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Iguidbashian J, Feng Z, Colborn KL, Barrett CS, Newman SR, Harris M, Campbell DN, Mitchell MB, Jaggers J, Stone ML. Open Chest Duration Following Congenital Cardiac Surgery Increases Risk for Surgical Site Infection. Pediatr Cardiol 2024; 45:1284-1288. [PMID: 36583758 DOI: 10.1007/s00246-022-03088-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
Surgical site infections (SSI) following congenital heart surgery (CHS) remain a significant source of morbidity. Delayed sternal closure (DSC) is often required to minimize the potential for hemodynamic instability. The purpose of this study was to determine the incidence of SSI among patients undergoing DSC versus primary chest closure (PCC) and to define a potential inflection point for increased risk of SSI as a function of open chest duration (OCD).A retrospective review of our institutional Society of Thoracic Surgeons dataset is to identify patients undergoing CHS at our institution between 2015 and 2020. Incidences of SSI were compared between DSC and PCC patients. DSC patients were evaluated to determine the association of OCD and the incidence of SSI.2582 operations were performed at our institution between 2015 and 2020, including 195 DSC and 2387 PCC cases. The incidence of SSI within the cohort was 1.8% (47/2,582). DSC patients had significantly higher incidences of SSI (17/195, 8.7%) than PCC patients (30/2387, 1.3%, p < 0.001). Further, patients with an OCD of four or more days had a significantly higher incidence of SSI (11/62, 17.7%, p = 0.006) than patients with an OCD less than 4 days (6/115, 5.3%).The incidence of SSI following CHS is higher in DSC patients compared to PCC patients. Prolonged OCD of 4 days or more significantly increases the risk of SSI and represents a potentially modifiable risk factor for SSI predisposition. These data support dedicated, daily post-operative assessment of candidacy for chest closure to minimize the risk of SSI.
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Affiliation(s)
- John Iguidbashian
- Department of Surgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA.
| | - Zihan Feng
- Department of Surgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado School of Medicine, 12605 E 16th Ave, Aurora, CO, 80045, USA
| | - Cindy S Barrett
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Shanna R Newman
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Marisa Harris
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - David N Campbell
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Max B Mitchell
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - James Jaggers
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
| | - Matthew L Stone
- Department of Cardiology and Cardiothoracic Surgery, Children's Hospital of Colorado, Aurora, CO, USA
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Surendran S, Nampoothiri V, Dhar P, Holmes A, Singh S, Charani E. Rationalizing irrational prescribing-infection-related attitudes and practices across paediatric surgery specialties in a hospital in South India. JAC Antimicrob Resist 2024; 6:dlae105. [PMID: 39005590 PMCID: PMC11245696 DOI: 10.1093/jacamr/dlae105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/18/2024] [Indexed: 07/16/2024] Open
Abstract
Background and objectives Antibiotic use in paediatric surgical specialties is understudied. We investigated the antibiotic prescribing practices of paediatric general and cardiovascular surgical teams in a tertiary hospital in South India. Methods Mixed-methods study including observations from ward rounds, semi-structured interviews, and review of antibiotic prescribing. Field notes from observations and interview transcripts were coded using NVivo and thematically analysed. Data collection and analysis were iterative and continued until thematic saturation. Quantitative data were analysed using descriptive statistics. Results Data included 62 h of observation, 24 interviews, one case study and 200 patient chart reviews (100/specialty). Senior surgeons make key decisions, referring to their own experience when prescribing antibiotics. Being outcome-driven, the doctors often prescribe antibiotics at the earliest indication of infection with a reluctance to de-escalate, even when an infection is not diagnosed. This practice is more acute among surgeons who consider themselves responsible for their patients' health and attribute the consistently low surgical site infection rates to this practice.In general surgery, 83.3% (80/96; 4 lost to follow-up) of patients were prescribed antibiotics for the duration of their stay with oral antibiotics prescribed at discharge. The surgeons use antibiotics prophylactically for patients who may be vulnerable to infection. The antimicrobial stewardship team was considered to have limited influence in the decision-making process. Conclusions Outcome-driven decision-making in surgery leads to overprescription of antibiotics and prolonged surgical prophylaxis. The rationale for suboptimal practices is complicated by the surgeons' beliefs about the contextual determinants of health in India.
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Affiliation(s)
- Surya Surendran
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala, India
- Health System and Equity, The George Institute for Global Health, New Delhi, India
| | - Vrinda Nampoothiri
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala, India
| | - Puneet Dhar
- Surgical Gastroenterology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Faridabad, India
| | - Alison Holmes
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Sanjeev Singh
- Department of Medical Admin, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Faridabad, India
| | - Esmita Charani
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Montoya AM, Roncancio GE, Franco L, López L, Vargas AR, Suárez S, Garcés CG, Guzmán M, Vanegas JM. Preventive strategies in paediatric cardiovascular surgery: impact on surgical site infections and beyond. J Hosp Infect 2024; 150:114-124. [PMID: 38740302 DOI: 10.1016/j.jhin.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/22/2024] [Accepted: 05/05/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Surgical management of congenital heart disease (CHD) has increased worldwide, but healthcare-associated infections (HAIs) can threaten these efforts. AIM To analyse the incidence of HAI, the impact of preventive interventions, and microbiological profiles in a paediatric cardiovascular surgery programme. METHODS Cohort study including children aged <12 years with CHD who underwent cardiovascular surgery between 2010 and 2021 in Medellín, Colombia (a middle-income setting). Data were collected from medical and laboratory records and infection control programme databases. Impact of various preventive interventions was assessed using a Poisson model. P < 0.05 was considered statistically significant. FINDINGS A total of 2512 surgeries were analysed. Incidence of surgical site infection (SSI) was 5.9%, followed by central line-associated bloodstream infection (CLABSI; 4.7%), catheter-associated urinary tract infection (CAUTI; 2.2%), and ventilator-associated pneumonia (VAP; 1.4%). Most of the strategies focused on preventing SSI, resulting in a reduction from 9.5% in 2010 to 3.0% in 2021 (P = 0.030). Antibiotic prophylaxis based on patient weight and continuous infusion had an impact on reducing SSI (RR: 0.56; 95% CI: 0.32-0.99). Vacuum-assisted closure (VAC) in clean wounds reduced 100% of infections. No significant risk reduction was observed for other HAI with the implemented interventions. CONCLUSION Preventive strategies effectively reduced SSI but no other infections, emphasizing the need for targeted approaches to address a broader spectrum of HAI successfully.
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Affiliation(s)
- A M Montoya
- Department of Microbiology, Clínica Cardio VID, Medellín, Colombia
| | - G E Roncancio
- Department of Infectious Diseases, Clínica Cardio VID, Medellín, Colombia
| | - L Franco
- Department of Microbiology, Clínica Cardio VID, Medellín, Colombia
| | - L López
- School of Health Sciences, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - A R Vargas
- Department of Epidemiology, Clínica Cardio VID, Medellín, Colombia
| | - S Suárez
- Department of Cardiovascular Surgery, Clínica Cardio VID, Medellín, Colombia
| | - C G Garcés
- Department of Paediatrics, Clínica Cardio VID, Medellín, Colombia
| | - M Guzmán
- Department of Paediatrics, Clínica Cardio VID, Medellín, Colombia
| | - J M Vanegas
- School of Health Sciences, Universidad Pontificia Bolivariana, Medellín, Colombia.
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Gebreyesus MS, Dresner A, Wiesner L, Coetzee E, Verschuuren T, Wasmann R, Denti P. Dose optimization of cefazolin in South African children undergoing cardiac surgery with cardiopulmonary bypass. CPT Pharmacometrics Syst Pharmacol 2024. [PMID: 38962872 DOI: 10.1002/psp4.13196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 05/27/2024] [Accepted: 06/18/2024] [Indexed: 07/05/2024] Open
Abstract
Cefazolin is an antibiotic used to prevent surgical site infections. During cardiac surgery with cardiopulmonary bypass (CPB), its efficacy target could be underachieved. We aimed to develop a population pharmacokinetic model for cefazolin in children and optimize the prophylactic dosing regimen. Children under 25 kg undergoing cardiac surgery with CPB and receiving cefazolin at standard doses (50 mg/kg IV every 4-6 h) were included in this analysis. A population pharmacokinetic model and Monte Carlo simulations were used to evaluate the probability of target attainment (PTA) for efficacy and toxicity with the standard regimen and an alternative regimen of continuous infusion, where loading and maintenance doses were calculated from model-derived individual parameters. Twenty-two patients were included, with median (range) age, body weight, and eGFR of 19.5 (1-94) months, 8.7 (2-21) kg, and 116 (48-159) mL/min, respectively. Six patients received an additional dose in the CPB circuit. A two-compartment disposition model with an additional compartment for the CPB was developed, including weight-based allometric scaling and eGFR. For a 10 kg patient with eGFR of 120 mL/min/1.73 m2, clearance was estimated as 0.856 L/h. Simulations indicated that the standard dosing regimen fell short of achieving the efficacy target >40% of the time within a dosing duration and in patients with good renal function, PTA ranged from <20% to 70% for the smallest to the largest patients, respectively, at high MICs. In contrast, the alternative regimen consistently maintained target concentrations throughout the procedure for all patients while using a lower overall dose.
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Affiliation(s)
- Manna Semere Gebreyesus
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Alexandra Dresner
- Department of Anesthesia and Perioperative Medicine, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ettienne Coetzee
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Tess Verschuuren
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Roeland Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Pathan SR, Bhende VV, Sharma TS, Kumar A, Patel VA, Sharma KB, Pandya SB. Antibiotic Utilization and Prophylaxis in Paediatric Cardiac Surgery: A Retrospective Observational Study at a Rural Tertiary Care Hospital in India. Cureus 2023; 15:e45107. [PMID: 37842391 PMCID: PMC10569353 DOI: 10.7759/cureus.45107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction Antimicrobial prophylaxis, involving short antibiotic courses preceding surgical procedures, is recommended to minimize postoperative infections. Paediatric cardiac surgeries are classified as clean procedures, though infection challenges persist due to illness severity and extended ICU stays. Antimicrobial prophylaxis varies, ranging from single doses to extended administration until catheters are removed. Typically lasting 24 to 48 hours, it has proven infection-reduction benefits. Despite these practices, uncertainties surround the optimal nature, timing, and duration of administration. This concern is amplified by escalating antimicrobial resistance driven by antibiotic overuse. Vulnerable paediatric populations bear heightened consequences of irrational antimicrobial use, contributing to global resistance trends. Yet, a defined optimal prophylaxis schedule for paediatric cardiac surgery is lacking. Importing adult guidelines may be inadequate due to paediatric research complexities and population diversity. Developing effective prophylaxis protocols is crucial for children undergoing cardiac surgery, given global antibiotic overuse and evolving drug resistance. Establishing an optimal prophylactic strategy remains a challenge, necessitating further research for evidence-based protocols to mitigate infections in this vulnerable patient cohort. Methods This study investigates antibiotic use in paediatric cardiac surgery. A retrospective analysis of 100 patients from a rural Indian hospital (2017-2018) assesses antibiotic patterns, including type, dose, duration, and adherence to prophylaxis protocols. Results In the studied cohort of paediatric cardiac surgery patients, complete compliance (100%) with antibiotic prophylaxis was observed. However, deviations were identified: 30% received antibiotics prematurely, and 30% did not align with institutional protocol criteria. Concerning antibiotic selection, 87% followed hospital policy with the recommended cefoperazone and sulbactam combination plus amikacin, while 9% received piperacillin/tazobactam + amikacin due to sepsis. Irregular use (22%) based on clinical records occurred. Furthermore, 4% received piperacillin/tazobactam + teicoplanin, with one instance of inappropriate higher antibiotic use. Regarding prophylaxis duration, only 27% adhered to the appropriate timeline, with 40% exceeding 48 hours, indicating extended use. Upon discharge, a notable proportion (45 patients) received antibiotic prescriptions. Among them, 73% were prescribed rationally, while 27% exhibited irrational antibiotic use. Conclusion The findings of this study shed a significant light on the issue of antibiotic misuse within the context of paediatric cardiac surgery. It underscores the pressing need for more stringent measures to regulate and address this concerning trend. The study underscores the pivotal importance of adhering rigorously to established protocols and guidelines for antibiotic prophylaxis. This adherence not only holds the potential to elevate the overall quality of patient care but also plays a critical role in combating the escalating challenge of antibiotic resistance. Through a concerted effort to optimize antibiotic usage, we can simultaneously enhance patient outcomes and contribute to the ongoing fight against the emergence of antibiotic-resistant strains, thus preserving the efficacy of these vital medications for future generations.
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Affiliation(s)
- Sohilkhan R Pathan
- Clinical Research Services (CRS), Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| | - Vishal V Bhende
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| | - Tanishq S Sharma
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| | - Amit Kumar
- Pediatric Cardiac Intensive Care, Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| | - Vishal A Patel
- Clinical Research Services (CRS), Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| | - Kruti B Sharma
- Clinical Research Services (CRS), Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| | - Shivangi B Pandya
- Clinical Research Services (CRS), Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
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Glenn ET, Harman JR, Marietta J, Lake J, Bailly DK, Ou Z, Griffiths ER, Ware AL. Impact of a Surgical Wound Infection Prevention Bundle in Pediatric Cardiothoracic Surgery. Ann Thorac Surg 2023; 115:126-134. [PMID: 36126719 DOI: 10.1016/j.athoracsur.2022.08.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/26/2022] [Accepted: 08/29/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this project was to decrease the incidence of surgical wound infection (SWI) to <1.5% in our pediatric cardiothoracic surgery patients using a prevention bundle and quality improvement process. METHODS An SWI prevention bundle addressing preoperative, intraoperative, and postoperative risks was implemented. The primary outcome was SWI based on Society of Thoracic Surgeons criteria (superficial, deep, or mediastinitis). Novel aspects of the bundle included standardization of surgical closure and wound coverage for 14 days with a negative pressure dressing or a silicone dressing. Data were collected from January 2017 to November 2021; bundle intervention began in December 2019. SWIs were tracked using a g-chart. Preintervention and postintervention cohorts were compared by standard descriptive statistics. There were no changes in SWI tracking methods during the study. RESULTS During the study, 1159 individuals underwent 1768 surgical interventions. Preintervention (n = 931) and postintervention (n = 837) groups were clinically similar, with fewer neonatal surgeries in the postintervention group. SWI decreased in all patients (preintervention period: 1 SWI per 22 surgeries; postintervention period: 1 SWI per 62.6 surgeries) and in neonates (preintervention period: 1 SWI per 12 surgeries; postintervention period: 1 SWI per 26.7 surgeries). Special cause variation was achieved in the entire cohort by March 2021 and in neonates by April 2021. Decreases in SWI occurred in superficial and deep wounds but not in mediastinitis. Annual rate of total SWIs decreased from 2.83% in 2019 to 1.15% in 2021. Intensive care unit and hospital length of stay did not change. CONCLUSIONS We demonstrated a reduction in SWI rates after implementing an SWI prevention bundle including standardized surgical closure and prolonged wound protection.
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Affiliation(s)
- Emilee T Glenn
- Heart Center, Intermountain Primary Children's Hospital, Salt Lake City, Utah.
| | - Jeremy R Harman
- Heart Center, Intermountain Primary Children's Hospital, Salt Lake City, Utah
| | - Jennifer Marietta
- Heart Center, Intermountain Primary Children's Hospital, Salt Lake City, Utah
| | - Jason Lake
- Division of Pediatric Infectious Disease, University of Utah, Salt Lake City, Utah
| | - David K Bailly
- Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Eric R Griffiths
- Division of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Adam L Ware
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, Utah
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Perioperative Antibiotic Prophylaxis in Pediatric Cardiac Surgery-Simple Is Better. Antibiotics (Basel) 2022; 12:antibiotics12010066. [PMID: 36671267 PMCID: PMC9854416 DOI: 10.3390/antibiotics12010066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/20/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022] Open
Abstract
Pediatric cardiac surgery requires perioperative antibiotic prophylaxis (PAP) to reduce the risk of surgical site infections. However, the complexity of these procedures and the metabolic immaturity of children impede the establishment of PAP regimens that are both efficacious and in line with antimicrobial stewardship (AMS). In this study, we compared two PAP regimens: cefazolin with gentamicin (in a retrospective group) and cefazolin only (prospectively) in children undergoing elective cardiac surgery. In the prospective group, additional elements of AMS were introduced, i.e., restricted access to cefazolin and more diligent use of empirical antibiotics proceeded by consultation with an AMS team. The rate of surgical site infections (SSI), the scope of PAP deviations, and the postoperative use of antibiotics other than PAP within 30 days after surgery were analyzed. There were no significant differences in the rate of SSIs between the groups (3.9% vs. 1.2% in the prospective and retrospective groups, respectively (p = 0.35)). However, in the prospective group, the PAP violation was significantly reduced compared with the retrospective group (full compliance with the PAP regimen was 45.5% vs. 4.8%, p < 0.001, respectively). In addition, a reduction of postoperative antibiotic use was observed in the prospective group (0.991 vs. 1.932 defined daily doses, respectively).
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de Arriba-Fernández A, Molina-Cabrillana J, Serra-Majem L, García-de Carlos P. Assessment of the surgical site infection in colon surgery and antibiotic prophylaxis adequacy: a multi-center incidence study. Cir Esp 2022; 100:718-724. [PMID: 35853568 DOI: 10.1016/j.cireng.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/19/2021] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Surgically site infections (SSIs) are a major problem that limits the benefits of surgical interventions. The cumulative incidence of SSIs in colon surgery and compliance with antibiotic prophylaxis as well as the causes of non-compliance were evaluated. METHODS Multi-centre prospective surveillance study between 2012 and 2019 in seven hospitals of the Canary Health Service using an active epidemiological surveillance system. SSIs was defined according to the criteria of the Centers for Disease Control and Prevention. RESULTS In 2019, the cumulative incidence of SSIs was 10.6% (n = 80), which implies maintaining the downward trend since 2012. The appearance of SSIs was more frequent during admission (76%). Surgical prophylaxis was adequate in 81.2%, the main causes of inadequacy being the excessive duration of the antimicrobial prescription (49%) and failure in the indication (33%). The incidence was higher in the group of organ-space infections (53.75% of the total) compared to superficial and deep infections. CONCLUTION The cumulative incidence of SSIs obtained is similar to that calculated in other studies carried out under similar conditions. Preoperative chemoprophylaxis was adequate in most of the interventions.
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Affiliation(s)
- Alejandro de Arriba-Fernández
- Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain; Complejo Hospitalario Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain.
| | - Jesús Molina-Cabrillana
- Complejo Hospitalario Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Lluís Serra-Majem
- Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain; Complejo Hospitalario Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Jaworski R, Dzierzanowska-Fangrat K, Grzywa-Czuba R, Kansy A. Postoperative kinetics of pentraxin 3 (PTX3) after congenital heart surgery with cardiopulmonary bypass in pediatric patients. Perioper Med (Lond) 2022; 11:35. [PMID: 35989325 PMCID: PMC9394006 DOI: 10.1186/s13741-022-00269-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pentraxins are inflammatory proteins and markers of acute-phase responses. They are divided into short and long subgroups based on the length of the N-terminal region. The most studied short pentraxin is the C-reactive protein (CRP), which is known to be expressed in various inflammatory conditions, including surgical procedures. On the other hand, much less is known about the kinetics of long pentraxin 3 (PTX3) in surgical patients, especially in the pediatric population.
The aim of this prospective study was to determine the early postoperative kinetics of PTX3 in relation to procalcitonin (PCT) and CRP levels in children undergoing congenital heart surgery with cardiopulmonary bypass (CPB).
Methods
A total of 21 children (9 boys and 12 girls, mean age 12 months) were included in the study. Blood samples for determination of CRP, PCT, and PTX3 levels were collected before the surgery and then immediately after its completion (postoperative day 0, POD 0) and subsequently at POD 1, 2, and 3.
Results
Serum PTX3 concentrations increased significantly between POD 0 and POD 1 (mean values were 12.2 and 72.4 ng/ml, respectively, p<0.001), decreased between POD 1 and POD 2 (mean values were 72.4 and 23.6 ng/ml, respectively, p<0.001), and normalized on POD 3 (the mean value was 1.2 ng/ml).
Conclusions
PTX3 concentrations are markedly elevated during the first postoperative day. Under normal circumstances, PTX3 rises and falls quickly, and its second rise in the early postoperative period may be abnormal, however, further studies are necessary.
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10
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Nthumba PM, Huang Y, Perdikis G, Kranzer K. Surgical Antibiotic Prophylaxis in Children Undergoing Surgery: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2022; 23:501-515. [PMID: 35834578 DOI: 10.1089/sur.2022.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: To establish the role of surgical antibiotic prophylaxis (SAP) in the prevention of surgical site infection (SSI) in children undergoing surgery. Design: A systematic review and meta-analysis of six databases: MEDLINE (PubMed), EMBASE, CINAHL Plus, Cochrane Library, Web of Science, and Scopus. Study Selection: Included studies (irrespective of design) compared outcomes in children undergoing surgery, aged 0 to 21 years who received SAP with those who did not, with SSI as an outcome, using the U.S. Centers for Disease Control and Prevention (CDC) definitions for SSI. Data Extraction: Two independent reviewers applied eligibility criteria, assessed the risk of bias, and extracted data. Results: A total of six randomized control trials and 26 observational studies including 202,593 surgical procedures among 202,405 participants were included in the review. The pooled odds ratio of SSI was 1.20; (95% confidence interval [CI], 0.91-1.58) comparing those receiving SAP with those not receiving SAP, with moderate heterogeneity in effect size between studies (τ2 = 0.246; χ2 = 69.75; p < 0.001; I2 = 57.0%). There was insufficient data on many factors known to be associated with SSI, such as cost, length of stay, re-admission, and re-operation; it was therefore not possible to perform subanalyses on these. Conclusions: This review and metanalysis did not find a preventive action of SAP against SSI, and our results suggest that SAP should not be used in surgical wound class (SWC) I procedures in children. However, considering the poor quality of included studies, the principal message of this study is in highlighting the absence of quality data to drive evidence-based decision-making in SSI prevention in children, and in advocating for more research in this field.
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Affiliation(s)
- Peter M Nthumba
- Department of Plastic Surgery, AIC Kijabe Hospital, Kenya.,Department of Plastic Surgery, Vanderbilt Medical University Center, Nashville, Tennesse, USA
| | - Yongxu Huang
- Department of Plastic Surgery, Vanderbilt Medical University Center, Nashville, Tennesse, USA
| | - Galen Perdikis
- Department of Plastic Surgery, Vanderbilt Medical University Center, Nashville, Tennesse, USA
| | - Katharina Kranzer
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Biomedical Research and Training Institute, Harare, Zimbabwe.,Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich, Munich, Germany
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11
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Peri-Operative Prophylaxis in Patients of Neonatal and Pediatric Age Subjected to Cardiac and Thoracic Surgery: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:antibiotics11050554. [PMID: 35625198 PMCID: PMC9137830 DOI: 10.3390/antibiotics11050554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023] Open
Abstract
Surgical site infections (SSIs) represent a potential complication of surgical procedures, with a significant impact on mortality, morbidity, and healthcare costs. Patients undergoing cardiac surgery and thoracic surgery are often considered patients at high risk of developing SSIs. This consensus document aims to provide information on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing cardiac and non-cardiac thoracic surgery. The following scenarios were considered: (1) cardiac surgery for the correction of congenital heart disease and/or valve surgery; (2) cardiac catheterization without the placement of prosthetic material; (3) cardiac catheterization with the placement of prosthetic material; (4) implantable cardiac defibrillator or epicardial pacemaker placement; (5) patients undergoing ExtraCorporal Membrane Oxygenation; (6) cardiac tumors and heart transplantation; (7) non-cardiac thoracic surgery with thoracotomy; (8) non-cardiac thoracic surgery using video-assisted thoracoscopy; (9) elective chest drain placement in the pediatric patient; (10) elective chest drain placement in the newborn; (11) thoracic drain placement in the trauma setting. This consensus provides clear and shared indications, representing the most complete and up-to-date collection of practice recommendations in pediatric cardiac and thoracic surgery, in order to guide physicians in the management of the patient, standardizing approaches and avoiding the abuse and misuse of antibiotics.
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Suna J, Moloney G, Marathe SP, Bierbach B, Roberts JA, Parker S, Ungerer JPJ, Mcwhinney B, Dorofaeff T, Venugopal P, Alphonso N. Perioperative cefazolin prophylaxis in paediatric cardiac surgery: a prospective, cohort study. Ann Thorac Surg 2022; 114:1434-1440. [PMID: 35292260 DOI: 10.1016/j.athoracsur.2022.02.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/31/2022] [Accepted: 02/09/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND This study's objective was to determine the effect of age, prolonged bypass, and hypothermia on serum cefazolin concentrations in children undergoing cardiac surgery. METHODS A prospective, single-centre, observational study was conducted. Children undergoing cardiac surgery were examined. Participants received cefazolin intravenously approximately 1 hour before skin incision, 3 hourly intraoperatively and 8 hourly postoperatively. Blood samples were collected at 6-8 timepoints intraoperatively and 6-time points in the first 24 hours postoperatively. Target unbound serum cefazolin concentrations were of 2 mg/L. RESULTS Sixty-eight patients were enrolled in the study, and 64 included in the analysis. All maintained concentrations ≥ 2 mg/L throughout the operation. Nineteen patients (30%) did not maintain concentrations ≥ 2 mg/L in the first 24 hours following surgery. Older, larger children (p < 0.0001) were significantly less likely to achieve target unbound serum cefazolin concentrations. CONCLUSIONS Intraoperative cefazolin concentrations reached the target concentration in all paediatric cardiac surgical cases. Postoperative cefazolin dosing appears insufficient to achieve minimum inhibitory concentrations in many patients.
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Affiliation(s)
- Jessica Suna
- Industry Fellow, University of Queensland, Brisbane, Australia; Deputy Director, Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, Australia.
| | - Gregory Moloney
- Senior Medical Officer, Department of Anaesthetics, Queensland Children's Hospital, Brisbane, Australia
| | - Supreet P Marathe
- Lecturer, University of Queensland Clinical School, Queensland Children's Hospital, University of Queensland, Brisbane, Australia; Senior Cardiac Surgery Fellow, Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
| | - Benjamin Bierbach
- Department of Paediatric Cardiac Surgery, University Hospital Bonn, Germany
| | - Jason A Roberts
- NHMRC Practitioner Fellow, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Consultant Pharmacist, Pharmacy Department and Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Scientific Consultant, Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
| | - Suzanne Parker
- NHMRC Early Career Research Fellow, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Jacobus P J Ungerer
- Director Chemical Pathology, Pathology Queensland, Queensland Health, Brisbane Australia; School of Biomedical Sciences, University of Queensland, Brisbane Australia
| | - Brett Mcwhinney
- Supervising Scientist, Pathology Queensland, Queensland Health, Brisbane Australia
| | - Tavey Dorofaeff
- Senior Lecturer, University of Queensland Clinical School Queensland Children's Hospital, University of Queensland, Brisbane, Australia; Senior Medical Officer, Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, Australia
| | - Prem Venugopal
- Senior Lecturer, University of Queensland Clinical School Queensland Children's Hospital, University of Queensland, Brisbane, Australia; Director of Cardiac Surgery, Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
| | - Nelson Alphonso
- Associate Professor, Child Health Research Centre, University of Queensland, Brisbane, Australia; Deputy Director of Cardiac Surgery, Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
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Jaworski R, Dzierzanowska-Fangrat K, Kansy A. Cefazolin prophylaxis in children undergoing cardiac surgery: neither too little nor too late. Eur J Cardiothorac Surg 2021; 62:6400287. [PMID: 34662381 DOI: 10.1093/ejcts/ezab451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 08/18/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Radoslaw Jaworski
- Department of Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Andrzej Kansy
- Department of Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
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Suna J, Alphonso N. Cefazolin prophylaxis in children undergoing cardiac surgery-is it too little too late? Eur J Cardiothorac Surg 2021; 61:34-35. [PMID: 34269388 DOI: 10.1093/ejcts/ezab327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jessica Suna
- Children's Centre for Health Research, University of Queensland, Brisbane, Australia.,Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, Australia.,Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
| | - Nelson Alphonso
- Children's Centre for Health Research, University of Queensland, Brisbane, Australia.,Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, Australia.,School of Clinical Medicine, Children's Health Queensland Clinical Unit, University of Queensland, Brisbane, Australia.,Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
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Jaworski R, Dzierzanowska-Fangrat K, Czajkowska A, Maruszewski B, Kansy A. Cefazolin prophylaxis in children undergoing cardiac surgery with the use of cardiopulmonary bypass-is the dosing correct? Eur J Cardiothorac Surg 2021; 61:27-33. [PMID: 34269390 DOI: 10.1093/ejcts/ezab251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To determine the recommended concentrations of cefazolin to be used for antibiotic prophylaxis during paediatric cardiac surgery with extracorporeal circulation (ECC). METHODS Twenty paediatric patients undergoing cardiac surgery with ECC and cefazolin antibiotic prophylaxis were included in the study. Blood samples for measurement of total cefazolin plasma concentration were collected at the following measurement time points: directly after skin incision, 15 min after ECC start, 5 min after ECC cessation and at skin closure. The target concentration was set for ≥40 mg/l, which corresponded to ≥8 mg/l of unbound cefazolin concentration. RESULTS The median total cefazolin plasma concentrations at the measurement time points were 62.8, 67.7, 45.8 and 34.2 mg/l, respectively, and target concentrations were achieved in 90%, 85%, 65% and 40% of children, respectively. Among patients who received ≥30 mg of cefazolin per 100 ml of ECC priming, target concentrations after ECC cessation were reached in 80% of patients, while in those with <30 mg cefazolin per 100 ml in 20% of patients (P = 0.031). CONCLUSIONS Direct extrapolation of antibiotic prophylaxis recommendations from adults to children may result in suboptimal antibiotic concentrations. An additional cefazolin dose to ECC priming appears necessary and the dosing should be based on ECC priming volume rather than on the weight of the patient.
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Affiliation(s)
- Radoslaw Jaworski
- Department of Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Agnieszka Czajkowska
- Department of Biochemistry, Radioimmunology and Experimental Medicine, Pharmacokinetics Laboratory, The Children's Memorial Health Institute, Warsaw, Poland
| | - Bohdan Maruszewski
- Department of Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | - Andrzej Kansy
- Department of Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
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de Arriba-Fernández A, Molina-Cabrillana J, Serra-Majem L, García-de Carlos P. Assessment of the surgical site infection in colon surgery and antibiotic prophylaxis adequacy: A multi-center incidence study. Cir Esp 2021; 100:S0009-739X(21)00206-2. [PMID: 34167798 DOI: 10.1016/j.ciresp.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/07/2021] [Accepted: 05/19/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Surgically site infections (SSIs) are a major problem that limits the benefits of surgical interventions. The cumulative incidence of SSIs in colon surgery and compliance with antibiotic prophylaxis as well as the causes of non-compliance were evaluated. METHODS Multi-centre prospective surveillance study between 2012 and 2019 in seven hospitals of the Canary Health Service using an active epidemiological surveillance system. SSIs was defined according to the criteria of the Centers for Disease Control and Prevention. RESULTS In 2019, the cumulative incidence of SSIs was 10.6% (n=80), which implies maintaining the downward trend since 2012. The appearance of SSIs was more frequent during admission (76%). Surgical prophylaxis was adequate in 81.2%, the main causes of inadequacy being the excessive duration of the antimicrobial prescription (49%) and failure in the indication (33%). The incidence was higher in the group of organ-space infections (53.75% of the total) compared to superficial and deep infections. CONCLUSION The cumulative incidence of SSIs obtained is similar to that calculated in other studies carried out under similar conditions. Preoperative chemoprophylaxis was adequate in most of the interventions.
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Affiliation(s)
- Alejandro de Arriba-Fernández
- Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España; Complejo Hospitalario Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, España.
| | - Jesús Molina-Cabrillana
- Complejo Hospitalario Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, España
| | - Lluís Serra-Majem
- Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, España; Complejo Hospitalario Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, España
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Brocard E, Reveiz L, Régnaux JP, Abdala V, Ramón-Pardo P, Del Rio Bueno A. Antibiotic prophylaxis for surgical procedures: a scoping review. Rev Panam Salud Publica 2021; 45:e62. [PMID: 34054932 PMCID: PMC8147733 DOI: 10.26633/rpsp.2021.62] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/12/2021] [Indexed: 12/16/2022] Open
Abstract
Objectives To map the current evidence on surgical antibiotic prophylaxis (SAP) administration and identify knowledge gaps in the literature available in this field. Methods The PubMed, Cochrane Library, Epistemonikos, and Health Systems Evidence databases were searched from January 2015 to March 2020 for systematic reviews published in English, French, Portuguese, and Spanish. Results Eighty-three systematic reviews were included, the quality of the reviews was assessed using AMSTAR 2, and data were extracted for all primary outcomes. Perioperative antibiotic administration, the use of first generation cephalosporins, and surgical site infection (SSI) were the most commonly reported for timing of antibiotic administration, drug class, and primary outcome, respectively. Findings showed that, overall, SAP may reduce SSIs compared with a placebo or with no SAP. Results suggested that intraoperative SAP may lower SSI, while postoperative SAP did not show a statistically significant difference. Conclusions Findings have confirmed the role of SAP in reducing postoperative SSI across various surgeries and do not support the use of antibiotics after surgery to prevent infections. The findings of this scoping review have enhanced the evidence base that can inform decisions regarding the development of global guidelines for the prevention of SSI. However, high-quality systematic reviews and research reflecting diverse populations and settings are needed.
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Affiliation(s)
- Eva Brocard
- Ecole des Hautes Etudes en Santé Publique (EHESP) Rennes France Ecole des Hautes Etudes en Santé Publique (EHESP), Rennes, France.,Pan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America
| | - Ludovic Reveiz
- Pan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America
| | - Jean-Philippe Régnaux
- Ecole des Hautes Etudes en Santé Publique (EHESP) Rennes France Ecole des Hautes Etudes en Santé Publique (EHESP), Rennes, France
| | - Veronica Abdala
- Pan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America
| | - Pilar Ramón-Pardo
- Pan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America
| | - Ana Del Rio Bueno
- Pan American Health Organization Washington, D.C. United States of America Pan American Health Organization, Washington, D.C., United States of America
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Abstract
A Fontan circulation requires a series of three-staged operations aimed to palliate patients with single-ventricle CHD. Currently, the most frequent technique is the extracardiac total cavopulmonary connection, an external conduit connecting the IVC and right pulmonary artery, bypassing the right side of the heart. Fontan candidates must meet strict criteria; they are assessed utilising both cardiac catheterisation and cardiac magnetic resonance. Postoperatively, treatment protocols prioritise antibiotic prophylaxis, diuretics, angiotensin-converting enzyme inhibitors, anticoagulation, and oxygen therapy with fluid restriction and a low-fat diet. These measures aim to reduce length of stay in the ICU and hospital by preventing acute complications such as infection, venous thromboembolism, low cardiac output, pleural effusion, and acute kidney injury. Late complications of a Fontan procedure include circulation failure, protein-losing enteropathy, plastic bronchitis, and Fontan-associated liver disease. The definitive management is cardiac transplantation, with promising innovations in selective embolisation of lymphatic vessels and Fontan-specific ventricular assist devices. Further research assessing current protocols in the perioperative management of Fontan patients would be beneficial for standardising current practice and improving outcomes.
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Ferrari F, Benegni S, Marinari E, Haiberger R, Garisto C, Rizza A, Giorni C, Quattrone MG, Arpicco S, Muntoni E, Milla P, Ricci Z. Vancomycin concentrations during cardiopulmonary bypass in pediatric cardiac surgery: a prospective study. Perfusion 2021; 37:553-561. [PMID: 33789546 DOI: 10.1177/02676591211006828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Few data are available regarding intraoperative plasma concentrations of vancomycin administered as prophylaxis in pediatric cardiac surgery. The aims of this study were to investigate during pediatric cardiac surgery with cardiopulmonary bypass(CPB) the attainment of the area-under-the-curve of the vancomycin serum concentrations versus time over surgery to minimum inhibitory concentration ratio(AUCintra/MIC) of 400 (mg × h)/l and/or a target concentration of 15-20 mg/l. METHODS In a prospective study, 40 patients divided into four subgroups (neonates, infants, children <10 years-old, ⩾10 years-old) undergoing cardiac surgery with cardiopulmonary bypass (CPB) were enrolled. A slow vancomycin bolus of 20 mg/kg, up to a maximum dose of 1000 mg was administered before skin incision and a further dose of 10 mg/kg (up to 500 mg) at CPB start. Vancomycin samples were collected intraoperatively at four time points. RESULTS The median (interquartile range) age was 241.5 days (47-3898) and the median weight was 7.1 kg (3.1-37). The median AUCintra/MIC was 254.73 (165.89-508.06). In 11 patients the AUCintra/MIC target was not reached. Neonates displayed the lowest AUCintra/MIC values, and these were significantly lower than those of children ⩾10 years old (p = 0.02). Vancomycin concentrations were above the maximal target of 20 mg/l in 82.5% and 80% of patients at surgery and CPB start, respectively. At CPB and surgery end, 42.5% of patients showed vancomycin concentrations above 20 mg/l and 42.5% below 15 mg/l. Patients⩾10 years old showed the highest peak values whereas neonates were those with the lowest troughs. AUCintra/MIC correlated with age(r:0.36, p = 0.02), weight(r:0.35, p = 0.03), intraoperative protein value(r:0.40, p = 0.01), CPB priming volume/kg(r:-0.33, p = 0.04), CPB duration(r:0.36, p = 0.02) and vancomycin troughs(r:0.35, p = 0.04). CONCLUSIONS An AUCintra/MIC ⩾400 target was not reached in one-quarter of children undergoing heart surgery. Vancomycin peaked before the start of surgery and neonates were those with the lowest troughs. Vancomycin concentrations are affected by CPB hemodilution and by patients' age and weight.
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Affiliation(s)
- Fiorenza Ferrari
- Intensive Care Unit, I.R.C.C.S. Fondazione Policlinico San Matteo, Pavia, Italy
| | - Simona Benegni
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Eleonora Marinari
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Roberta Haiberger
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Cristiana Garisto
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandra Rizza
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Chiara Giorni
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Silvia Arpicco
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Elisabetta Muntoni
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Paola Milla
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Zaccaria Ricci
- Azienda Ospedaliero Universitaria Meyer, Firenze, Italy.,Università di Firenze, Firenze, Italy
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Shah A, Sampathkumar P, Stevens RW, Bohman JK, Lahr BD, Dhungana P, Vashistha K, O’Horo JC. Reducing Broad-Spectrum Antimicrobial Use in Extracorporeal Membrane Oxygenation: Reduce AMMO Study. Clin Infect Dis 2021; 73:e988-e996. [DOI: 10.1093/cid/ciab118] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. There are currently no guidelines for antimicrobial prophylaxis. We analyzed 7 years of prophylactic antimicrobial use across 3 time series for patients on ECMO at our institution in the development, improvement, and streamlining of our ECMO antimicrobial prophylaxis protocol.
Methods
In this quasi-experimental interrupted time series analysis, we evaluated the impact of an initial ECMO antimicrobial prophylaxis protocol, implemented in 2014, on antimicrobial use and National Healthcare Safety Network–reportable infection rates. Then, following a revision and streamlining of the protocol in November 2018, we reevaluated the same metrics.
Results
Our study population included 338 intensive care unit patients who received ECMO between July 2011 and November 2019. After implementation of the first version of the protocol, we did not observe significant changes in antimicrobial use or infection rates in these patients; however, following revision and streamlining of the protocol, we demonstrated a significant reduction in broad-spectrum antimicrobial use for prophylaxis in patients on ECMO without any evidence of a compensatory increase in infection rates.
Conclusions
Our final protocol significantly reduces broad-spectrum antimicrobial use for prophylaxis in patients on ECMO. We propose a standard antimicrobial prophylaxis regimen for patients on ECMO based on current evidence and our experience.
Summary: There are no guidelines for antimicrobial prophylaxis in patients on extracorporeal membrane oxygenation (ECMO). A rational approach employing concepts of antimicrobial stewardship can drive logical antimicrobial selection for prophylaxis in patients on ECMO without adversely impacting outcomes.
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Affiliation(s)
- Aditya Shah
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Priya Sampathkumar
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan W Stevens
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota, USA
| | - John K Bohman
- Division of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Prabij Dhungana
- Division of Internal Medicine, Medstar Hospital, Baltimore, Maryland, USA
| | | | - John C O’Horo
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Khan FU, Fang Y, Khan Z, Khan FU, Malik ZI, Ahmed N, Khan AH, Rehman A. Occurrence, associated risk factors, and treatment of surgical site infections in Pakistan. EUR J INFLAMM 2020. [DOI: 10.1177/2058739220960547] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Globally, surgical site infections are one of the common infections which lead to a large amount of mortality and morbidity in postsurgical care. The risk for surgical site infection is multidimensional which includes mainly; patient, surgery, and hospital-related factors. This study is aimed to determine the burden of SSIs along with contributed risk factors. A prospective observational cross-sectional study was conducted in one of the largest public-sector hospitals in Pakistan. A total of 412 patients were recruited in the study with full consent and monitored for 30 days after surgery with direct and indirect surveillance. Overall, in seven different surgical procedures the incidence (29.8%) rate of SSI was observed; in appendectomy ( n = 17, 4.1%), exploratory laparotomy ( n = 51, 12.6%), laparoscopic cholecystectomy ( n = 12, 2.90%), mesh repair ( n = 17, 4.01%), thyroidectomy (5, 1.2%), transurethral resection of the prostate ( n = 11, 2.6%), and transurethral resection of the bladder (10, 2.4%). The average SSI rate in every single procedure was about 18 (4.27%) per surgical procedure out of 123 (29.85%) SSI cases. Types of SSI identified were superficial, deep incisional and organ/space ( n = 76, 18.4%, n = 23, 5.5%, and n = 24, 5.7%). Incidence of SSIs during admission, at readmission, and post-surveillance cases were ( n = 50, 12.1%, n = 25, 6.0% and n = 48, 11.6%). Associated risk factors found contributed to the incidence of SSI ( p < 0.05). Pre-operative ( n = 348, 84.5%) and 6 (1.5%) surgical patients did not received the post-operative antibiotics. The P. aeruginosa ( n = 15, 12.1%) and S. aureus (13, 10.5%). Cefoperazone and sulbactam were the most prescribed antibiotics. Associated risk factors and treatment outcomes of surgical patients have a direct association with the incidence of SSI. Hospital-based antimicrobial stewardship, implementation of surgical guidelines, patient care, and education are needed to develop at wards level in hospitals.
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Affiliation(s)
- Faiz Ullah Khan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Health Science Centre, Xi’an Jiaotong University, China
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Health Science Centre, Xi’an Jiaotong University, China
| | - Zakir Khan
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
- Department of Pharmacology, Institute of Health Sciences, Cukurova University, Adana, Turkey
| | - Farman Ullah Khan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Health Science Centre, Xi’an Jiaotong University, China
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Zafar Iqbal Malik
- Shaheed Zulfiqar Ali Bhutto Medical University, and General Surgical Wards, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | - Naveed Ahmed
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Amir Hayat Khan
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Minden Penang, Malaysia
| | - Asim.ur. Rehman
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
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22
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Yeo HJ, Kim D, Ha M, Je HG, Kim JS, Cho WH. Chlorhexidine bathing of the exposed circuits in extracorporeal membrane oxygenation: an uncontrolled before-and-after study. Crit Care 2020; 24:595. [PMID: 33023624 PMCID: PMC7538059 DOI: 10.1186/s13054-020-03310-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/24/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Although the prevention of extracorporeal membrane oxygenation (ECMO) catheter-related infection is crucial, scientific evidence regarding best practices are still lacking. METHODS We conducted an uncontrolled before-and-after study to test whether the introduction of disinfection with 2% chlorhexidine gluconate (CHG) and 70% isopropyl alcohol (IPA) of the exposed circuits and hub in patients treated with ECMO would affect the rate of blood stream infection (BSI) and microbial colonization of the ECMO catheter. We compared the microbiological and clinical data before and after the intervention. RESULTS A total of 1740 ECMO catheter days in 192 patients were studied. These were divided into 855 ECMO catheter days in 96 patients before and 885 ECMO catheter days in 96 patients during the intervention. The rates of BSI were significantly decreased during the intervention period at 11.7/1000 ECMO catheter days before vs. 2.3/1000 ECMO catheter days during (difference 9.4, 95% confidence interval (CI) 1.5-17.3, p = 0.019). Furthermore, the colonization of the ECMO catheter was similarly significantly reduced during the intervention period at 10.5/1000 ECMO catheter days before vs. 2.3/1000 ECMO catheter days during intervention (difference 8.3, 95% CI 0.7-15.8, p = 0.032). Hospital mortality (41.7% vs. 24%, p = 0.009) and sepsis-related death (17.7% vs. 6.3%, p = 0.014) were also significantly decreased during intervention. CONCLUSION Extensive disinfection of exposed ECMO circuits and hub with 2% CHG/IPA was associated with a reduction in both BSI and microbial colonization of ECMO catheters. A further randomized controlled study is required to verify these results. TRIAL REGISTRATION KCT 0004431.
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Affiliation(s)
- Hye Ju Yeo
- Department of Pulmonology and Critical Care Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Geumo-ro 20, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Republic of Korea
| | - Dohyung Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Mihyang Ha
- Interdisciplinary program of Genomic Science, Pusan National University, Yangsan-si, South Korea
| | - Hyung Gon Je
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Jeong Soo Kim
- Division of cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-si, South Korea
| | - Woo Hyun Cho
- Department of Pulmonology and Critical Care Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Geumo-ro 20, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Republic of Korea.
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Snyder E, Mohan C, Michael J, Ross S. Inclusion of surgical antibiotic regimens in pediatric urology publications: A systematic review. J Pediatr Urol 2020; 16:595.e1-595.e7. [PMID: 32641230 DOI: 10.1016/j.jpurol.2020.05.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/27/2020] [Accepted: 05/14/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Perioperative antibiotics prevent infections after surgery. Guidelines for antibiotic use allow the surgeon to balance the risks of adverse events and drug resistance with the benefit of reduced infection rates. However, due to a lack of evidence-based guidelines within pediatric urology, antibiotic practices vary widely. We performed a systematic literature review to investigate when and how authors report their antibiotic usage and infectious outcomes. Our aim was to analyze the available data on perioperative antibiotics and infection rates within pediatric urology. METHODS This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search strategy was devised to identify reports of pediatric urology surgery and use of antibiotics or infectious outcomes. Embase and Medline were queried with no year restrictions with subject heading terms to identify publications on common pediatric urology surgeries. The procedures studied were hypospadias repair, pyeloplasty, orchidopexy, ureteral reimplant, and circumcision. Two independent reviewers screened all titles and abstracts, followed by relevant full texts, for eligibility. Articles were included if the procedure was performed on the majority of study patients, the procedure was performed by urologic surgeons, and the population studied was a pediatric population defined as 0-18 years of age. Case reports, meta-analyses, and editorials were excluded. Data was extracted by one independent reviewer into a preformatted database. Collected data included journal type, date of publication, patient demographics, preoperative and postoperative antibiotic details including regimens, and infection outcomes. The primary outcome was reporting of antibiotic use preoperatively or postoperatively. Secondary outcomes included: reporting of infection, antibiotic class and dosage. Since all studies were diverse, only qualitative analysis was conducted. RESULTS We identified 1483 publications with 297 meeting inclusion criteria. Of these, 9% reported their use of preoperative antibiotics, and 34% reported their use of postoperative antibiotics. Only 6% of studies reported the specific antibiotic class, 15% reported duration, and 1% reported dosage and frequency. Infection outcomes were reported in 58% of studies. Only 57% of studies that reported on infection outcomes described their antibiotics practices. CONCLUSIONS Surgical antibiotic regimens and infection outcomes are infrequently included in pediatric urology studies, limiting the data available for development of evidence-based guidelines. Routine incorporation of antibiotic regimens, infection outcomes and adverse events in the pediatric urology literature will increase our ability to identify indications for antibiotics. Reporting of perioperative antibiotic outcomes in pediatric urology procedures will allow the eventual development of strong evidence-based guidelines.
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Affiliation(s)
- Elizabeth Snyder
- University of North Carolina (UNC) Department of Urology, 101 Manning Dr, Chapel Hill NC, 27514, United States.
| | | | | | - Sherry Ross
- UNC Department of Urology, North Carolina Children's Hospital, United States
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Targeted Multidrug Resistant Organism Antimicrobial Prophylaxis and Postoperative Infections in Pediatric Cardiothoracic Surgical Patients. Pediatr Infect Dis J 2020; 39:514-518. [PMID: 32084113 DOI: 10.1097/inf.0000000000002620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To determine if receiving targeted antimicrobial (AM) prophylaxis has an effect on the rate of postoperative infections in patient's colonized with a multidrug resistant organism (MDRO) undergoing cardiothoracic surgery (CTS). METHODS Single-center, retrospective medical record review of pediatric patients from birth to 18 years of age undergoing CTS from January 2013 to September 2018. Demographic data collected included age, specific MDRO, site of MDRO colonization, type of surgery, perioperative AM agent and type of infection. Patients were stratified into 2 groups, MDRO+ and MDRO-. Demographic and clinical characteristics were compared between groups with a Student's t test for continuous variables and a χ2, Fisher exact test or Mann-Whitney U test for noncontinuous variables. A 2-sided significance level of α = 0.05 was used to determine statistical significance. All analyses were performed using IBM SPSS Version 24 (SPSS Inc., Chicago, IL). RESULTS Fifty patients (26 males/24 females) were included in the MDRO (+) group and 295 patients (168 males/127 females) in the MDRO (-) group. The median age was 0.48 years (interquartile range 0.24-1 year) and 0.9 years (interquartile range 0.19-8 years) in the MDRO (+) and MDRO (-) groups, P = 0.003. 2 of 50 (4%) MDRO (+) patients and 15 of 295 (5.1 %) MDRO (-) patients developed an infection, P = 1. 10 of 50 (20%) MDRO (+) patients received targeted AM toward the MDRO and none developed an infection. Of the 2 MDRO (+) patients with infection, 1 was infected with the MDRO. For MDRO (+) patients, there was no difference in the rate of infection whether targeted AM therapy was received, P = 1. CONCLUSIONS There was no difference in the rate of postoperative infection between MDRO (+) and MDRO (-) patients. Additionally, these preliminary pediatric data suggest targeting AM agents to a specific MDRO does not impact the rate of postoperative infection in children undergoing CTS. Larger studies are warranted to confirm these findings.
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Ing RJ, Twite M. The Year in Review: Anesthesia for Congenital Heart Disease 2018. Semin Cardiothorac Vasc Anesth 2019; 23:205-211. [DOI: 10.1177/1089253219845414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This review article surveys the published literature from January 2018 to March 2019. Three themes were identified and articles were selected based on their originality and interest to anesthesiologists caring for patients with congenital heart disease.
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Affiliation(s)
- Richard J. Ing
- Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, USA
- University of Colorado, Aurora, CO, USA
| | - Mark Twite
- Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, USA
- University of Colorado, Aurora, CO, USA
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