for adults undergoing cardiac surgery is unknown and guideline recommendations are inconsistent. METHODS We searched MEDLINE, EMBASE, CINAHL, and CENTRAL for parallel-group randomized trials comparing any antibiotic prophylaxis administered for <24 hours to any antibiotic prophylaxis for ≥24 hours in adult patients undergoing open heart surgery. Reference lists of selected articles, clinical practice guidelines, review articles, and congress abstracts were searched. Study selection, data extraction and assessment of risk of bias were performed independently by 2 reviewers. RESULTS Of the 1338 citations identified by our search strategy, 12 studies involving 7893 patients were selected. Compared with short-term antibiotic prophylaxis, longer-term antibiotic prophylaxis reduced the risk of sternal surgical site infection (SSI) by 38% (risk ratio 1.38, 95% confidence interval (CI) 1.13-1.69, P = 0.002) and deep sternal SSI by 68% (risk ratio 1.68, 95% CI 1.12-2.53, P = 0.01). There were no statistically significant differences in mortality, infections overall and adverse events. Eleven of the trials were at high risk for bias due to limitations in study design. CONCLUSIONS Perioperative antibiotic prophylaxis of ≥24 hours may be more efficacious in preventing sternal SSIs in patients undergoing cardiac surgery compared to shorter regimens. The findings however are limited by the heterogeneity of antibiotic regimens used and the risk of bias in the published studies.
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20
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Gentamicin bound to the nanofibre microdispersed oxidized cellulose in the treatment of deep surgical site infections. J Appl Biomed 2011. [DOI: 10.2478/v10136-009-0033-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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21
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Shann FA. Antibiotic prophylaxis for cardiac surgery - are we getting it right? Med J Aust 2010; 193:62; author reply 62-3. [PMID: 20618123 DOI: 10.5694/j.1326-5377.2010.tb03752.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 04/11/2010] [Indexed: 11/17/2022]
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22
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Christiansen KJ. Antibiotic prophylaxis for cardiac surgery — are we getting it right? Med J Aust 2010. [DOI: 10.5694/j.1326-5377.2010.tb03753.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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23
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Tamayo E, Gualis J, Flórez S, Castrodeza J, Eiros Bouza JM, Álvarez FJ. Comparative study of single-dose and 24-hour multiple-dose antibiotic prophylaxis for cardiac surgery. J Thorac Cardiovasc Surg 2008; 136:1522-7. [DOI: 10.1016/j.jtcvs.2008.05.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Revised: 04/16/2008] [Accepted: 05/04/2008] [Indexed: 10/21/2022]
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24
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Willemsen I, van den Broek R, Bijsterveldt T, van Hattum P, Winters M, Andriesse G, Kluytmans J. A standardized protocol for perioperative antibiotic prophylaxis is associated with improvement of timing and reduction of costs. J Hosp Infect 2007; 67:156-60. [PMID: 17881087 DOI: 10.1016/j.jhin.2007.07.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 07/26/2007] [Indexed: 11/21/2022]
Abstract
The objectives of this study were to implement a uniform guideline for perioperative antibiotic prophylaxis (PAP) and to measure the impact on timing and costs of PAP. The effects of implementation of the new guideline describing the application of PAP were measured by comparing the choice of agents and their timing in a random sample of procedures before and after implementation. Before the intervention, 153 procedures from different specialties were observed; eight different antibiotics in different dosages were used and in 20% of the procedures, PAP was given after the incision. Two months after the intervention, 147 procedures were observed; three different antibiotics were given and all were used in the correct dosage. There was a significant reduction of administration of PAP after the incision from 20 to 7% (P=0.002). Besides the quality improvements, the modified PAP protocol resulted in a net annual savings of at least 112,000 US dollars. This study shows that the implementation of a uniform, simple and clear protocol for PAP is associated with improved dosing and timing. The costs of PAP were also reduced.
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Affiliation(s)
- I Willemsen
- Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands.
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25
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Alphonso N, Anagnostopoulos PV, Scarpace S, Weintrub P, Azakie A, Raff G, Karl TR. Perioperative antibiotic prophylaxis in paediatric cardiac surgery. Cardiol Young 2007; 17:12-25. [PMID: 17244387 DOI: 10.1017/s1047951107000066] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2006] [Indexed: 11/05/2022]
Affiliation(s)
- Nelson Alphonso
- Paediatric Heart Center, University of California San Francisco Children's Hospital, San Francisco, California 94143-0117, USA
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26
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Lim TJ. Surgical Site Infection and Surveillance. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2007. [DOI: 10.5124/jkma.2007.50.10.908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Tae Jin Lim
- Department of Surgery, Keimyung University College of Medicine, Korea.
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27
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Fry DE. The Surgical Infection Prevention Project: Processes, Outcomes, and Future Impact. Surg Infect (Larchmt) 2006. [DOI: 10.1089/sur.2006.7.s3-17] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Donald E. Fry
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
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28
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Edwards FH, Engelman RM, Houck P, Shahian DM, Bridges CR. The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic Prophylaxis in Cardiac Surgery, Part I: Duration. Ann Thorac Surg 2006; 81:397-404. [PMID: 16368422 DOI: 10.1016/j.athoracsur.2005.06.034] [Citation(s) in RCA: 193] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2005] [Revised: 05/21/2005] [Accepted: 06/03/2005] [Indexed: 01/08/2023]
Affiliation(s)
- Fred H Edwards
- Division of Cardiothoracic Surgery, University of Florida, Jacksonville, Florida 32209, USA.
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Zuvela M, Milićević M, Galun D, Lekić N, Basarić D, Tomić D, Petrović M, Palibrk I. Infekcija u hirurgiji kila. ACTA ACUST UNITED AC 2005; 52:9-26. [PMID: 16119310 DOI: 10.2298/aci0501009z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Traditionally, the operation of hernia is considered as a clean operation due to expected, low incidence of infection, on the spot of surgical work (SSI). The incidence of SSI in hernia surgery is more frequent then it is assumed. The important risk factors for SSI are the following: type of hernia (inguinal, incisional), operative approach (open - laparoscopic), usage of the prosthetic material and drainage. Comparing to inguinal hernia repair, incisional hernia repair, is more frequently followed by the infection. The laparoscopic operations are followed with the lower incidence of SSI then in the case of open operation. The usage of the mesh does not increase the incidence of SSI, although the consequences of the mesh infection may be severe. A type I of the prosthesis is more resistant to the infection then prosthesis II and III. The mesh infection (type I) never involves its body but it is present around sutures and bended edges. The mesh infection Type II involves entire prosthesis while in the case of Type III it is present in its peripheral part. In the case of SSI, a prosthesis Type I is possible to be saved, while prosthesis Type II must be removed completely; and the same is for the Type III (the partial removal is rarely suggested). The defect that remained after excision of non-resorptive prosthesis is a long-term and very complicated surgical problem. In regard to the position of the mesh, SSI is more common if the mesh is placed subcutaneously then in the case of sub-aponeurotic peri-muscular, pre-aponeurotic retromuscular or pre-peritoneal mesh placemen. If the infection is present the non-tension techniques using non-resorptive prosthetic implants are not recommended. the presence of drainage and its duration increases the incidence of SSI. It is more common for incisional hernioplasty then for inguinal hernia repair. If there is an indication for drainage it should be as short as possible. The cause of SSI for elective operations are bacteria?s that arrives from the skin, while in the case of opening of various organs dominant bacteria?s originate from them. The superficial infection does not lead to the recurrence, while it is very possible in the case for deep infection. There are no prospective studies that justify the usage of antibiotic prophylaxes in hernia surgery. The antibiotic prophylaxis in hernia surgery. The antibiotic prophylaxis is indicated for the clean operations when placing the implants and when severe complication is expected. The appearance of SSI increases the price of treatment and may lead to the recurrence.
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Affiliation(s)
- M Zuvela
- Institut za bolesti digestivnog sistema KSC, Beograd
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Helou S, Bastien O, Vandenesch F, Ninet J, Lehot JJ. [Antibiotic prophylaxis in cardiac surgery: practice patterns]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21:241-4. [PMID: 11963391 DOI: 10.1016/s0750-7658(02)00577-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To assess the prescription patterns in French and foreign centres for antibiotic prophylaxis in cardiac surgery. MATERIAL AND METHODS Phone and written surveys concerned 64 French and 70 foreign centres. It focused on the first injection, the duration of treatment and the recommended agents. RESULTS 87% of the French centres and 67% of the foreign centres answered the questionnaire. The first injection took place at anaesthesia induction in all French centres but during administration of premedication in 11% of foreign centres (p < 0.05). The duration of prophylaxis was restricted to the intraoperative period only in 20% and 15% of centres, respectively (ns), as specified by the recommendations. No French centres carried on the antibiotics more than 48 h versus 11% of foreign centres (p < 0.05). Cephalosporines of the second generation were prescribed in 84 and 49% of centres, respectively (p < 0.05). The combination of two antibiotics was less frequent in France than in foreign countries (5 versus 17%, p < 0.01). In absence of betalactamin allergy glycopeptides were not utilized in France versus 8% in foreign countries (p < 0.05). In case of allergy vancomycin was used in 66% of French and 42% of foreign centres. CONCLUSION The French recommendations may have influenced favourably the antibiotic choice but the prophylaxis duration was too long in most of the non French European centres.
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Affiliation(s)
- S Helou
- Service d'anesthésie-réanimation, hôpital cardiovasculaire et pneumologique Louis Pradel, BP Lyon Montchat, 69394 Lyon, France
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31
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Abstract
The most important nosocomial cardiac infections include nosocomial infective endocarditis on native and prosthetic valves, and nosocomial infections related to transvenous permanent pacemakers, implantable cardioverter-defibrillators and left ventricular assist devices. Although representing rare complications, they are of great importance because they are associated with high morbidity and mortality. Most of them are encountered in older-age groups, related to nosocomial invasive procedures performed within the preceding four to eight weeks of hospital admission. Nosocomial bacteraemia associated with infected central intravascular devices, genitourinary or gastrointestinal tract surgery and instrumentation, breaks in sterile surgical techniques at the implantation of prosthetic valves and cardiac devices as well as wound and skin infections, represent the most important risk factors. Staphylococcus aureus in native valve endocarditis and S. epidermidis in the presence of foreign bodies are the main implicated pathogens. However, because of the steeply increasing incidence of candidaemia in tertiary hospitals, nosocomial cardiac infections caused by Candida spp. have also been steadily increasing over the last decades. Diagnosis of nosocomial cardiac infections, particularly in the presence of foreign bodies, is often difficult because of the severity of patients' co-morbid illnesses and the co-existence of several risk factors. Diagnosis should be based on positive blood cultures and transoesophageal echocardiographic findings in febrile high-risk patients. Therapy necessitates a combination of antibiotics and surgical removal of foreign bodies. Prophylaxis should mainly target the prevention and/or appropriate treatment of bacteraemias secondary to infected intravascular devices, as well as application of prophylaxis guidelines whenever invasive hospital-based procedures are performed in high-risk individuals.
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Affiliation(s)
- H Giamarellou
- Athens University School of Medicine, Sismanoglion Hospital, Athens, Greece
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32
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Harbarth S, Samore MH, Lichtenberg D, Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation 2000; 101:2916-21. [PMID: 10869263 DOI: 10.1161/01.cir.101.25.2916] [Citation(s) in RCA: 364] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite evidence supporting short antibiotic prophylaxis (ABP), it is still common practice to continue ABP for more than 48 hours after coronary artery bypass graft (CABG) surgery. METHODS AND RESULTS To compare the effect of short (<48 hours) versus prolonged (>48 hours) ABP on surgical site infections (SSIs) and acquired antimicrobial resistance, we conducted an observational 4-year cohort study at a tertiary-care center. An experienced infection control nurse performed prospective surveillance of 2641 patients undergoing CABG surgery. The main exposure was the duration of ABP, and main outcomes were the adjusted rate of SSI and the isolation of cephalosporin-resistant enterobacteriaceae and vancomycin-resistant enterococci (acquired antibiotic resistance). Adjustment for confounding was performed by multivariable modeling. A total of 231 SSIs (8.7%) occurred after a median of 16 days, including 93 chest-wound infections (3.5%) and 13 deep-organ-space infections (0. 5%). After 1502 procedures using short ABP, 131 SSIs were recorded, compared with 100 SSIs after 1139 operations with prolonged ABP (crude OR, 1.0; CI, 0.8 to 1.3). After adjustment for possible confounding, prolonged ABP was not associated with a decreased risk of SSI (adjusted OR, 1.2; CI, 0.8 to 1.6) and was correlated with an increased risk of acquired antibiotic resistance (adjusted OR, 1.6; CI, 1.1 to 2.6). CONCLUSIONS Our findings confirm that continuing ABP beyond 48 hours after CABG surgery is still widespread; however, this practice is ineffective in reducing SSI, increases antimicrobial resistance, and should therefore be avoided.
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Affiliation(s)
- S Harbarth
- Department of Epidemiology , Harvard School of Public Health, and Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Abstract
Antimicrobial prophylaxis is used by clinicians for the prevention of numerous infections, including sexually transmitted diseases, human immunodeficiency virus infection, tuberculosis, rheumatic fever, recurrent cellulitis, meningococcal disease, recurrent uncomplicated urinary tract infections in women, spontaneous bacterial peritonitis in patients with cirrhosis, influenza, malaria, infective endocarditis, pertussis, plague, anthrax, early-onset group B streptococcal disease in neonates, and animal bite wounds. Certain opportunistic infections such as Pneumocystis carinii pneumonia in immunocompromised patients also can be effectively prevented with primary antimicrobial prophylaxis. Perioperative antimicrobial prophylaxis is recommended for various surgical procedures to prevent surgical site infection. Optimal antimicrobial agents for prophylaxis are bactericidal, nontoxic, inexpensive, and active against the typical pathogens that cause surgical site infection postoperatively. To maximize its effectiveness, intravenous perioperative prophylaxis should be given within 30 to 60 minutes before the time of surgical incision. Antibiotic prophylaxis should be of short duration to decrease toxicity, antimicrobial resistance, and excess cost.
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Affiliation(s)
- D R Osmon
- Division of Infectious Diseases and Internal Medicine, Mayo Clinic Rochester, Minnesota 55905, USA
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Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999. [PMID: 10196487 DOI: 10.1016/s0196-6553(99)70088-x] [Citation(s) in RCA: 1921] [Impact Index Per Article: 76.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
EXECUTIVE SUMMARY The "Guideline for Prevention of Surgical Site Infection, 1999" presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.1,2 Part I, "Surgical Site Infection: An Overview," describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis. Part II, "Recommendations for Prevention of Surgical Site Infection," represents the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) regarding strategies for the prevention of SSIs.3 Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, there are a limited number of studies that clearly validate risk factors and prevention measures for SSI. By necessity, available studies have often been conducted in narrowly defined patient populations or for specific kinds of operations, making generalization of their findings to all specialties and types of operations potentially problematic. This is especially true regarding the implementation of SSI prevention measures. Finally, some of the infection control practices routinely used by surgical teams cannot be rigorously studied for ethical or logistical reasons (e.g., wearing vs not wearing gloves). Thus, some of the recommendations in Part II are based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific knowledge.It has been estimated that approximately 75% of all operations in the United States will be performed in "ambulatory," "same-day," or "outpatient" operating rooms by the turn of the century.4 In recommending various SSI prevention methods, this document makes no distinction between surgical care delivered in such settings and that provided in conventional inpatient operating rooms. This document is primarily intended for use by surgeons, operating room nurses, postoperative inpatient and clinic nurses, infection control professionals, anesthesiologists, healthcare epidemiologists, and other personnel directly responsible for the prevention of nosocomial infections. This document does not: Specifically address issues unique to burns, trauma, transplant procedures, or transmission of bloodborne pathogens from healthcare worker to patient, nor does it specifically address details of SSI prevention in pediatric surgical practice. It has been recently shown in a multicenter study of pediatric surgical patients that characteristics related to the operations are more important than those related to the physiologic status of the patients.5 In general, all SSI prevention measures effective in adult surgical care are indicated in pediatric surgical care. Specifically address procedures performed outside of the operating room (e.g., endoscopic procedures), nor does it provide guidance for infection prevention for invasive procedures such as cardiac catheterization or interventional radiology. Nonetheless, it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures. Specifically recommend SSI prevention methods unique to minimally invasive operations (i.e., laparoscopic surgery). Available SSI surveillance data indicate that laparoscopic operations generally have a lower or comparable SSI risk when contrasted to open operations.6-11 SSI prevention measures applicable in open operations (e.g., open cholecystectomy) are indicated for their laparoscopic counterparts (e.g., laparoscopic cholecystectomy). Recommend specific antiseptic agents for patient preoperative skin preparations or for healthcare worker hand/forearm antisepsis. Hospitals should choose from products recommended for these activitie
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Affiliation(s)
- A J Mangram
- Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services, Atlanta, Georgia 30333, USA
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Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20:250-78; quiz 279-80. [PMID: 10219875 DOI: 10.1086/501620] [Citation(s) in RCA: 2730] [Impact Index Per Article: 109.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The “Guideline for Prevention of Surgical Site Infection, 1999” presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.Part I, “Surgical Site Infection: An Overview,” describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis.
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Affiliation(s)
- A J Mangram
- Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services, Atlanta, GA 30333, USA
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McDonald M, Grabsch E, Marshall C, Forbes A. Single- versus multiple-dose antimicrobial prophylaxis for major surgery: a systematic review. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1998; 68:388-96. [PMID: 9623456 DOI: 10.1111/j.1445-2197.1998.tb04785.x] [Citation(s) in RCA: 171] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Single-dose antimicrobial prophylaxis for major surgery is a widely accepted principle; recommendations have been based on laboratory studies and numerous clinical trials published in the last 25 years. In practice, single-dose prophylaxis has not been universally accepted and multiple-dose regimens are still used in some centres. Moreover, the principle has recently been challenged by the results of an Australian study of vascular surgery. The aim of this current systematic review is to determine the overall efficacy of single versus multiple-dose antimicrobial prophylaxis for major surgery and across surgical disciplines. METHODS Relevant studies were identified in the medical literature using the MEDLINE database and other search strategies. Trials included in the review were prospective and randomized, had the same antimicrobial in each treatment arm and were published in English. Rates of postoperative surgical site infections (SSI) were extracted, 2 x 2 tables prepared and odds ratios (OR) [with 95% confidence intervals (95% CI)] calculated. Data were then combined using fixed and random effects models to provide an overall figure. In this context, a high value for the combined OR, with 95% CI > 1.0, indicates superiority of multiple-dose regimens and a low OR, with 95% CI < 1.0, suggests the opposite. A combined OR close to 1.0, with narrow 95% CI straddling 1.0, indicates no clear advantage of one regimen over another. Further subgroup analyses were also performed. RESULTS Combined OR by both fixed (1.06, 95% CI, 0.89-1.25) and random effects (1.04, 95% CI, 0.86-1.25) models indicated no clear advantage of either single or multiple-dose regimens in preventing SSI. Likewise, subgroup analysis showed no statistically significant differences associated with type of antimicrobial used (beta-lactam vs other), blinded wound assessment, length of the multiple-dose arm (> 24 h vs 24 h or less) or type of surgery (obstetric and gynaecological vs other). CONCLUSIONS Continued use of single-dose antimicrobial prophylaxis for major surgery is recommended. Further studies are required, especially in previously neglected surgical disciplines.
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Affiliation(s)
- M McDonald
- Infectious Diseases Service, The Geelong Hospital, Victoria, Australia.
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Vuorisalo S, Pokela R, Syrjälä H. Comparison of Vancomycin and Cefuroxime for Infection Prophylaxis in Coronary Artery Bypass Surgery. Infect Control Hosp Epidemiol 1998. [DOI: 10.2307/30142413] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Vuorisalo S, Pokela R, Syrjälä H. Is single-dose antibiotic prophylaxis sufficient for coronary artery bypass surgery? An analysis of peri- and postoperative serum cefuroxime and vancomycin levels. J Hosp Infect 1997; 37:237-47. [PMID: 9421775 DOI: 10.1016/s0195-6701(97)90252-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Preliminary findings have suggested that a single intravenous dose of antibiotic is effective for infection prophylaxis in cardiac surgery. However there are still insufficient data on this proposed regimen. We measured serum cefuroxime and vancomycin levels after three different dosage regimens, in patients undergoing coronary artery bypass grafting (CABG). Sixty patients were randomized into three cefuroxime and three vancomycin groups with 10 patients in each: a group given a one-day course, or an additional dose during cardiopulmonary bypass or a single dose. Serum levels of the antibiotics were measured at various times throughout the operative procedure and until 48 h after the start of prophylaxis. Each of the six dosage regimens maintained serum levels adequate for infection prophylaxis throughout the operative procedure. Serum levels remained above 2 mg/L for more than 8 h postoperatively, even in the single-dose cefuroxime group and above 4 mg/L for more than 24 h with all the vancomycin dosage regimens. Thus a single dose of cefuroxime (3 g or 1.5 g) or vancomycin (1.5 g) seems to achieve and maintain serum levels sufficient for infection prophylaxis several hours after CABG procedures.
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Affiliation(s)
- S Vuorisalo
- Department of Surgery, University of Oulu, Finland
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