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Okoro T, Wan M, Mukabeta TD, Malev E, Gross M, Williams C, Manjra M, Kuiper JH, Murnaghan J. Assessment of the effectiveness of weight-adjusted antibiotic administration, for reduced duration, in surgical prophylaxis of primary hip and knee arthroplasty. World J Orthop 2024; 15:170-179. [PMID: 38464351 PMCID: PMC10921182 DOI: 10.5312/wjo.v15.i2.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/08/2023] [Accepted: 01/05/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Prophylactic antibiotics have significantly led to a reduction in the risk of post-operative surgical site infections (SSI) in orthopaedic surgery. The aim of using antibiotics for this purpose is to achieve serum and tissue drug levels that exceed, for the duration of the operation, the minimum inhibitory concentration of the likely organisms that are encountered. Prophylactic antibiotics reduce the rate of SSIs in lower limb arthroplasty from between 4% and 8% to between 1% and 3%. Controversy, however, still surrounds the optimal frequency and dosing of antibiotic administration. AIM To evaluate the impact of introduction of a weight-adjusted antibiotic prophylaxis regime, combined with a reduction in the duration of administration of post-operative antibiotics on SSI incidence during the 2 years following primary elective total hip and knee arthroplasty. METHODS Following ethical approval, patients undergoing primary total hip arthroplasty (THA)/total knee arthroplasty (TKA) with the old regime (OR) of a preoperative dose [cefazolin 2 g intravenously (IV)], and two subsequent doses (2 h and 8 h), were compared to those after a change to a new regime (NR) of a weight-adjusted preoperative dose (cefazolin 2 g IV for patients < 120 kg; cefazolin 3g IV for patients > 120 kg) and a post-operative dose at 2 h. The primary outcome in both groups was SSI rates during the 2 years post-operatively. RESULTS A total of n = 1273 operations (THA n = 534, TKA n = 739) were performed in n = 1264 patients. There was no statistically significant difference in the rate of deep (OR 0.74% (5/675) vs NR 0.50% (3/598); fishers exact test P = 0.72), nor superficial SSIs (OR 2.07% (14/675) vs NR 1.50% (9/598); chi-squared test P = 0.44) at 2 years post-operatively. With propensity score weighting and an interrupted time series analysis, there was also no difference in SSI rates between both groups [RR 0.88 (95%CI 0.61 to 1.30) P = 0.46]. CONCLUSION A weight-adjusted regime, with a reduction in number of post-operative doses had no adverse impact on SSI incidence in this population.
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Affiliation(s)
- Tosan Okoro
- Department of Arthroplasty, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, United Kingdom
- School of Medicine, Keele University, Staffordshire ST5 5BG, United Kingdom
| | - Michael Wan
- St Joseph’s Health Centre, Unity Health Toronto, Toronto M6R 1B5, Canada
| | - Takura Darlington Mukabeta
- Department of Arthroplasty, The Royal London Hospital, Barts Health NHS Trust, London E1 1BB, United Kingdom
| | - Ella Malev
- Department of Arthroplasty, Sunnybrook Holland Orthopaedic and Arthritis Centre, Toronto M4Y 1H1, Canada
| | - Marketa Gross
- Department of Arthroplasty, Sunnybrook Holland Orthopaedic and Arthritis Centre, Toronto M4Y 1H1, Canada
| | - Claudia Williams
- Department of Arthroplasty, Sunnybrook Holland Orthopaedic and Arthritis Centre, Toronto M4Y 1H1, Canada
| | - Muhammad Manjra
- Department of Arthroplasty, Sunnybrook Holland Orthopaedic and Arthritis Centre, Toronto M4Y 1H1, Canada
| | - Jan Herman Kuiper
- Institute for Science and Technology in Medicine, Keele University, Staffordshire ST5 1BG, United Kingdom
| | - John Murnaghan
- Department of Arthroplasty, Sunnybrook Holland Orthopaedic and Arthritis Centre, Toronto M4Y 1H1, Canada
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Sartelli M, Coccolini F, Labricciosa FM, Al Omari AH, Bains L, Baraket O, Catarci M, Cui Y, Ferreres AR, Gkiokas G, Gomes CA, Hodonou AM, Isik A, Litvin A, Lohsiriwat V, Kotecha V, Khokha V, Kryvoruchko IA, Machain GM, O’Connor DB, Olaoye I, Al-Omari JAK, Pasculli A, Petrone P, Rickard J, Sall I, Sawyer RG, Téllez-Almenares O, Catena F, Siquini W. Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle. Antibiotics (Basel) 2024; 13:100. [PMID: 38275329 PMCID: PMC10812782 DOI: 10.3390/antibiotics13010100] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/03/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
In the multimodal strategy context, to implement healthcare-associated infection prevention, bundles are one of the most commonly used methods to adapt guidelines in the local context and transfer best practices into routine clinical care. One of the most important measures to prevent surgical site infections is surgical antibiotic prophylaxis (SAP). This narrative review aims to present a bundle for the correct SAP administration and evaluate the evidence supporting it. Surgical site infection (SSI) prevention guidelines published by the WHO, CDC, NICE, and SHEA/IDSA/APIC/AHA, and the clinical practice guidelines for SAP by ASHP/IDSA/SIS/SHEA, were reviewed. Subsequently, comprehensive searches were also conducted using the PubMed®/MEDLINE and Google Scholar databases, in order to identify further supporting evidence-based documentation. The bundle includes five different measures that may affect proper SAP administration. The measures included may be easily implemented in all hospitals worldwide and are based on minimal drug pharmacokinetics and pharmacodynamics knowledge, which all surgeons should know. Antibiotics for SAP should be prescribed for surgical procedures at high risk for SSIs, such as clean-contaminated and contaminated surgical procedures or for clean surgical procedures where SSIs, even if unlikely, may have devastating consequences, such as in procedures with prosthetic implants. SAP should generally be administered within 60 min before the surgical incision for most antibiotics (including cefazolin). SAP redosing is indicated for surgical procedures exceeding two antibiotic half-lives or for procedures significantly associated with blood loss. In principle, SAP should be discontinued after the surgical procedure. Hospital-based antimicrobial stewardship programmes can optimise the treatment of infections and reduce adverse events associated with antibiotics. In the context of a collaborative and interdisciplinary approach, it is essential to encourage an institutional safety culture in which surgeons are persuaded, rather than compelled, to respect antibiotic prescribing practices. In that context, the proposed bundle contains a set of evidence-based interventions for SAP administration. It is easy to apply, promotes collaboration, and includes measures that can be adequately followed and evaluated in all hospitals worldwide.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, 62100 Macerata, Italy;
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Unit, Pisa University Hospital, 56124 Pisa, Italy;
| | | | - AbdelKarim. H. Al Omari
- Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan;
| | - Lovenish Bains
- Department of General Surgery, Maulana Azad Medical College, New Delhi 110002, India;
| | - Oussama Baraket
- Department of General Surgery, Bizerte Hospital, Bizerte 7000, Tunisia;
| | - Marco Catarci
- General Surgery Unit, Sandro Pertini Hospital, 00157 Rome, Italy;
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin 300052, China;
| | - Alberto R. Ferreres
- Department of Surgery, University of Buenos Aires, Buenos Aires 1428, Argentina;
| | - George Gkiokas
- Department of Surgery, Medical School, “Aretaieio” Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Carlos Augusto Gomes
- Department of Surgery, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital Universitário Terezinha de Jesus, Juiz de Fora 25520, Brazil;
| | - Adrien M. Hodonou
- Department of Surgery, Faculty of Medicine, University of Parakou, Parakou 03 BP 10, Benin;
| | - Arda Isik
- Department of Surgery, Istanbul Medeniyet University, Istanbul 34000, Turkey;
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, 246000 Gomel, Belarus;
| | - Varut Lohsiriwat
- Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand;
| | - Vihar Kotecha
- Department of General Surgery, Catholic University of Health and Allied Sciences, Mwanza P.O. Box 1464, Tanzania;
| | - Vladimir Khokha
- General Surgery Unit, Podhalanski Specialized Hospital, 34-400 Nowy Targ, Poland;
| | - Igor A. Kryvoruchko
- Department of Surgery No. 2, Kharkiv National Medical University, 61000 Kharkiv, Ukraine;
| | - Gustavo M. Machain
- Department of Surgery, Universidad Nacional de Asuncion, San Lorenzo 1055, Paraguay;
| | - Donal B. O’Connor
- Department of Surgery, School of Medicine, Trinity College, D02 PN40 Dublin, Ireland;
| | - Iyiade Olaoye
- Department of Surgery, University of Ilorin Teaching Hospital, Ilorin 240101, Nigeria;
| | - Jamal A. K. Al-Omari
- Medical College, Al-Balqa Applied University, Al-Hussein Hospital, Zarqa 13313, Jordan;
| | - Alessandro Pasculli
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), Unit of Academic General Surgery “V. Bonomo”, University of Bari “A. Moro”, 70125 Bari, Italy;
| | - Patrizio Petrone
- Department of Surgery, NYU Grossman Long Island School of Medicine, NYU Langone Hospital—Long Island, Mineola, NY 11501, USA;
| | - Jennifer Rickard
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Dakar 3006, Senegal;
| | - Robert G. Sawyer
- Department of Surgery, School of Medicine, Western Michigan University, Kalamazoo, MI 49008, USA;
| | - Orlando Téllez-Almenares
- General Surgery Department of Saturnino Lora Provincial Hospital, University of Medical Sciences of Santiago de Cuba,
26P2+J7X, Santiago de Cuba 90100, Cuba;
| | - Fausto Catena
- Department of Surgery, “Bufalini” Hospital, 47521 Cesena, Italy;
| | - Walter Siquini
- Department of Surgery, Macerata Hospital, 62100 Macerata, Italy;
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Baker AL, McElrath A, Giancola SE, Schumaker AL, Barsoumian AE. A Multidisciplinary Approach to Improvements in Perioperative Antibiotic Prophylaxis at a Military Treatment Facility. Mil Med 2023; 188:e1854-e1858. [PMID: 36762987 DOI: 10.1093/milmed/usad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/07/2022] [Accepted: 01/17/2023] [Indexed: 02/11/2023] Open
Abstract
INTRODUCTION Surgical site infections complicate 2%-5% of surgeries. According to the Centers for Disease Control and Prevention, half of all surgical site infections are preventable. Adherence to published recommendations regarding perioperative antibiotic administration decreases the incidence of surgical site infections. Members of the Department of Anesthesia noticed casual observations of inaccurate prescribing of antibiotics at our institution, Brooke Army Medical Center, and approached the Antimicrobial Stewardship Program to collaborate on this issue. MATERIALS AND METHODS A team of anesthesiologists, clinical pharmacists, and infectious disease specialists collaborated with the Department of Surgery to improve this effort as part of a multiyear project from 2018 to 2021. We first assessed adherence to recommended perioperative antibiotic use to establish a baseline and next, noticing gaps, created a project with the goal to improve compliance to >90% across surveyed measures. Our key interventions included educational initiatives, creation of facility-specific guidelines, peer benchmarking, updating order sets, interdisciplinary collaboration, creation of intraoperative reminders and visual aids, and tailored presentations to selected services. RESULTS Of 292 charts (2.3% of cases from January to October 2018) reviewed pre-intervention, compliance rates were 84% for antibiotic choice, 92% for dose, 65% for redosing, and 71% for postoperative administration. Of doses, 100% were timed correctly, and thus, this variable was not targeted. Post-intervention, our review of 387 charts (10% of cases from May to November 2020) showed no change in correct antibiotic choice (84%) and statistical improvement to 96% for correct dose, 95% for correct redosing, and 85% for correct postoperative administration (P < .05 for all). CONCLUSIONS Our multidisciplinary approach of collaboration with multiple departments, creating guidelines and providing feedback, improved compliance with perioperative antibiotic administration recommendations.
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Affiliation(s)
- Amelia L Baker
- Department of Anesthesiology, Eglin Air Force Base Hospital, Eglin AFB, FL 32542, USA
| | - Angela McElrath
- Department of Anesthesiology, Brooke Army Medical Center, San Antonio, TX 78234, USA
| | - Stephanie E Giancola
- Patient Safety Program, Clinical Support Division, Defense Health Agency, San Antonio, TX 78205, USA
| | - Annabel L Schumaker
- Department of Pharmacy, Brooke Army Medical Center, San Antonio, TX 78219, USA
| | - Alice E Barsoumian
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, San Antonio, TX 78234, USA
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Sartelli M, Boermeester MA, Cainzos M, Coccolini F, de Jonge SW, Rasa K, Dellinger EP, McNamara DA, Fry DE, Cui Y, Delibegovic S, Demetrashvili Z, De Simone B, Gkiokas G, Hardcastle TC, Itani KMF, Isik A, Labricciosa FM, Lohsiriwat V, Marwah S, Pintar T, Rickard J, Shelat VG, Catena F, Barie PS. Six Long-Standing Questions about Antibiotic Prophylaxis in Surgery. Antibiotics (Basel) 2023; 12:908. [PMID: 37237811 PMCID: PMC10215114 DOI: 10.3390/antibiotics12050908] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
Surgical site infections (SSIs) are the most common adverse event occurring in surgical patients. Optimal prevention of SSIs requires the bundled integration of a variety of measures before, during, and after surgery. Surgical antibiotic prophylaxis (SAP) is an effective measure for preventing SSIs. It aims to counteract the inevitable introduction of bacteria that colonize skin or mucosa into the surgical site during the intervention. This document aims to guide surgeons in appropriate administration of SAP by addressing six key questions. The expert panel identifies a list of principles in response to these questions that every surgeon around the world should always respect in administering SAP.
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Affiliation(s)
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, 1105AZ Amsterdam, The Netherlands
| | - Miguel Cainzos
- Department of Surgery, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - Federico Coccolini
- Department of Emergency and Trauma Surgery, Pisa University Hospital, University of Pisa, 55126 Pisa, Italy
| | - Stijn W. de Jonge
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, 1105AZ Amsterdam, The Netherlands
| | - Kemal Rasa
- Department of Surgery, Anadolu Medical Center, 41200 Kocaeli, Turkey
| | | | - Deborah A. McNamara
- Department of Colorectal Surgery, Beaumont Hospital, D09V2N0 Dublin, Ireland
| | - Donald E. Fry
- Department of Surgery, Northwestern University, Chicago, IL 60208, USA
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin 300100, China
| | - Samir Delibegovic
- Department of Surgery, University Clinical Center of Tuzla, 75000 Tuzla, Bosnia and Herzegovina
| | - Zaza Demetrashvili
- Department General Surgery, Kipshidze Central University Hospital, Tbilisi 0162, Georgia
| | - Belinda De Simone
- Department of Emergency and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy/Saint Germain en Laye, 78300 Poissy CEDEX, France
| | - George Gkiokas
- Second Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, 10679 Athens, Greece
| | - Timothy C. Hardcastle
- Department of Surgery, Nelson R. Mandela School of Clinical Medicine, University of KwaZulu-Natal, Mayville 4058, South Africa
| | - Kamal M. F. Itani
- Department of Surgery, VA Boston Health Care System, Boston University and Harvard Medical School, Boston, MA 02118, USA
| | - Arda Isik
- Division of General Surgery, School of Medicine, Istanbul Medeniyet University, 34700 Istanbul, Turkey
| | | | - Varut Lohsiriwat
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Sanjay Marwah
- Department of Surgery, BDS Post-Graduate Institute of Medical Sciences, Rohtak 124001, India
| | - Tadeja Pintar
- Department of Abdominal Surgery, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
| | - Jennifer Rickard
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA
| | - Vishal G. Shelat
- Department of Hepato-Pancreatic-Biliary Surgery, Tan Tok Seng Hospital, Singapore 308433, Singapore
| | - Fausto Catena
- Department of Surgery, “Bufalini” Hospital, 47023 Cesena, Italy
| | - Philip S. Barie
- Department of Surgery, Weill Cornell Medicine, E. Northport, New York, NY 11731, USA
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Johnson TM, Whitman Webster LC, Mehta M, Johnson JE, Cortés-Penfield N, Rivera CG. Pushing the agenda for intravenous push administration in outpatient parenteral antimicrobial therapy. Ther Adv Infect Dis 2023; 10:20499361231193920. [PMID: 37600976 PMCID: PMC10434178 DOI: 10.1177/20499361231193920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/25/2023] [Indexed: 08/22/2023] Open
Abstract
Intravenous push (IVP) antimicrobial administration refers to rapid bolus infusion of medication. This drug delivery method offers improved patient convenience, superior patient and nursing satisfaction, and cost savings when used in outpatient parenteral antimicrobial therapy (OPAT). Antimicrobial agents must demonstrate optimal physiochemical and pharmacologic characteristics, as well as sufficient syringe stability, to be administered in this manner. Additionally, impacts on medication tolerability, patient safety, and effectiveness must be considered. This narrative review summarizes the available data and practical implications of IVP administration of antimicrobials in the OPAT setting.
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Affiliation(s)
- Tanner M. Johnson
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | | | - Meera Mehta
- West Virginia University Hospitals, Morgantown, WV, USA
| | - Jessica E. Johnson
- Department of Medicine, Section of Infectious Diseases, West Virginia University, Morgantown, WV, USA
| | | | - Christina G. Rivera
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Cefazolin prophylaxis in spine surgery: patients are frequently underdosed and at increased risk for infection. Spine J 2022; 22:1442-1450. [PMID: 35680016 DOI: 10.1016/j.spinee.2022.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/03/2022] [Accepted: 05/25/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Perioperative antibiotics are critical in reducing the risk of postoperative spine infections. However, the efficacy and optimal weight-based prophylactic cefazolin dosing is unclear. PURPOSE To determine (1) if inadequate weight-based prophylactic dosing of cefazolin affects infection rates after spinal fusions, and (2) identify the optimal dosing of cefazolin. STUDY DESIGN/SETTING Single center retrospective cohort PATIENT SAMPLE: Patients undergoing posterior cervical or lumbar spinal fusion between January 2000 and October 2020 OUTCOME MEASURES: Postoperative surgical site infection status METHODS: Patients were grouped based on our institutionally derived dosing adequacy standards, 1 g for <60 kg, 2 g for 60 to 120 kg, and 3 g for >120 kg. Univariate comparisons and multivariate regressions identified the effect of inadequate dosing on infection rate. Patients were subsequently regrouped into cefazolin dose (grams) administered and logistic regression and receiver operating characteristic curves were compiled to determine the probability of infection based on cefazolin dose and patient weight. Alpha was set at 0.05. RESULTS A total of 2,643 patients met inclusion criteria and 95 infections (3.6%) were identified. The infection rate was higher in the inadequate dosing group (5.86% vs. 2.58%, p<.001). Adequate dosing was a predictor of decreased infections after lumbar fusion (OR: 0.43, p<.001), but not posterior cervical fusions (OR: 0.47, p=.065). Patients were subsequently regrouped into 1 g or 2 g of cefazolin administered resulting in a 5.01% and 2.77% infection rate, respectively (p=.005). The area under the curve (AUC) and 95% confidence interval for one (0.850 [0.777-0.924]) and two (0.575 [0.493-0.657]) g of cefazolin demonstrated lower infection rates for patients given 2 g cefazolin. CONCLUSIONS Patients receiving an inadequate weight-based dose of preoperative cefazolin had an increased risk of infection following spinal fusion surgery. Two grams prophylactic cefazolin significantly reduces the likelihood of infection.
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Ryan RL, Jackson D, Hopkins G, Eley V, Christensen R, Van Zundert AAJ, Wallis SC, Lipman J, Parker SL, Roberts JA. Plasma and Interstitial Fluid Pharmacokinetics of Prophylactic Cefazolin in Elective Bariatric Surgery Patients. Antimicrob Agents Chemother 2022; 66:e0041922. [PMID: 35762797 PMCID: PMC9295570 DOI: 10.1128/aac.00419-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/09/2022] [Indexed: 12/30/2022] Open
Abstract
Guidelines for surgical prophylactic dosing of cefazolin in bariatric surgery vary in terms of recommended dose. This study aimed to describe the plasma and interstitial fluid (ISF) cefazolin pharmacokinetics in patients undergoing bariatric surgery and to determine an optimum dosing regimen. Abdominal subcutaneous ISF concentrations (measured using microdialysis) and plasma samples were collected at regular time points after administration of cefazolin 2 g intravenously. Total and unbound cefazolin concentrations were assayed and then modeled using Pmetrics. Monte Carlo dosing simulations (n = 5,000) were used to define cefazolin dosing regimens able to achieve a fractional target attainment (FTA) of >95% in the ISF suitable for the MIC for Staphylococcus aureus in isolates of ≤2 mg · L-1 and for a surgical duration of 4 h. Fourteen patients were included, with a mean (standard deviation [SD]) bodyweight of 148 (35) kg and body mass index (BMI) of 48 kg · m-2. Cefazolin protein binding ranged from 14 to 36% with variable penetration into ISF of 58% ± 56%. Cefazolin was best described as a four-compartment model including nonlinear protein binding. The mean central volume of distribution in the final model was 18.2 (SD 3.31) L, and the mean clearance was 32.4 (SD 20.2) L · h-1. A standard 2-g dose achieved an FTA of >95% for all patients with BMIs ranging from 36 to 69 kg · m-2. A 2-g prophylactic cefazolin dose achieves appropriate unbound plasma and ISF concentrations in obese and morbidly obese bariatric surgery patients.
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Affiliation(s)
- Rochelle L. Ryan
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Dwane Jackson
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - George Hopkins
- Department of Surgery, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
| | - Victoria Eley
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Rebecca Christensen
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Andre A. J. Van Zundert
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Steven C. Wallis
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Jeffrey Lipman
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Suzanne L. Parker
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Jason A. Roberts
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- Department of Pharmacy, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
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8
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Coates M, Shield A, Peterson GM, Hussain Z. Prophylactic Cefazolin Dosing in Obesity-a Systematic Review. Obes Surg 2022; 32:3138-3149. [PMID: 35809198 PMCID: PMC9392691 DOI: 10.1007/s11695-022-06196-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 11/02/2022]
Abstract
Currently, there is no consensus on whether a standard 2-g prophylactic cefazolin dose provides sufficient antimicrobial coverage in obese surgical patients. This systematic review analysed both outcome and pharmacokinetic studies, aiming to determine the appropriate cefazolin dose. A systematic search was conducted using 4 databases. In total, 3 outcome and 15 pharmacokinetic studies met the inclusion criteria. All 3 outcome studies concluded that there is no need for increased dose. Also, 9 pharmacokinetic studies reached this conclusion; however, 6 pharmacokinetic studies recommended that 2-g dose is insufficient to achieve adequate plasma or tissue concentrations. The stronger body of evidence supports that 2-g dose of cefazolin is sufficient for surgery lasting up to 4 h; however, large-scale outcome studies are needed to confirm this evidence.
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Affiliation(s)
- Matthew Coates
- Faculty of Health, University of Canberra, 1 Kirinari Street, Bruce, Canberra, ACT, 2617, Australia
| | - Alison Shield
- Faculty of Health, University of Canberra, 1 Kirinari Street, Bruce, Canberra, ACT, 2617, Australia
| | - Gregory M Peterson
- Faculty of Health, University of Canberra, 1 Kirinari Street, Bruce, Canberra, ACT, 2617, Australia.,School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Australia
| | - Zahid Hussain
- Faculty of Health, University of Canberra, 1 Kirinari Street, Bruce, Canberra, ACT, 2617, Australia.
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Sommerstein R, Atkinson A, Kuster SP, Vuichard-Gysin D, Harbarth S, Troillet N, Widmer AF. Association Between Antimicrobial Prophylaxis With Double-Dose Cefuroxime and Surgical Site Infections in Patients Weighing 80 kg or More. JAMA Netw Open 2021; 4:e2138926. [PMID: 34910149 PMCID: PMC8674749 DOI: 10.1001/jamanetworkopen.2021.38926] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Many guidelines recommend a weight-adopted dose increase of cefuroxime for surgical antimicrobial prophylaxis (SAP). However, the evidence that this approach is associated with lower rates of surgical site infection (SSI) is limited. OBJECTIVE To assess whether double-dose cefuroxime SAP was associated with a decreased SSI rate in patients weighing at least 80 kg. DESIGN, SETTING, AND PARTICIPANTS This cohort study included adult patients (>18 years) weighing at least 80 kg who underwent 9 major surgical procedures with a cefuroxime SAP administration from the Swissnoso SSI surveillance system between January 2015 and December 2019 at 142 Swiss hospitals. The follow-up was 30 days for all surgical procedures and 1 year for implant-related operations. EXPOSURES Cefuroxime SAP dose (1.5 vs 3.0 g). MAIN OUTCOMES AND MEASURES Overall SSI. A mixed-effects logistic regression adjusted for institutional, epidemiological, and perioperative variables was applied. Results were stratified by weight categories as well as by wound contamination classes. RESULTS Of 41 076 eligible patients, 37 640 were included, with 22 625 (60.1%) men and a median (IQR) age of 61.9 (49.9-71.1) years. The outcome SSI was met by 1203 patients (3.2%). Double-dose cefuroxime was administered to 13 246 patients (35.2%) and was not significantly associated with a lower SSI rate (adjusted odds ratio [aOR], 0.89; 95% CI, 0.78-1.02; P = .10). After stratification by weight category, double-dose SAP vs single-dose SAP was associated with lower SSI rates among 16 605 patients weighing at least 80 to less than 90 kg (aOR, 0.76; 95% CI, 0.61-0.97; P = .02) but not in the other weight categories (≥90 to <100 kg, 10 342 patients: aOR, 1.12; 95% CI, 0.87-1.47; P = .37; ≥100 to <120 kg, 8099 patients: aOR, 0.99; 95% CI, 0.76-1.30; P = .96; ≥120 kg, 2594 patients: aOR, 0.65; 95% CI, 0.42-1.04; P = .06). After stratification by contamination class, double-dose SAP was associated with lower SSI rates among 1946 patients with contaminated wounds (aOR, 0.49; 95% CI, 0.30-0.84; P = .008) but not those with clean wounds (25 680 patients; aOR, 0.92; 95% CI, 0.76-1.12; P = .44) or clean-contaminated wounds (10 014 patients; aOR, 0.90; 95% CI, 0.73-1.12; P = .37) compared with a single dose. CONCLUSIONS AND RELEVANCE In this study, double-dose SAP with cefuroxime for patients weighing at least 80 kg was not consistently associated with a lower SSI rate.
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Affiliation(s)
- Rami Sommerstein
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Andrew Atkinson
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Danielle Vuichard-Gysin
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Infectious Diseases, Cantonal Hospital Thurgau, Switzerland
| | - Stephan Harbarth
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Nicolas Troillet
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Service of Infectious Diseases, Central Institute, Valais Hospitals, Sion, Switzerland
| | - Andreas F. Widmer
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Department of Infectious Diseases, University Hospital Basel, Basel, Switzerland
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10
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Dorn C, Petroff D, Stoelzel M, Kees MG, Kratzer A, Dietrich A, Kloft C, Zeitlinger M, Kees F, Wrigge H, Simon P. Perioperative administration of cefazolin and metronidazole in obese and non-obese patients: a pharmacokinetic study in plasma and interstitial fluid. J Antimicrob Chemother 2021; 76:2114-2120. [PMID: 33969405 DOI: 10.1093/jac/dkab143] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/11/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess plasma and tissue pharmacokinetics of cefazolin and metronidazole in obese patients undergoing bariatric surgery and non-obese patients undergoing intra-abdominal surgery. PATIENTS AND METHODS Fifteen obese and 15 non-obese patients received an IV short infusion of 2 g cefazolin and 0.5 g metronidazole for perioperative prophylaxis. Plasma and microdialysate from subcutaneous tissue were sampled until 8 h after dosing. Drug concentrations were determined by HPLC-UV. Pharmacokinetic parameters were calculated non-compartmentally. RESULTS In obese patients (BMI 39.5-69.3 kg/m2) compared with non-obese patients (BMI 18.7-29.8 kg/m2), mean Cmax of total cefazolin in plasma was lower (115 versus 174 mg/L) and Vss was higher (19.4 versus 14.2 L). The mean differences in t½ (2.7 versus 2.4 h), CL (5.14 versus 4.63 L/h) and AUC∞ (402 versus 450 mg·h/L) were not significant. The influence of obesity on the pharmacokinetics of metronidazole was similar (Cmax 8.99 versus 14.7 mg/L, Vss 73.9 versus 51.8 L, t½ 11.9 versus 9.1 h, CL 4.62 versus 4.13 L/h, AUC∞ 116 versus 127 mg·h/L). Regarding interstitial fluid (ISF), mean concentrations of cefazolin remained >4 mg/L until 6 h in both groups, and those of metronidazole up to 8 h in the non-obese group. In obese patients, the mean ISF concentrations of metronidazole were between 3 and 3.5 mg/L throughout the measuring interval. CONCLUSIONS During the time of surgery, cefazolin concentrations in plasma and ISF of subcutaneous tissue were lower in obese patients, but not clinically relevant. Regarding metronidazole, the respective differences were higher, and may influence dosing of metronidazole for perioperative prophylaxis in obese patients.
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Affiliation(s)
- Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - David Petroff
- Clinical Trial Centre, University of Leipzig, Leipzig, Germany.,Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
| | - Melanie Stoelzel
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, Leipzig, Germany
| | - Martin G Kees
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Alexander Kratzer
- Hospital Pharmacy, University Hospital Regensburg, Regensburg, Germany
| | - Arne Dietrich
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Surgery, University of Leipzig, Leipzig, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, Regensburg, Germany
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Philipp Simon
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, Leipzig, Germany
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11
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Hasler A, Unterfrauner I, Olthof MGL, Jans P, Betz M, Achermann Y, Uçkay I. Deep surgical site infections following double-dose perioperative antibiotic prophylaxis in adult obese orthopedic patients. Int J Infect Dis 2021; 108:537-542. [PMID: 34119675 DOI: 10.1016/j.ijid.2021.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Obesity is a risk factor for surgical site infections (SSI). Based on retrospective comparisons and pharmacology, many orthopedic centers have adopted weight- or body mass index (BMI)-related antibiotic prophylaxis. METHODS Double-dose prophylaxis was introduced in March 2017 for patients weighting >80 kg. The period April 2014 to March 2017 ('before') was compared to the period March 2017 to June 2019 ('after') regarding the impact on deep SSIs. RESULTS A total of 9318 surgeries 'before' were compared to 7455 interventions 'after' the introduction of double-dose prophylaxis. Baseline demographic characteristics (age, sex, BMI, American Society of Anesthesiologists score, and duration of surgery) were similar. In the period 'after', 3088 cases (3088/16 773; 18%) received double-dose prophylaxis. Overall, 82 deep SSIs were observed (0.5%). The pathogens were resistant to the standard cefuroxime prophylaxis in 30 cases (30/82; 37%). Excluding these prophylaxis-resistant cases and all of the five hematogenous SSIs, the remaining 47 SSIs (57%) could have been prevented by the preceding prophylaxis. Double-dosing of parenteral cefuroxime from 1.5 g to 3.0 g in obese patients did not reduce deep SSIs (hazard ratio 0.7, 95% confidence interval 0.3-1.6). In the direct group comparison among obese patients >80 kg, the double-dose prophylaxis equally failed to alter the SSI risk (3088/16 726 non-infections vs 8/47 SSI despite double-dose prophylaxis; Chi-square test, P = 0.78). CONCLUSIONS In this single-center before-and-after study with almost 17 000 orthopedic surgeries in adult patients, systemic doubling of the perioperative antibiotic prophylaxis in obese patients clinically failed to reduce the overall deep SSI risk.
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Affiliation(s)
- Anita Hasler
- Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Ines Unterfrauner
- Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Maurits G L Olthof
- Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Peter Jans
- Medical Informatics Service, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Michael Betz
- Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Yvonne Achermann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ilker Uçkay
- Unit of Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland; Infection Control, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
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12
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Moon TS, Van de Putte P, De Baerdemaeker L, Schumann R. The Obese Patient: Facts, Fables, and Best Practices. Anesth Analg 2021; 132:53-64. [PMID: 32282384 DOI: 10.1213/ane.0000000000004772] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The prevalence of obesity continues to rise worldwide, and anesthesiologists must be aware of current best practices in the perioperative management of the patient with obesity. Obesity alters anatomy and physiology, which complicates the evaluation and management of obese patients in the perioperative setting. Gastric point-of-care ultrasound (PoCUS) is a noninvasive tool that can be used to assess aspiration risk in the obese patient by evaluating the quantity and quality of gastric contents. An important perioperative goal is adequate end-organ perfusion. Standard noninvasive blood pressure (NIBP) is our best available routine surrogate measurement, but is vulnerable to greater inaccuracy in patients with obesity compared to the nonobese population. Current NIBP methodologies are discussed. Obese patients are at risk for wound and surgical site infections, but few studies conclusively guide the exact dosing of intraoperative prophylactic antibiotics for them. We review evidence for low-molecular-weight heparins and weight-based versus nonweight-based administration of vasoactive medications. Finally, intubation and extubation of the patient with obesity can be complicated, and evidence-based strategies are discussed to mitigate danger during intubation and extubation.
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Affiliation(s)
- Tiffany S Moon
- From the Department of Anesthesiology and Pain, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Roman Schumann
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, Massachusetts
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13
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Salm L, Marti WR, Stekhoven DJ, Kindler C, Von Strauss M, Mujagic E, Weber WP. Impact of bodyweight-adjusted antimicrobial prophylaxis on surgical-site infection rates. BJS Open 2020; 5:6044705. [PMID: 33688947 PMCID: PMC7944861 DOI: 10.1093/bjsopen/zraa027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/30/2020] [Accepted: 09/19/2020] [Indexed: 12/12/2022] Open
Abstract
Background Antimicrobial prophylaxis (AMP) adjustment according to bodyweight to prevent surgical-site infections (SSI) is controversial. The impact of weight-adjusted AMP dosing on SSI rates was investigated here. Methods Results from a first study of patients undergoing visceral, vascular or trauma operations, and receiving standard AMP, enabled retrospective evaluation of the impact of bodyweight and BMI on SSI rates, and identification of patients eligible for weight-adjusted AMP. In a subsequent observational prospective study, patients weighing at least 80 kg were assigned to receive double-dose AMP. Risk factors for SSI, including ASA classification, duration and type of surgery, wound class, diabetes, weight in kilograms, BMI, age, and AMP dose, were evaluated in multivariable analysis. Results In the first study (3508 patients), bodyweight and BMI significantly correlated with higher rates of all SSI subclasses (both P < 0.001). An 80-kg cut-off identified patients receiving single-dose AMP who were at higher risk of SSI. In the prospective study (2161 patients), 546 patients weighing 80 kg or more who received only single-dose AMP had higher rates of all SSI types than a group of 1615 who received double-dose AMP (odds ratio (OR) 4.40, 95 per cent c.i. 3.18 to 6.23; P < 0.001). In multivariable analysis including 5021 patients from both cohorts, bodyweight (OR 1.01, 1.00 to 1.02; P = 0.008), BMI (OR 1.01, 1.00 to 1.02; P = 0.007) and double-dose AMP (OR 0.33, 0.23 to 0.46; P < 0.001) among other variables were independently associated with SSI rates. Conclusion Double-dose AMP decreases SSI rates in patients weighing 80 kg or more.
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Affiliation(s)
- L Salm
- Department of General Surgery, Kantonsspital Aarau, Aarau, Switzerland
| | | | - D J Stekhoven
- NEXUS Personalized Health Technologies, ETH Zurich, Zurich, Switzerland
| | - C Kindler
- Department of Anaesthesia, Kantonsspital Aarau, Aarau, Switzerland
| | - M Von Strauss
- Department of General Surgery, University Hospital Basle, Basle, Switzerland
| | - E Mujagic
- Department of General Surgery, University Hospital Basle, Basle, Switzerland
| | - W P Weber
- Department of General Surgery, University Hospital Basle, Basle, Switzerland
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14
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Morris AJ, Roberts SA, Grae N, Frampton CM. Surgical site infection rate is higher following hip and knee arthroplasty when cefazolin is underdosed. Am J Health Syst Pharm 2020; 77:434-440. [PMID: 31950139 DOI: 10.1093/ajhp/zxz344] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
PURPOSE While many guidelines recommend higher doses of cefazolin for patients with higher body weights, there are scant outcome data showing the benefit of higher doses. Surgical site infection (SSI) rates by dose of cefazolin used for surgical prophylaxis after hip or knee arthroplasty were analyzed. METHODS Analysis of patient data entered into New Zealand's national, prospective, surveillance and quality improvement SSI Improvement Programme database for the period July 2013 through December 2017 was conducted. The US Centers for Disease Control and Prevention's National Healthcare Safety Network SSI definitions were used, and patients were followed for 90 days after surgery. Underdosing was defined as use of 1 g of cefazolin in patients weighing 80 kg or more or a cefazolin dose of <3 g in those weighing 120 kg or more. RESULTS There were 38,288 procedures where cefazolin was used for prophylaxis; patient body weight was known for all these procedures. Of the 1,840 patients who received 1 g of cefazolin, 676 (37%) weighed 80 kg or more. Of the 2,011 patients weighing 120 kg or more, 1,464 (73%) were underdosed. After multivariable analysis, male gender, higher total surgical risk scores, performance of revision and hip arthroplasties, and cefazolin underdosing were associated with higher SSI rates. For the 2,106 underdosed patients, the odds ratio for SSI was 2.19 (95% confidence interval, 1.61-2.99; P < 0.0001). The number of higher-weight patients needed to treat to prevent 1 SSI was 83, with an estimated cost of <NZ$500 to prevent 1 infection costing an estimated NZ$40,000. CONCLUSION Patients undergoing hip or knee arthroplasty and with weights of ≥80 kg and those with weights of ≥120 kg should receive cefazolin doses of 2 g and ≥3 g, respectively, for SSI prophylaxis. The question of whether a dose of ≥4 g is needed in patients weighing 120 kg or more or who are above a given body mass index threshold (eg, >35 kg/m2 or >40 kg/m2) remains unanswered.
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Affiliation(s)
- Arthur J Morris
- Auckland City Hospital, Auckland, New Zealand.,New Zealand Surgical Site Infection Improvement Programme, Health Quality and Safety Commission, Wellington, New Zealand
| | - Sally A Roberts
- Auckland City Hospital, Auckland, New Zealand.,Infection Prevention and Control Programme, Health Quality and Safety Commission, Wellington, New Zealand
| | - Nikki Grae
- Infection Prevention and Control Programme, Health Quality and Safety Commission, Wellington, New Zealand
| | - Chris M Frampton
- Department of Medicine, University of Otago, Christchurch, New Zealand
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15
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Kaufman EJ, Hatchimonji JS, Ma LW, Passman J, Holena DN. Complications and Failure to Rescue After Abdominal Surgery for Trauma in Obese Patients. J Surg Res 2020; 251:211-219. [PMID: 32171135 DOI: 10.1016/j.jss.2020.01.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/06/2020] [Accepted: 01/31/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although obesity is considered an epidemic in the United States, there is mixed evidence regarding the impact of obesity on outcomes after traumatic injury and major surgery. We hypothesized that obese patients undergoing trauma laparotomy would be at increased risk of failure to rescue (FTR), defined as death after a complication. METHODS We analyzed trauma registry data for adult patients who underwent abdominal exploration for trauma at all 30 level I and II Pennsylvania trauma centers, 2011-2014. We used competing risks regression to identify significant risk factors for complications. We used multivariable logistic regression to identify significant risk factors for FTR. RESULTS Of 95,806 admitted patients, 15,253 (15.9%) were categorized as obese. Overall, 3228 (3.4%) underwent laparotomy, including 2681 (83.1%) nonobese and 547 (17.0%) obese patients. Among obese patients, 47.2% had at least one complication and 28.7% had two or more complications, compared with 33.5% and 18.7% of nonobese patients, respectively. The most common complication was pneumonia (15.0% of obese and 10.5% of nonobese patients; P = 0.003), followed by sepsis (8.8% versus 4.2%; P < 0.001) and deep vein thrombosis (8.4% versus 5.9%; P < 0.001). Obesity was independently associated with complications (hazard ratio, 1.4; 95% confidence interval, 1.2-1.6). In multivariable analysis, obesity was not associated with FTR (odds ratio, 1.3; 95% confidence interval, 0.9-2.0). CONCLUSIONS Obesity is a risk factor for complications after traumatic injury but not for FTR. The increased risk of complications may reflect processes of care that are not attuned to the needs of this population, offering opportunities for improvement in care.
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Affiliation(s)
- Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania.
| | - Justin S Hatchimonji
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lucy W Ma
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jesse Passman
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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16
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Hussain Z, Curtain C, Mirkazemi C, Gadd K, Peterson GM, Zaidi STR. Prophylactic Cefazolin Dosing and Surgical Site Infections: Does the Dose Matter in Obese Patients? Obes Surg 2019; 29:159-165. [PMID: 30267229 PMCID: PMC6320352 DOI: 10.1007/s11695-018-3497-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Most surgical prophylaxis guidelines recommend a 3-g cefazolin intravenous dose in patients weighing ≥ 120 kg. However, this recommendation is primarily based on pharmacokinetic studies rather than robust clinical evidence. This study aimed to compare the prevalence of surgical site infections (SSIs) in obese and non-obese patients (body mass index ≥ 30 kg/m2 and < 30 kg/m2), and those weighing ≥ 120 kg and < 120 kg, who received 2- g cefazolin preoperatively. METHODS A retrospective case-control study was conducted in adult elective surgical patients. Patients receiving 2- g cefazolin were grouped as obese and non-obese, and by weight (≥ 120 kg or < 120 kg). The 90-day prevalence of SSI and potential contributing factors were investigated. RESULTS We identified 152 obese (median 134 kg) and 152 non-obese control (median 73 kg) patients. Baseline characteristics were similar between groups, except for an increased prevalence in the obese group of diabetes (35.5% vs 13.2%; p < 0.001) and an American Society of Anaesthesiologists Score of 3 (61.8% vs 17.1%; p < 0.001). While not statistically significant, the prevalence of SSI in the obese group was almost double that in the non-obese group (8.6% vs 4.6%; p = 0.25) and in patients weighing ≥ 120 kg (n = 102) compared to those weighing < 120 kg (n = 202) (9.8% vs 5.0%; p = 0.17). CONCLUSION The prevalence of SSI was not significantly increased in obese patients, or those weighing ≥ 120 kg, who received cefazolin 2- g prophylactically; however, trends toward an increase were evident. Large-scale randomised trials are needed to examine whether a 2-g or 3-g cefazolin is adequate to prevent SSI in obese (and ≥ 120 kg) individuals.
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Affiliation(s)
- Zahid Hussain
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Colin Curtain
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Corinne Mirkazemi
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Karl Gadd
- Department of Anaesthesia, Launceston General Hospital, Launceston, Tasmania, Australia.,Head of Anaesthesia Discipline, Launceston Clinical School, University of Tasmania, Launceston, Tasmania, Australia
| | - Gregory M Peterson
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Syed Tabish R Zaidi
- Division of Pharmacy, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia. .,School of Healthcare, University of Leeds, Leeds, LS2 9JT, UK.
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17
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Blum S, Cunha CB, Cunha BA. Lack of Pharmacokinetic Basis of Weight-Based Dosing and Intra-Operative Re-Dosing with Cefazolin Surgical Prophylaxis in Obese Patients: Implications for Antibiotic Stewardship. Surg Infect (Larchmt) 2019; 20:439-443. [PMID: 31112072 DOI: 10.1089/sur.2019.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Traditionally, there have been uniform antibiotic dosing guidelines for prophylaxis for clean-clean-contaminated surgery in both non-obese and obese adults. All other factors predisposing to surgical site infections (SSIs) being equal, over time, the preferred drug is cefazolin. The usual dose, given immediately pre-procedure, has been 1 g intravenously (IV) in non-penicillin-allergic patients, which has been highly effective, Recently, it has become common practice to use high-dose cefazolin; i.e., 3 g IV, in obese patients. This article reviews the literature on high-dose cefazolin prophylactic regimens in the obese from a pharmacokinetic (PK) point of view. There are no comparative studies to support this approach, which is based largely on the theory "more must be better." Weight-based dosing of cefazolin in the obese is flawed, because it does not take into account PK factors, which are critical in the obese. Cefazolin is a water-soluble (hydrophilic) antibiotic that does not penetrate adipose tissue regardless of IV dose. Importantly, adipose tissue is not a valid target tissue in clean-clean-contaminated SSI prophylaxis, as it does not become infected. Higher doses result in proportionately higher serum/non-adipose tissue concentrations, but adipose tissue concentrations are unaffected. Cefazolin displays time-dependent killing kinetics so that as long as serum/tissue concentrations are above the minimum inhibitory concentration (MIC) of SSI pathogens, there is no enhanced killing with higher concentrations relative to concentration-dependent antibiotics. Taking into account PK principles, a cefazolin 1 g IV bolus results in peak serum concentrations of ∼185 mcg/mL, provides at least six hours of intra-operative protection, aside from any post-antibiotic effects, and eliminates any rationale for intra-operative re-dosing for procedures lasting six hours or less. Some have argued that a cefazolin 3 g IV dose in the obese does not matter, as more must necessarily be better. However, from an antibiotic stewardship program (ASP) perspective, unneeded antibiotics are unnecessary. Moreover, the costs of cefazolin 1 g (IV push) at $0.75 versus 2 g (IV piggyback) at $ 6.83 can be significant in large centers using cefazolin prophylaxis for cardiothoracic, orthopedic, obstetric/gynecology, and bariatric surgery. Excessive antibiotics also expose the patient to potential adverse effects; i.e., Clostridium difficile. There is no dose-dependent or duration of exposure effect on resistance with one or two pre-operative or intra-operative doses. Well-done PK-based studies in obese patients clearly demonstrate the lack of benefit of using a 3-g dose or intra-operative re-dosing and show no incremental increase in adipose tissue concentrations with high doses. From an ASP point of view, antibiotic dosing recommendations should be reviewed and revised on the basis of PK principles that indicate that weight-based dosing has no basis for pre-operative prophylaxis in obese patients.
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Affiliation(s)
- Sharon Blum
- 1Department of Pharmacy, NYU Winthrop Hospital, Mineola, New York
| | - Cheston B Cunha
- 2Division of Infectious Disease, Rhode Island Hospital and The Miriam Hospital and Brown University Alpert School of Medicine, Providence, Rhode Island
| | - Burke A Cunha
- 3Infectious Disease Division, NYU Winthrop Hospital, Mineola and State University of New York School of Medicine, Stony Brook, New York
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18
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Rondon AJ, Kheir MM, Tan TL, Shohat N, Greenky MR, Parvizi J. Cefazolin Prophylaxis for Total Joint Arthroplasty: Obese Patients Are Frequently Underdosed and at Increased Risk of Periprosthetic Joint Infection. J Arthroplasty 2018; 33:3551-3554. [PMID: 30093266 DOI: 10.1016/j.arth.2018.06.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 06/26/2018] [Accepted: 06/28/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND One of the most effective prophylactic strategies against periprosthetic joint infection (PJI) is administration of perioperative antibiotics. Many orthopedic surgeons are unaware of the weight-based dosing protocol for cefazolin. This study aimed at elucidating what proportion of patients receiving cefazolin prophylaxis are underdosed and whether this increases the risk of PJI. METHODS A retrospective study of 17,393 primary total joint arthroplasties receiving cefazolin as perioperative prophylaxis from 2005 to 2017 was performed. Patients were stratified into 2 groups (underdosed and adequately dosed) based on patient weight and antibiotic dosage. Patients who developed PJI within 1 year following index procedure were identified. A bivariate and multiple logistic regression analyses were performed to control for potential confounders and identify risk factors for PJI. RESULTS The majority of patients weighing greater than 120 kg (95.9%, 944/984) were underdosed. Underdosed patients had a higher rate of PJI at 1 year compared with adequately dosed patients (1.51% vs 0.86%, P = .002). Patients weighing greater than 120 kg had higher 1-year PJI rate than patients weighing less than 120 kg (3.25% vs 0.83%, P < .001). Patients who were underdosed (odds ratio, 1.665; P = .006) with greater comorbidities (odds ratio, 1.259; P < .001) were more likely to develop PJI at 1 year. CONCLUSION Cefazolin underdosing is common, especially for patients weighing more than 120 kg. Our study reports that underdosed patients were more likely to develop PJI. Orthopedic surgeons should pay attention to the weight-based dosing of antibiotics in the perioperative period to avoid increasing risk of PJI.
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Affiliation(s)
| | - Michael M Kheir
- Department of Orthopaedics at Indiana University, Indianapolis, IN
| | - Timothy L Tan
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Noam Shohat
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Max R Greenky
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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Palmer K, Walker S, Richardson R, Jassal SV, Battistella M. Pharmacokinetic Study of Cefazolin in Short Daily Hemodialysis. Ann Pharmacother 2018; 53:348-356. [DOI: 10.1177/1060028018809695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: A number of centers across the world offer short daily hemodialysis (SDHD) treatments. To date, cefazolin pharmacokinetics have not been described in patients undergoing SDHD. Objective: The purpose of this study was to investigate the effect of SDHD on the pharmacokinetics of cefazolin. Methods: This was a prospective, open-label, pharmacokinetic study of cefazolin during SDHD in 10 noninfected patients. Participants received a 1-g intravenous (IV) infusion of cefazolin after SDHD on study day 1 and a second dose after SDHD on study day 2. To determine the concentration of cefazolin, 6 blood samples were drawn at 0, 1, 2, 2.3, 4, and 24 hours after initiation of dialysis on day 2, and 2 dialysate samples were drawn at 1 and 2 hours after initiation of dialysis on day 2. Samples were analyzed using high-performance liquid chromatography, and pharmacokinetic parameters were determined. Results: Median interdialysis clearance was 0.16 L/h (interquartile range [IQR]: 0.11-0.21 L/h), and median intradialysis clearance was 1.95 L/h (IQR: 1.66-2.45 L/h). Median interdialysis half-life was 28.2 hours (IQR: 23.5-59.3 hours) as compared with a median intradialysis half-life of 2.3 hours (IQR: 1.7-2.7 hours). The median percentage removal of cefazolin during dialysis was 41% (IQR: 35%-53%). Conclusion and Relevance: Estimated cefazolin dialysis clearance is similar to previous estimates with conventional thrice-weekly regimens. Current dosing recommendations of 1 g IV post-SDHD achieve total serum drug concentrations greater than 40 mg/L in all patients, which is the total drug concentration required for bactericidal activity against Staphylococcus species.
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Affiliation(s)
- Katie Palmer
- University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Scott Walker
- University of Toronto, Toronto, ON, Canada
- Sunnybrook & Women’s College Health Sciences Centre, Toronto, ON, Canada
| | - Robert Richardson
- University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Sarbjit V. Jassal
- University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Marisa Battistella
- University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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Surgical antibiotic prophylaxis – The evidence and understanding its impact on consensus guidelines. Infect Dis Health 2018. [DOI: 10.1016/j.idh.2018.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
OBJECTIVES To determine the frequency and effect of under-dosing prophylactic weight-based antibiotics in patients with open tibial fractures. We hypothesized that patients who did not receive appropriate weight-based dosing of prophylactic antibiotics would have higher rates of infection. DESIGN Retrospective cohort study. SETTING Level 1 Trauma Center. PATIENTS/PARTICIPANTS Patients 18 years of age or older with high-grade (Gustilo-Anderson type IIIA or IIIB) open extraarticular tibial fractures over a 5-year period. MAIN OUTCOME The primary outcome was deep infection within one year of initial injury. Appropriate weight-based dosing of cefazolin was defined as: at least 1 g for patients <80 kg, 2 g for patients between 80 and 120 kg, and 3 g for patients >120 kg. RESULTS Sixty-three patients met the inclusion criteria; 21 (33%) were under-dosed with cefazolin at the time of initial presentation. Among the 20 patients who subsequently developed deep infection, only 55% were appropriately dosed with cefazolin; of the patients who did not develop deep infection, 72% were appropriately dosed with cefazolin (P = 0.18). Univariate analysis revealed that hypertension was associated with infection (P = 0.049). Multivariable logistic regression analysis of infection due to all organisms did not reveal a statistically significant reduction in the odds of infection with appropriate weight-based dosing of cefazolin [Odds ratio = 0.42 (95% confidence interval, 0.12-1.48), P = 0.177]. Five of 7 (71%) of the gram positive, non-methicillin-resistant Staphylococcus aureus, infections occurred in patients who were under-dosed with cefazolin. Five (23.8%) of 21 patients who were under-dosed with cefazolin had gram-positive, non-methicillin-resistant S. aureus infections, compared to 2 (4.8%) of 42 patients who were appropriately dosed (P = 0.036). CONCLUSIONS Under-dosing of weight-based antibiotics in the treatment of open fractures is common. Appropriate weight-based dosing of cefazolin for prophylaxis in high-grade open tibial fractures reduces the frequency of infection due to cefazolin-sensitive organisms. Interestingly, organisms not susceptible to cefazolin were responsible for the majority of infections. The effect of under-dosing of cefazolin and other weight-based antibiotics deserves further investigation in larger studies. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Reducing Hypotension and Acute Kidney Injury in the Elective Total Joint Arthroplasty Population: A Multi-Disciplinary Approach. J Arthroplasty 2018. [PMID: 29526330 DOI: 10.1016/j.arth.2018.01.061] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND When critically analyzing our hospital system's rate of hypotension and acute kidney injury (AKI) after total joint arthroplasty, our incidence rates (14.54%, 6.02%) were much higher than our peers (7.17%, 2.03%) and national rates (2.0%, 3.3%). We present a multi-disciplinary management intervention that aimed to decrease overall complication rates. METHOD A multi-disciplinary team implemented a protocol at our suburban hospital to limit complication rates after joint replacement surgery. Hypotension, AKI, length of stay (LOS), re-admission rates, and mortality rates were compared before the protocol was implemented, after protocol implementation, and after protocol integration into our EMR (electronic medical record). RESULTS In total, 1233 patients over 36 months were followed. Hypotension rates after protocol implementation into EMR (group 3) were significantly lower than rates before the protocol (group 1) (P = .002), with rates after protocol implementation without EMR (group 2) trending toward a significant decrease from group 1 (P = .064). AKI rates in group 3 were significantly lower than group 1 (P = .000) and group 2 (P = .006). No difference was seen in hypotension rates between group 2 and 3 (P = .792) or AKI rates between group 1 and 2 (P = .533). Finally, no significant difference was seen between groups in LOS (P = .560), re-admission rates (P = .378), and mortality rates (all 0.0%). CONCLUSION By implementing a comprehensive electronic protocol consisting of pre-operative risk stratification, multi-disciplinary medical optimization, and an evolving post-operative management plan, significant decreases in hypotension and AKI can be seen.
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Palma EC, Meinhardt NG, Stein AT, Heineck I, Fischer MI, de Araújo B, Dalla Costa T. Efficacious Cefazolin Prophylactic Dose for Morbidly Obese Women Undergoing Bariatric Surgery Based on Evidence from Subcutaneous Microdialysis and Populational Pharmacokinetic Modeling. Pharm Res 2018; 35:116. [DOI: 10.1007/s11095-018-2394-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/19/2018] [Indexed: 11/30/2022]
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Optimal Cefazolin Prophylactic Dosing for Bariatric Surgery: No Need for Higher Doses or Intraoperative Redosing. Obes Surg 2017; 27:626-629. [PMID: 27520693 DOI: 10.1007/s11695-016-2331-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE The goal of this pharmacokinetic (PK) study was to evaluate whether a single 2-g prophylactic dose of cefazolin given (IV) bolus provides effective protective cefazolin levels for prophylaxis against methicillin-sensitive S. aureus (MSSA), the primary skin pathogen in bariatric surgery. MATERIALS AND METHODS Thirty-seven patients having gastric bypass or sleeve gastrectomy received cefazolin 2-g preoperative prophylaxis. Serum, subcutaneous adipose tissue, and deep peri-gastric adipose tissue specimens were collected at incision and before skin closure. Cefazolin concentrations in serum and adipose tissue were determined by high-performance liquid chromatography. RESULTS Penetration of cefazolin, a water soluble antibiotic, into adipose tissue was only 6-8 % of simultaneous serum levels. However, cefazolin tissue concentrations in all adipose tissue specimens, exceeded mean MIC for MSSA. CONCLUSIONS Prophylactic cefazolin, given as a single 2 g (IV bolus 3-5 min before skin incision) was more than adequate in providing protective cefazolin levels for the duration of bariatric surgery. Cefazolin 2 g (IV dose bolus given just before skin incision) achieves protective adipose tissue levels (> MIC of MSSA) for the duration (usually < 4 h) of bariatric surgical procedures. In this study, cefazolin 2 g (IV bolus) provided protective adipose tissue levels for 4.8 h. Since cefazolin is a water soluble antibiotic (V d = 0.2 L/Kg), penetration into adipose tissue is not V d not dose-dependent. Extremely high-dosed cefazolin, i.e., 3 or 4 g is excessive and unnecessary for bariatric surgery prophylaxis. A single cefazolin 2 g preoperative dose also eliminates the need for intraoperative redosing at 4 h.
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Cefazolin tissue concentrations with a prophylactic dose administered before sleeve gastrectomy in obese patients: a single centre study in 116 patients. Br J Anaesth 2017; 120:1202-1208. [PMID: 29793587 DOI: 10.1016/j.bja.2017.10.023] [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] [Received: 11/19/2016] [Revised: 10/19/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND In obese patients undergoing sleeve gastrectomy, the blood and fatty-tissue concentrations of cefazolin required for adequate antibiotic prophylaxis are uncertain. METHODS This was a single centre prospective study in obese (Group A: 40≤ BMI ≤50 kg m-2) and severely obese (Group B: 50< BMI ≤65 kg m-2) patients undergoing bariatric surgery. Blood and fatty-tissue samples were collected after a cefazolin 4 g i.v. injection. The primary aim was to compare cefazolin concentrations in subcutaneous fatty tissue with a targeted tissue concentration of 4 μg g-1 according to Staphylococcus aureus resistance breakpoint. RESULTS One hundred and sixteen patients were included: 79 in Group A and 37 in Group B. At the beginning of the surgery, cefazolin concentration in subcutaneous fatty tissue was 12.2 (5.4) μg g-1 in Group A and 12 (6.1) μg g-1 in Group B (P=0.7). At the end, cefazolin concentrations in subcutaneous fatty tissue were 9.0 (4.9) and 7.8 (4.2) μg g-1 in Groups A and B, respectively (P=0.2). The plasma concentration of free cefazolin during surgery was higher in Group A than in Group B (P<0.0001). Fatty-tissue concentrations of 95% and 83% patients in Groups A and B, respectively, were above S. aureus resistance breakpoint. CONCLUSIONS After a 4 g dose, the concentrations of cefazolin in fatty tissue were above the 4 μg g-1 tissue concentration target, providing adequate antibiotic tissue concentrations during bariatric surgery. As cefazolin concentration in fatty tissue is a surrogate endpoint, the results should be considered in conjunction with the results on free cefazolin concentrations in subcutaneous tissue. CLINICAL TRIAL REGISTRATION NCT01537380.
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Ierano C, Nankervis JAM, James R, Rajkhowa A, Peel T, Thursky K. Surgical antimicrobial prophylaxis. Aust Prescr 2017; 40:225-229. [PMID: 29377021 DOI: 10.18773/austprescr.2017.073] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Courtney Ierano
- National Centre for Antimicrobial Stewardship, Doherty Institute, Royal Melbourne Hospital/University of Melbourne
| | | | - Rod James
- National Centre for Antimicrobial Stewardship, Doherty Institute, Royal Melbourne Hospital/University of Melbourne
| | - Arjun Rajkhowa
- National Centre for Antimicrobial Stewardship, Doherty Institute, Royal Melbourne Hospital/University of Melbourne
| | - Trisha Peel
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne
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Chirca I, Marculescu C. Prevention of Infection in Orthopedic Prosthetic Surgery. Infect Dis Clin North Am 2017; 31:253-263. [PMID: 28292539 DOI: 10.1016/j.idc.2017.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Total joint arthroplasty is a generally safe orthopedic procedure; however, infection is a potentially devastating complication. Multiple risk factors have been identified for development of prosthetic joint infections. Identification of patients at risk and preoperative correction of known risk factors, such as smoking, diabetes mellitus, anemia, malnutrition, and decolonization of Staphylococcus carriers, represent well-established actions to decrease the infection risk. Careful operative technique, proper draping and skin preparation, and appropriate selection and dosing of antimicrobials for perioperative prophylaxis are also very important in prevention of infection.
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Affiliation(s)
- Ioana Chirca
- Department of infectious Diseases, University Hospital, 1350 Walton Way, Augusta, GA 30909, USA
| | - Camelia Marculescu
- Division of Infectious Diseases, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA.
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Grupper M, Kuti JL, Swank ML, Maggio L, Hughes BL, Nicolau DP. Population Pharmacokinetics of Cefazolin in Serum and Adipose Tissue From Overweight and Obese Women Undergoing Cesarean Delivery. J Clin Pharmacol 2016; 57:712-719. [DOI: 10.1002/jcph.851] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/07/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Mordechai Grupper
- Center for Anti-Infective Research and Development; Hartford Hospital; Hartford CT, USA
| | - Joseph L. Kuti
- Center for Anti-Infective Research and Development; Hartford Hospital; Hartford CT, USA
| | | | | | - Brenna L. Hughes
- Division of Maternal-Fetal Medicine; Department of Obstetrics & Gynecology; Women & Infants Hospital of Rhode Island; Warren Alpert Medical School of Brown University; Providence RI, USA
| | - David P. Nicolau
- Center for Anti-Infective Research and Development; Hartford Hospital; Hartford CT, USA
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Peppard WJ, Eberle DG, Kugler NW, Mabrey DM, Weigelt JA. Association between Pre-Operative Cefazolin Dose and Surgical Site Infection in Obese Patients. Surg Infect (Larchmt) 2016; 18:485-490. [PMID: 27906601 PMCID: PMC5466014 DOI: 10.1089/sur.2016.182] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A fixed dose of cefazolin results in serum concentrations that decrease as body mass increases. Current national guidelines suggest a pre-operative cefazolin dose of two grams may be insufficient for patients ≥120 kg; thus a three gram dose is recommended. These recommendations, however, are based on pharmacokinetic rather than outcome data. We evaluate the efficacy of pre-operative cefazolin two gram and three gram doses as measured by the rate of surgical site infection (SSI). PATIENTS AND METHODS We conducted a retrospective review of adult patients ≥100 kg who were prescribed cefazolin as surgical prophylaxis between September 1, 2012 and May 31, 2013 at an academic medical center. Patients were excluded if cefazolin was prescribed but not administered, had a known infection at the site of surgery, or inappropriately received cefazolin prophylaxis based on surgical indication. The SSIs were identified by documentation of SSI in the medical record or findings consistent with the standard Centers for Disease Control and Prevention definition. Inpatient and outpatient records up to 90 days post-operative were reviewed for delayed SSI. RESULTS Four hundred eighty-three surgical cases were identified in which pre-operative cefazolin was prescribed. Forty-seven patients were excluded leaving a total of 436 patients for final analysis: 152 in the cefazolin two gram group and 284 in the three gram group. Baseline demographics were similar between groups with a mean follow-up duration of 77 days for both groups. Unadjusted SSI rates were 7.2% and 7.4% (odds ratio [OR] 0.98, p = 0.95), for the two gram and three gram groups, respectively. When differences in follow-up between groups were considered and logistic regression was adjusted with propensity score, there remained no difference in SSI rates (OR 0.87, 95% confidence interval 0.36-2.06, p = 0.77). CONCLUSION In otherwise similar obese surgical patients weighing ≥100 kg, the administration of a pre-operative cefazolin two gram dose is associated with a similar rate of SSI compared with patients who received a three gram dose.
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Affiliation(s)
- William J. Peppard
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Surgery, Division of Trauma and Critical Care, The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David G. Eberle
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathan W. Kugler
- Department of Surgery, Division of Trauma and Critical Care, The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Danielle M. Mabrey
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John A. Weigelt
- Department of Surgery, Division of Trauma and Critical Care, The Medical College of Wisconsin, Milwaukee, Wisconsin
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Hites M, Deprez G, Wolff F, Ickx B, Verleije A, Closset J, Loi P, Prévost J, Taccone FS, Racapé J, Cotton F, Jacobs F. Evaluation of total body weight and body mass index cut-offs for increased cefazolin dose for surgical prophylaxis. Int J Antimicrob Agents 2016; 48:633-640. [PMID: 28128093 DOI: 10.1016/j.ijantimicag.2016.08.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 08/08/2016] [Accepted: 08/13/2016] [Indexed: 10/20/2022]
Abstract
French and American guidelines recommend increased dosage regimens of cefazolin (CFZ) for surgical prophylaxis in patients with a body mass index (BMI) ≥ 35 kg/m2 or with a total body weight (TBW) ≥ 120 kg. The objective of this study was to evaluate the accuracy of these cut-offs in identifying patients who require CFZ dose adjustment. A pharmacokinetic study was conducted in patients of varying TBW and BMI who received 2 g of CFZ intravenously for prophylaxis prior to digestive surgery. Adequacy of therapy, defined as a serum concentration of unbound CFZ (fCFZ) ≥ 4 mg/L, was evaluated 180 min (T180) and 240 min (T240) after the start of CFZ infusion. Possible factors associated with insufficient fCFZ levels were also assessed. A P-value of <0.05 was considered statistically significant. A total of 63 patients were included in the study, categorised according to BMI (<35 kg/m2, 20 patients; and ≥35 kg/m2, 43 patients) and TBW (<120 kg, 41 patients; and ≥120 kg, 22 patients). All patients had adequate drug levels at T180 but only 40/63 patients (63%) had adequate levels at T240. At T240, therapy was adequate in 15/20 patients (75%) and 25/43 patients (58%) with BMI <35 kg/m2 and ≥35 kg/m2, respectively (P = 0.20), and in 28/41 patients (68%) and 12/22 patients (55%) with TBW <120 kg and ≥120 kg, respectively (P = 0.28). No factor associated with insufficient fCFZ was identified. In conclusion, current BMI and TBW cut-offs are poor indicators of which patients could benefit from increased CFZ dosage regimens.
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Affiliation(s)
- Maya Hites
- Department of Infectious Diseases, CUB-Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium.
| | - Guillaume Deprez
- Department of Clinical Chemistry, CUB-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fleur Wolff
- Department of Clinical Chemistry, CUB-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Brigitte Ickx
- Department of Anesthesiology, CUB-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Anita Verleije
- Department of Anesthesiology, CUB-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Closset
- Department of Digestive Surgery, CUB-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrizia Loi
- Department of Digestive Surgery, CUB-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jessica Prévost
- Department of Infectious Diseases, CUB-Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, CUB-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Judith Racapé
- Research Center of Epidemiology, Biostatistics and Clinical Research, School of Public Health, CUB-Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Frédéric Cotton
- Department of Clinical Chemistry, CUB-Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Frédérique Jacobs
- Department of Infectious Diseases, CUB-Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
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Pharmacokinetic and Pharmacodynamic Evaluation of a Weight-Based Dosing Regimen of Cefoxitin for Perioperative Surgical Prophylaxis in Obese and Morbidly Obese Patients. Antimicrob Agents Chemother 2016; 60:5885-93. [PMID: 27458209 DOI: 10.1128/aac.00585-16] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 06/22/2016] [Indexed: 11/20/2022] Open
Abstract
The objective of this study was to determine the pharmacokinetics and pharmacodynamics (PK/PD) of a weight-based cefoxitin dosing regimen for surgical prophylaxis in obese patients. Patients received a single dose of cefoxitin at 40 mg/kg based on total body weight. Cefoxitin samples were obtained over 3 h from serum and adipose tissue, and concentrations were determined by validated high-performance liquid chromatography. Noncompartmental pharmacokinetic analysis was performed, followed by Monte Carlo simulations to estimate probability of target attainment (PTA) for Staphylococcus aureus, Escherichia coli, and Bacteroides fragilis over 4-h periods postdose. Thirty patients undergoing bariatric procedures were enrolled. The body mass index (mean ± standard deviation [SD])was 45.9 ± 8.0 kg/m(2) (range, 35.0 to 76.7 kg/m(2)); the median cefoxitin dose was 5 g (range, 4.0 to 7.5 g). The mean maximum concentrations were 216.15 ± 41.80 μg/ml in serum and 12.62 ± 5.89 in tissue; the mean tissue/serum ratio was 8% ± 3%. In serum, weight-based regimens achieved ≥90% PTA (goal time during which free [unbound] drug concentrations exceed pathogen MICs [fT>MIC] of 100%) for E. coli and S. aureus over 2 h and for B. fragilis over 1 h; in tissue this regimen failed to achieve goal PTA at any time point. The 40-mg/kg regimens achieved higher PTAs over longer periods in both serum and tissue than did the standard 2-g doses. However, although weight-based cefoxitin regimens were better than fixed doses, achievement of desired pharmacodynamic targets was suboptimal in both serum and tissue. Alternative dosing regimens and agents should be explored in order to achieve more favorable antibiotic performance during surgical prophylaxis in obese patients.
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Lillico R, Sayre CL, Sitar DS, Davies NM, Baron CM, Lakowski TM. Quantification of cefazolin in serum and adipose tissue by ultra high performance liquid chromatography-Tandem mass spectrometry (UHPLC-MS/MS): application to a pilot study of obese women undergoing cesarean delivery. J Chromatogr B Analyt Technol Biomed Life Sci 2016; 1031:94-98. [PMID: 27469905 DOI: 10.1016/j.jchromb.2016.07.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/13/2016] [Accepted: 07/17/2016] [Indexed: 11/18/2022]
Abstract
Higher doses of cefazolin are required in obese patients for preoperative antibiotic prophylaxis, owing to its low lipophilicity. An ultra high performance liquid chromatography-tandem mass spectrometry method was developed to quantify cefazolin in serum and adipose tissue from 6 obese patients undergoing cesarean delivery, and using stable-isotope labeled cefazolin as an internal standard. The method has a 2μg/g lower limit of quantitation. The concentration in adipose tissue was 3.4±1.6μg/mL, which is less than half of the reported minimum inhibitory concentration of 8μg/mL for cefazolin. Serum cefazolin concentrations were more than 30-fold higher than in adipose tissue.
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Affiliation(s)
- Ryan Lillico
- The Rady Faculty of Health Sciences, College of Pharmacy, Pharmaceutical Analysis Laboratory, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Casey L Sayre
- The Rady Faculty of Health Sciences, College of Pharmacy, Pharmaceutical Analysis Laboratory, University of Manitoba, Winnipeg, Manitoba, Canada; College of Pharmacy, Roseman University of Health Sciences, South Jordan, UT, USA
| | - Daniel S Sitar
- The Rady Faculty of Health Sciences, College of Pharmacy, Pharmaceutical Analysis Laboratory, University of Manitoba, Winnipeg, Manitoba, Canada; Clinical Pharmacology Section, The Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Neal M Davies
- The Rady Faculty of Health Sciences, College of Pharmacy, Pharmaceutical Analysis Laboratory, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Cynthia M Baron
- Department of Anesthesia, The Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ted M Lakowski
- The Rady Faculty of Health Sciences, College of Pharmacy, Pharmaceutical Analysis Laboratory, University of Manitoba, Winnipeg, Manitoba, Canada.
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Russell JM, Nick-Dart RL, Nornhold BD. Development of a pharmacist-driven protocol for automatic medication dosage adjustments in obese patients. Am J Health Syst Pharm 2016; 72:1656-63. [PMID: 26386107 DOI: 10.2146/ajhp140315] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE A hospital protocol utilizing automatic dosage adjustments and pharmacist consultations to optimize the use of certain medications in obese patients is described. SUMMARY After conducting a literature search focused on medication dosing in obese patients, pharmacists at a large community hospital developed a list of commonly ordered medications appropriate for inclusion in a pharmacy-driven institutional protocol for automatic medication dosage adjustment in adult patients with obesity. Evidence-based recommendations on initial dosing of eight antimicrobials and two anticoagulant agents according to weight and renal function were formulated. Under the protocol, pharmacists receive electronic alerts regarding protocol-eligible patients during initial order verification and automatically adjust medication dosages as appropriate. For patients prescribed anticoagulants at specified dosage levels, clinical pharmacists consult with prescribers to help ensure safe and effective initial and ongoing therapy. Multidisciplinary educational initiatives were conducted prior to protocol implementation. During two designated three-week postimplementation data collection periods, pharmacists received a total of 372 protocol-eligible medication orders. Pharmacists adjusted a total of 149 dosages and verified an additional 183 dosages consistent with the protocol as originally ordered. Clinical pharmacy consults were completed for 10-15% of patients, with laboratory monitoring ordered in 25-30% of those cases (all patients were found to have appropriate test values). There have been no documented adverse drug reactions in patients whose medication dosages were adjusted per protocol. CONCLUSION Pharmacists implemented weight- and renal function-based dosage adjustments for obese patients in 40% of evaluated protocol-eligible cases to achieve 89% compliance with the protocol. Heparin and cefazolin were the medications most likely to require obesity-related dosage adjustments.
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Affiliation(s)
- Justine M Russell
- Justine M. Russell, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Emergency Department; Rebecca L. Nick-Dart, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Brandon D. Nornhold, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Saint Vincent Hospital, Erie, PA.
| | - Rebecca L Nick-Dart
- Justine M. Russell, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Emergency Department; Rebecca L. Nick-Dart, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Brandon D. Nornhold, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Saint Vincent Hospital, Erie, PA
| | - Brandon D Nornhold
- Justine M. Russell, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Emergency Department; Rebecca L. Nick-Dart, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Brandon D. Nornhold, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Saint Vincent Hospital, Erie, PA
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Ross EL, Heizer J, Mixon MA, Jorgensen J, Valdez CA, Czaja AS, Reiter PD. Development of recommendations for dosing of commonly prescribed medications in critically ill obese children. Am J Health Syst Pharm 2015; 72:542-56. [PMID: 25788508 DOI: 10.2146/ajhp140280] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The development and use of a decision support tool to help formulate recommendations for dosing of commonly prescribed medications in critically ill obese children are described. METHODS Medications prescribed in 2010 to critically ill infants and children (younger than 18 years) were identified from the Pediatric Health Information System. The most commonly prescribed and therapeutically monitored medications were extracted. Supportive evidence for obesity dosing was identified through a standardized computerized search involving medical subject heading terminology and age filters using PubMed and Ovid. A usefulness scoring system was developed to rate the strength and applicability of the literature to critically ill obese children. A decision supporttool was then created to aid in the formulation of a dosing weight for each medication based on the usefulness score, published pharmacokinetic properties, clinical studies available in the primary literature, and consideration of clinical consequences of underdosing or overdosing. RESULTS A total of 113 medications were evaluated, and 122 discrete citations, supporting 66 medications, were reviewed. Seventy-two percent of citations had general obesity dosing information, and 13% had pediatric-specific information. The overall mean usefulness score was 5.1±4.7 (median, 7). The decision support tool was incorporated to make final dosing weight recommendations for obese children. Ultimately, total body weight was recommended for 52 medications, adjusted weight for 43 medications, and ideal body weight for 18 medications. CONCLUSION The inadequacy of obesity dosing information for most medications commonly ordered for children admitted to a pediatric intensive care unit led to the development of a decision support tool to aid in formulating dosing recommendations.
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Affiliation(s)
- Emma L Ross
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC.
| | - Justin Heizer
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC
| | - Mark A Mixon
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC
| | - Jennifer Jorgensen
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC
| | - Connie A Valdez
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC
| | - Angela S Czaja
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC
| | - Pamela D Reiter
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC
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Dhurandhar NV, Bailey D, Thomas D. Interaction of obesity and infections. Obes Rev 2015; 16:1017-29. [PMID: 26354800 DOI: 10.1111/obr.12320] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/20/2015] [Accepted: 08/03/2015] [Indexed: 12/11/2022]
Abstract
There is evidence that certain infections may induce obesity. Obese persons may also have more severe infections and have compromised response to therapies. The objective of this study is to review the available literature identifying infections that potentially contribute to greater body mass index (BMI) and differential responses of overweight and obese persons to infections. A systematic literature review of human studies examining associations between infections and weight gain, differential susceptibility, severity, and response to prevention and treatment of infection according to BMI status (January 1980-July 2014) was conducted. Three hundred and forty-three studies were eligible for inclusion. Evidence indicated that viral infection by human adenovirus Ad36 and antibiotic eradication of Helicobacter pylori were followed by weight gain. People who were overweight or obese had higher susceptibility to developing post-surgical infections, H1N1 influenza and periodontal disease. More severe infections tended to be present in people with a larger BMI. People with a higher BMI had a reduced response to vaccinations and antimicrobial drugs. Higher doses of antibiotics were more effective in obese patients. Infections may influence BMI, and BMI status may influence response to certain infections, as well as to preventive and treatment measures. These observations have potential clinical implications.
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Affiliation(s)
- N V Dhurandhar
- Department of Nutritional Sciences, Texas Tech University, Lubbock, TX, USA
| | - D Bailey
- Department of Nutritional Sciences, Texas Tech University, Lubbock, TX, USA
| | - D Thomas
- Center for Quantitative Obesity Research, Department of Mathematical Sciences, Montclair State University, Montclair, NJ, USA
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Cardiac Implantable Electronic Device Infection: From an Infection Prevention Perspective. Adv Prev Med 2015; 2015:357087. [PMID: 26550494 PMCID: PMC4621323 DOI: 10.1155/2015/357087] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/13/2015] [Indexed: 01/18/2023] Open
Abstract
A cardiac implantable electronic device (CIED) is indicated for patients with severely reduced ejection fraction or with life-threatening cardiac arrhythmias. Infection related to a CIED is one of the most feared complications of this life-saving device. The rate of CIED infection has been estimated to be between 2 and 25; though evidence shows that this rate continues to rise with increasing expenditure to the patient as well as healthcare systems. Multiple risk factors have been attributed to the increased rates of CIED infection and host comorbidities as well as procedure related risks. Infection prevention efforts are being developed as defined bundles in numerous hospitals around the country given the increased morbidity and mortality from CIED related infections. This paper aims at reviewing the various infection prevention measures employed at hospitals and also highlights the areas that have relatively less established evidence for efficacy.
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Pharmacokinetics of cefazolin prophylaxis in obese gravidae at time of cesarean delivery. Am J Obstet Gynecol 2015; 213:541.e1-7. [PMID: 26103528 DOI: 10.1016/j.ajog.2015.06.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 05/15/2015] [Accepted: 06/15/2015] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The objective of the study was to compare the pharmacokinetics of 2 g and 3 g doses of cefazolin when used for perioperative prophylaxis in obese gravidae undergoing cesarean delivery. STUDY DESIGN We performed a double-blinded, randomized controlled trial from August 2013 to April 2014. Twenty-six obese women were randomized to receive either 2 or 3 g intravenous cefazolin within 30 minutes of a skin incision. Serial maternal plasma samples were obtained at specific time points up to 8 hours after drug administration. Umbilical cord blood was obtained after placental delivery. Maternal adipose samples were obtained prior to fascial entry, after closure of the hysterotomy, and subsequent to fascial closure. Pharmacokinetic parameters were determined via noncompartmental analysis. RESULTS The median area under the plasma concentration vs time curve was significantly greater in the 3 g group than in the 2 g group (27204 μg/mL per minute vs 14058 μg/mL per minute; P = .001). Maternal plasma concentrations had an impact by body mass index. For every 1 kg/m(2) increase in body mass index at the time of the cesarean delivery, there was an associated 13.77 μg/mL lower plasma concentration of cefazolin across all time points (P = .01). By the completion of cesarean delivery, cefazolin concentrations in maternal adipose were consistently above the minimal inhibitory concentration for both Gram-positive and Gram-negative bacteria with both the 2 g and 3 g doses. The median umbilical cord blood concentrations were significantly higher in the 3 g vs the 2 g group (34.5 μg/mL and 21.4 μg/mL; P = .003). CONCLUSION Cefazolin concentrations in maternal adipose both at time of hysterotomy closure and fascial closure were above the minimal inhibitory concentration for both Gram-positive and Gram-negative bacteria when either 2 g or 3 g cefazolin was administered as perioperative surgical prophylaxis. Maternal cefazolin concentrations in plasma and maternal adipose tissue are related to both dose and body mass index.
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Swank ML, Wing DA, Nicolau DP, McNulty JA. Increased 3-gram cefazolin dosing for cesarean delivery prophylaxis in obese women. Am J Obstet Gynecol 2015; 213:415.e1-8. [PMID: 26003059 DOI: 10.1016/j.ajog.2015.05.030] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/22/2015] [Accepted: 05/14/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this study was to determine tissue concentrations of cefazolin after the administration of a 3-g prophylactic dose for cesarean delivery in obese women (body mass index [BMI] >30 kg/m(2)) and to compare these data with data for historic control subjects who received 2-g doses. Acceptable coverage was defined as the ability to reach the minimal inhibitory concentration (MIC) of 8 μg/mL for cefazolin. STUDY DESIGN We conducted a 2-phase investigation. The current phase is a prospective cohort study of the effects of obesity on tissue concentrations after prophylactic 3-g cefazolin doses at the time of cesarean delivery. Concentration data after 3-g were compared with data for historic control subjects who had received 2-g. Three grams of parenteral cefazolin was given 30-60 minutes before skin incision. Adipose samples were collected at both skin incision and closure. Cefazolin concentrations were determined with the use of a validated high-performance liquid chromatography assay. RESULTS Twenty-eight obese women were enrolled in the current study; 29 women were enrolled in the historic cohort. BMI had a proportionally inverse relationship on antibiotic concentrations. An increase of the cefazolin dose dampened this effect and improved the probability of reaching the recommended MIC of ≥8 μg/mL. Subjects with a BMI of 30-40 kg/m(2) had a median concentration of 6.5 μg/g (interquartile range [IQR], 4.18-7.18) after receiving 2-g vs 22.4 μg/g (IQR, 20.29-34.36) after receiving 3-g. Women with a BMI of >40 kg/m(2) had a median concentration of 4.7 μg/g (IQR, 3.11-4.97) and 9.6 μg/g (IQR, 7.62-15.82) after receiving 2- and 3-g, respectively. With 2 g of cefazolin, only 20% of the cohort with a BMI of 30-40 kg/m(2) and none of the cohort with a BMI of >40 kg/m(2) reached an MIC of ≥8 μg/mL. With 3-g, all women with a BMI of 30-40 kg/m(2) reached target MIC values; 71% of the women with a BMI of >40 kg/m(2) attained this cutoff. CONCLUSION Higher adipose concentrations of cefazolin were observed after the administration of an increased prophylactic dose. This concentration-based pharmacology study supports the use of 3 g of cefazolin at the time of cesarean delivery in obese women. Normal and overweight women (BMI <30 kg/m(2)) reach adequate cefazolin concentrations with the standard 2-g dosing.
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Bosco JA, Bookman J, Slover J, Edusei E, Levine B. Principles of Antibiotic Prophylaxis in Total Joint Arthroplasty: Current Concepts. J Am Acad Orthop Surg 2015; 23:e27-35. [PMID: 26209148 DOI: 10.5435/jaaos-d-15-00017] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Infection is a rare, serious complication following total joint arthroplasty and constitutes a considerable emotional and financial burden for patients, surgeons, and healthcare systems. Prevention of surgical site and periprosthetic joint infections is crucial. This requires knowledge of the microorganisms that commonly cause these infections, including Staphylococcus species. Selection of the appropriate antibiotic regimen to treat infection remains controversial, but cefazolin and cefuroxime are the most commonly recommended antibiotics for prophylaxis. Appropriate timing of administration before surgery, with redosing performed as needed, can help to ensure optimal antibiotic concentration during surgery. Given the increasing evidence that S aureus colonization is a risk factor for periprosthetic joint infection, an exploration of the potential benefits of preoperative S aureus carrier screening and decolonization protocols is warranted. The use of antibiotic-loaded bone cement in primary total joint arthroplasty and antibiotic powder at wound closure are other controversial topics that require additional research.
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Tucker CE, Lockwood AM, Nguyen NH. Antibiotic dosing in obesity: the search for optimum dosing strategies. Clin Obes 2014; 4:287-95. [PMID: 25826157 DOI: 10.1111/cob.12076] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 08/01/2014] [Accepted: 09/05/2014] [Indexed: 02/07/2023]
Abstract
Global obesity has nearly doubled and is now a common occurrence in high-income and developing countries. The World Health Organization estimates that more than 1.4 billion adults are obese. Although the prevalence of obesity is increasing over the last decades, pharmacokinetic evaluations are still conducted in individuals with a body weight of approximately 70 kg. Morbid obesity is associated with several pathophysiological changes that can profoundly affect drug distribution and clearance. There are currently no specific dosing recommendations for antibiotics in obese patients, making dosing suggestions primarily based on pharmacokinetic characteristics of the medications and dosing recommendations in other disease states. Understanding of the pharmacokinetic alterations and maximum doses of antibiotics safely used is paramount to appropriate treatment in the obese population.
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Affiliation(s)
- C E Tucker
- Department of Pharmacy, St. Vincent's Medical Center, Jacksonville, FL, USA
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Unger NR, Stein BJ. Effectiveness of Pre-Operative Cefazolin in Obese Patients. Surg Infect (Larchmt) 2014; 15:412-6. [DOI: 10.1089/sur.2012.167] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nathan R. Unger
- College of Pharmacy, Nova Southeastern University, Palm Beach Gardens, Florida
| | - Bradley J. Stein
- Pharmacy Service, James A. Haley Veterans' Hospital, Tampa, Florida
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Super obesity in pregnancy: difficulties in clinical management. J Perinatol 2014; 34:495-502. [PMID: 24503915 DOI: 10.1038/jp.2014.4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 12/23/2013] [Accepted: 01/07/2014] [Indexed: 01/29/2023]
Abstract
As the obesity pandemic continues in the United States, obesity in pregnancy has become an area of interest. Many studies focus on women with body mass index (BMI) ⩾ 30 kg m(-2). Unfortunately, the prevalence of patients with BMI ⩾ 50 kg m(-2) is rapidly increasing, and there are few studies specifically looking at pregnant women in this extreme category. The purpose of this article is to highlight some of the challenges faced and review the literature available to help guide obstetricians who might encounter such patients.
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Cefazolin should be administered maximum 30min before incision in total knee arthroplasty when tourniquet is used. Med Hypotheses 2014; 82:766-8. [DOI: 10.1016/j.mehy.2014.03.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 03/16/2014] [Indexed: 11/18/2022]
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Anlicoara R, Ferraz ÁAB, da P. Coelho K, de Lima Filho JL, Siqueira LT, de Araújo JGC, Campos JM, Ferraz EM. Antibiotic Prophylaxis in Bariatric Surgery with Continuous Infusion of Cefazolin: Determination of Concentration in Adipose Tissue. Obes Surg 2014; 24:1487-91. [DOI: 10.1007/s11695-014-1231-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Hansen E, Belden K, Silibovsky R, Vogt M, Arnold WV, Bicanic G, Bini SA, Catani F, Chen J, Ghazavi MT, Godefroy KM, Holham P, Hosseinzadeh H, Kim KII, Kirketerp-Møller K, Lidgren L, Lin JH, Lonner JH, Moore CC, Papagelopoulos P, Poultsides L, Randall RL, Roslund B, Saleh K, Salmon JV, Schwarz EM, Stuyck J, Dahl AW, Yamada K. Perioperative antibiotics. J Arthroplasty 2014; 29:29-48. [PMID: 24355256 DOI: 10.1016/j.arth.2013.09.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Erik Hansen
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Katherine Belden
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Randi Silibovsky
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Markus Vogt
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - William V Arnold
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Goran Bicanic
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Stefano A Bini
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Fabio Catani
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jiying Chen
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mohammad T Ghazavi
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karine M Godefroy
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Paul Holham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Hamid Hosseinzadeh
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kang I I Kim
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Lars Lidgren
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jian Hao Lin
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jess H Lonner
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christopher C Moore
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Lazaros Poultsides
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - R Lor Randall
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Brian Roslund
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Khalid Saleh
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Julia V Salmon
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Edward M Schwarz
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jose Stuyck
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Annette W Dahl
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Koji Yamada
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Hansen E, Belden K, Silibovsky R, Vogt M, Arnold W, Bicanic G, Bini S, Catani F, Chen J, Ghazavi M, Godefroy KM, Holham P, Hosseinzadeh H, Kim KII, Kirketerp-Møller K, Lidgren L, Lin JH, Lonner JH, Moore CC, Papagelopoulos P, Poultsides L, Randall RL, Roslund B, Saleh K, Salmon JV, Schwarz E, Stuyck J, Dahl AW, Yamada K. Perioperative antibiotics. J Orthop Res 2014; 32 Suppl 1:S31-59. [PMID: 24464896 DOI: 10.1002/jor.22549] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Stitely M, Sweet M, Slain D, Alons L, Holls W, Hochberg C, Briggs F. Plasma and Tissue Cefazolin Concentrations in Obese Patients Undergoing Cesarean Delivery and Receiving Differing Pre-Operative Doses of Drug. Surg Infect (Larchmt) 2013; 14:455-9. [PMID: 23859672 DOI: 10.1089/sur.2012.040] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael Stitely
- Department of Women's and Children's Health, University of Otago, Dunedin School of Medicine, Dunedin, New Zealand
| | - Michael Sweet
- Center for Quality Outcomes, West Virginia University, Morgantown, West Virginia
| | - Douglas Slain
- Departments of Clinical Pharmacy and Infectious Diseases, Schools of Pharmacy and Medicine, West Virginia University, Morgantown, West Virginia
| | - Lindsy Alons
- Department of Obstetrics and Gynecology, School of Medicine, West Virginia University, Morgantown, West Virginia
| | - William Holls
- Department of Obstetrics and Gynecology, School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Charles Hochberg
- Department of Obstetrics and Gynecology, School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Frank Briggs
- Center for Quality Outcomes, West Virginia University, Morgantown, West Virginia
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