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Tsoulis MW, Hsu Blatman KS, Chow VW, Stewart KO, Wang R, Reigh EL. A nurse-driven penicillin allergy risk score in the preoperative setting was associated with increased cefazolin use perioperatively. J Clin Anesth 2024; 95:111443. [PMID: 38484506 DOI: 10.1016/j.jclinane.2024.111443] [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: 09/14/2023] [Revised: 02/19/2024] [Accepted: 03/07/2024] [Indexed: 04/29/2024]
Abstract
STUDY OBJECTIVE To characterize and assess the effects of a preoperative, nurse-driven penicillin allergy risk stratification tool on rates of perioperative cefazolin and second-line antibiotic use. DESIGN Quasi-experimental quality improvement study of penicillin-allergic surgical patients undergoing procedures for which cefazolin is indicated. SETTING Outpatient Perioperative Care Clinic (PCC) for preoperative surgical patients at a tertiary care center. PATIENTS 670 and 1371 adult penicillin-allergic PCC attendants and non-attendants, respectively. INTERVENTION A paper penicillin allergy risk stratification questionnaire was administered during the PCC visit. Nurses were educated on its use. MEASUREMENTS Antibiotic (cefazolin, clindamycin, vancomycin) use rates in the 24 months before and 17 months after intervention implementation in November 2020 (November 2018 - April 2022) were assessed in penicillin-allergic PCC attendants with statistical process control charts. Multivariable logistic regression assessed antibiotic use rates pre- and post-intervention adjusting for age, sex, surgical specialty and penicillin allergy history severity. Similar analyses were done in penicillin-allergic PCC non-attendants. MAIN RESULTS Of 670 penicillin-allergic PCC attendants, 451 (median [IQR] age, 66 (Sousa-Pinto et al., 2021 [14])) were analyzed pre-intervention and 219 (median [IQR] age, 66 (Mine et al., 1970 [13])) post-intervention. One month after implementation, process measures demonstrated an upward shift in cefazolin use for PCC attendants versus no shift or other special cause variation for PCC non-attendants. There were increased odds of cefazolin use (aOR 1.67, 95% CI [1.09-2.57], P = 0.019), decreased odds of clindamycin use (aOR 0.61, 95% CI [0.42-0.89], P = 0.010) and decreased odds of vancomycin use (aOR 0.56, 95% CI [0.35-0.88], P = 0.013) in PCC attendants post-intervention. This effect did not occur in PCC non-attendants. There was no increase in perioperative anaphylaxis post-intervention. CONCLUSIONS A simple penicillin allergy risk stratification tool implemented in the preoperative setting was associated with increased use of cefazolin and decreased rates of second-line agents post implementation.
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Affiliation(s)
- Michael W Tsoulis
- Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive Lebanon, NH 03756, USA
| | - Karen S Hsu Blatman
- Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive Lebanon, NH 03756, USA; Section of Allergy and Clinical Immunology, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA; Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA
| | - Vinca W Chow
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA; Department of Anesthesiology, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Kathleen O Stewart
- The Dartmouth Institute for Health Policy and Clinical Practice, 1 Medical Center Drive, Lebanon, NH 03766, USA; Collaborative Healthcare-associated Infection Prevention Program, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Rebecca Wang
- Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive Lebanon, NH 03756, USA; Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA; The Dartmouth Institute for Health Policy and Clinical Practice, 1 Medical Center Drive, Lebanon, NH 03766, USA; Section of Infectious Disease and International Health, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Erin L Reigh
- Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive Lebanon, NH 03756, USA; Section of Allergy and Clinical Immunology, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA; Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA.
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2
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Cunningham CA, Grys TE, Downey FX, Saling CF, Orenstein R, Blair JE. Deep Sternal Wound Infection Caused by Rhizopus Species After Coronary Artery Bypass Graft. Open Forum Infect Dis 2024; 11:ofae302. [PMID: 38872847 PMCID: PMC11170494 DOI: 10.1093/ofid/ofae302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024] Open
Abstract
Deep sternal wound infection is a rare complication of cardiac surgery that is typically caused by skin resident flora, such as species of Staphylococcus and Streptococcus. Infections caused by fungi are less common and are generally caused by Candida species. Regardless of etiology, these infections are associated with significant morbidity and mortality. We present a case of postoperative mediastinitis that occurred following a 5-vessel coronary artery bypass graft and was caused by a filamentous fungus of the Rhizopus genus. The patient was treated with serial debridement, liposomal amphotericin B, and isavuconazonium and was discharged from the hospital in stable condition. Fungal mediastinitis is a rare entity, and clinicians must maintain a high level of suspicion to make the diagnosis. A fungal cause of postoperative mediastinitis should be considered in patients with negative bacterial cultures, uncontrolled diabetes, or current immunosuppression or those who present weeks after surgery with a subacute onset of symptoms.
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Affiliation(s)
- Cody A Cunningham
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Scottsdale, Arizona, USA
| | - Thomas E Grys
- Department of Pathology and Laboratory Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Francis X Downey
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Robert Orenstein
- Division of Infectious Disease, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Janis E Blair
- Division of Infectious Disease, Mayo Clinic Arizona, Phoenix, Arizona, USA
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3
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Cuervo G, Quintana E, Regueiro A, Perissinotti A, Vidal B, Miro JM, Baddour LM. The Clinical Challenge of Prosthetic Valve Endocarditis: JACC Focus Seminar 3/4. J Am Coll Cardiol 2024; 83:1418-1430. [PMID: 38599718 DOI: 10.1016/j.jacc.2024.01.037] [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: 12/18/2023] [Revised: 01/17/2024] [Accepted: 01/29/2024] [Indexed: 04/12/2024]
Abstract
During the past 6 decades, there have been numerous changes in prosthetic valve endocarditis (PVE), currently affecting an older population and increasing in incidence in patients with transcatheter-implanted valves. Significant microbiologic (molecular biology) and imaging diagnostic (fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography) advances have been incorporated into the 2023 Duke-International Society for Cardiovascular Infectious Diseases infective endocarditis diagnostic criteria, thus increasing the diagnostic sensitivity for PVE without sacrificing specificity in validation studies. PVE is a life-threatening disease requiring management by multidisciplinary endocarditis teams in cardiac centers to improve outcomes. Novel surgical options are now available, and an increasing set of patients may avoid surgical intervention despite indication. Selected patients may complete parenteral or oral antimicrobial treatment at home. Finally, patients with prosthetic valves implanted surgically or by the transcatheter approach are candidates for antibiotic prophylaxis before invasive dental procedures.
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Affiliation(s)
- Guillermo Cuervo
- Department of Infectious Diseases, Hospital Clinic, August Pi I Sunyer Institute of Biomedical Research (IDIBAPS), University of Barcelona, Barcelona, Spain; Biomedical Network Research Center for Infectious Diseases (CIBERINFEC), Carlos III Health Institute, Madrid, Spain
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Ander Regueiro
- Department of Cardiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Andrés Perissinotti
- Department of Nuclear Medicine, Hospital Clinic, August Pi I Sunyer Institute of Biomedical Research (IDIBAPS) and Biomedical Research Networking Center of Bioengineering, Biomaterials, and Nanomedicine (CIBER-BBN), Carlos III Health Institute, Barcelona, Spain
| | - Barbara Vidal
- Department of Cardiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jose M Miro
- Department of Infectious Diseases, Hospital Clinic, August Pi I Sunyer Institute of Biomedical Research (IDIBAPS), University of Barcelona, Barcelona, Spain; Biomedical Network Research Center for Infectious Diseases (CIBERINFEC), Carlos III Health Institute, Madrid, Spain.
| | - Larry M Baddour
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Departments of Medicine and Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Zelenitsky SA. Effective Antimicrobial Prophylaxis in Surgery: The Relevance and Role of Pharmacokinetics-Pharmacodynamics. Antibiotics (Basel) 2023; 12:1738. [PMID: 38136772 PMCID: PMC10741006 DOI: 10.3390/antibiotics12121738] [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: 11/19/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
Appropriate surgical antimicrobial prophylaxis (SAP) is an important measure in preventing surgical site infections (SSIs). Although antimicrobial pharmacokinetics-pharmacodynamics (PKPD) is integral to optimizing antibiotic dosing for the treatment of infections, there is less research on preventing infections postsurgery. Whereas clinical studies of SAP dose, preincision timing, and redosing are informative, it is difficult to isolate their effect on SSI outcomes. Antimicrobial PKPD aims to explain the complex relationship between antibiotic exposure during surgery and the subsequent development of SSI. It accounts for the many factors that influence the PKs and antibiotic concentrations in patients and considers the susceptibilities of bacteria most likely to contaminate the surgical site. This narrative review examines the relevance and role of PKPD in providing effective SAP. The dose-response relationship i.e., association between lower dose and SSI in cefazolin prophylaxis is discussed. A comprehensive review of the evidence for an antibiotic concentration-response (SSI) relationship in SAP is also presented. Finally, PKPD considerations for improving SAP are explored with a focus on cefazolin prophylaxis in adults and outstanding questions regarding its dose, preincision timing, and redosing during surgery.
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Affiliation(s)
- Sheryl A. Zelenitsky
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0T5, Canada;
- Department of Pharmacy, St. Boniface Hospital, Winnipeg, MB R2H 2A6, Canada
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5
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AlRiyami FM, AL-Rawajfah OM, Al Sabei S, Al Sabti HA. Incidence and risk factors of surgical site infections after coronary artery bypass grafting surgery in Oman. J Infect Prev 2022; 23:285-292. [PMID: 36277861 PMCID: PMC9583440 DOI: 10.1177/17571774221127553] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 06/13/2022] [Indexed: 10/31/2023] Open
Abstract
Background There is limited information about the incidence and risk factors of surgical site infections (SSIs) after coronary artery bypass (CABG) surgeries in the Omani population. Aim To estimate the prevalence and describe possible risk factors of SSIs after CABG surgeries in Oman. Method A retrospective nested case-control design was used to screen 596 patients who underwent CABG surgeries over 2 years (2016-2017) in two tertiary hospitals in Oman. The CDC definition for SSIs was used to identify the infected cases. Results Prevalence rate of SSIs was 17.4% and 17.5% in 2016 and 2017, respectively. The most isolated microorganism was Gram-positive bacteria (45.2%). Risk factors of SSIs include female gender (OR = 3.2, p < 0.001), diabetes (OR = 5.83, p < 0.001), overweight or obese (OR = 2.14, p < 0.05) and shaving technique [using razor shaving] (OR = 8.4, p < 0.001). Readmission rate for the case group was 44.2%. Conclusion The infection rate of SSIs after CABG surgeries in developing countries, such as Oman, is considerably high. There is an urgent need to establish SSIs preventive program at the national level. Frequent and systematic assessment of infection control practices before and after CABG surgeries is fundamental and priority strategy to prevent SSIs.
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Affiliation(s)
- Fatma M AlRiyami
- Cardiothoracic Unit, Sultan Qaboos University
Hospital, Muscat, Oman
| | - Omar M AL-Rawajfah
- College of Nursing, Adult and
Critical Care Department, Sultan Qaboos
University, Muscat, Oman
- Faculty of Nursing, Adult
Department, Al Al-Bayt University, Jordan
| | - Sulaiman Al Sabei
- College of Nursing, Department of
Fundamental and Nursing Administration, Sultan Qaboos
University, Muscat, Oman
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6
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Surat G, Bernsen D, Schimmer C. Antimicrobial stewardship measures in cardiac surgery and its impact on surgical site infections. J Cardiothorac Surg 2021; 16:309. [PMID: 34670594 PMCID: PMC8527641 DOI: 10.1186/s13019-021-01693-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 10/11/2021] [Indexed: 12/24/2022] Open
Abstract
Objective The goal of this study was to monitor the compliance and impact on a protocol change of surgical antimicrobial prophylaxis in cardiac surgery favouring cefazolin instead cefuroxime, initiated by the hospital’s antimicrobial stewardship team. Methods This quality improvement study was performed in a tertiary care hospital in collaboration with the department of cardiothoracic surgery and the hospitals antimicrobial stewardship team following a revision of the standard for surgical antimicrobial prophylaxis including 1029 patients who underwent cardiac surgery. 582 patients receiving cefuroxime and 447 patients receiving cefazolin respectively were compared without altering any other preventative perioperative measures including its postoperative duration of less than 24 h. Adherence and surgical site infections were compiled and analysed. Results A complete adherence was achieved. Overall surgical site infections occurred in 37 (3.6%) of the cases, 20 (3.4%) in cefuroxime patients and 17 (3.8%) in cefazolin patients (p value = 0.754). No statistically significant differences could be found in any of the primary endpoints, but there was a trend towards less deep sternal wound infections in the cefazolin group. Conclusions The study supports the role of antimicrobial stewardship in cardiac surgery and mirrors the success of a multidisciplinary team aiming to minimize adverse events by optimizing antibiotic use. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01693-7.
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Affiliation(s)
- Güzin Surat
- Unit for Infection Control and Antimicrobial Stewardship, University Hospital of Würzburg, Würzburg, Germany.
| | | | - Christoph Schimmer
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital of Würzburg, Würzburg, Germany
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Rakic M, Jaboyedoff M, Bachmann S, Berger C, Diezi M, do Canto P, Forrest CB, Frey U, Fuchs O, Gervaix A, Gluecksberg AS, Grotzer M, Heininger U, Kahlert CR, Kaiser D, Kopp MV, Lauener R, Neuhaus TJ, Paioni P, Posfay-Barbe K, Ramelli GP, Simeoni U, Simonetti G, Sokollik C, Spycher BD, Kuehni CE. Clinical data for paediatric research: the Swiss approach : Proceedings of the National Symposium in Bern, Switzerland, Dec 5-6, 2019. BMC Proc 2021; 15:19. [PMID: 34538238 PMCID: PMC8450032 DOI: 10.1186/s12919-021-00226-3] [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] [Accepted: 08/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND PURPOSE Continuous improvement of health and healthcare system is hampered by inefficient processes of generating new evidence, particularly in the case of rare diseases and paediatrics. Currently, most evidence is generated through specific research projects, which typically require extra encounters with patients, are costly and entail long delays between the recognition of specific needs in healthcare and the generation of necessary evidence to address those needs. The Swiss Personalised Health Network (SPHN) aims to improve the use of data obtained during routine healthcare encounters by harmonizing data across Switzerland and facilitating accessibility for research. The project "Harmonising the collection of health-related data and biospecimens in paediatric hospitals throughout Switzerland (SwissPedData)" was an infrastructure development project funded by the SPHN, which aimed to identify and describe available data on child health in Switzerland and to agree on a standardised core dataset for electronic health records across all paediatric teaching hospitals. Here, we describe the results of a two-day symposium that aimed to summarise what had been achieved in the SwissPedData project, to put it in an international context, and to discuss the next steps for a sustainable future. The target audience included clinicians and researchers who produce and use health-related data on children in Switzerland. KEY HIGHLIGHTS The symposium consisted of state-of-the-art lectures from national and international keynote speakers, workshops and plenary discussions. This manuscript summarises the talks and discussions in four sections: (I) a description of the Swiss Personalized Health Network and the results of the SwissPedData project; (II) examples of similar initiatives from other countries; (III) an overview of existing health-related datasets and projects in Switzerland; and (IV) a summary of the lessons learned and future prospective from workshops and plenary discussions. IMPLICATIONS Streamlined processes linking initial collection of information during routine healthcare encounters, standardised recording of this information in electronic health records and fast accessibility for research are essential to accelerate research in child health and make it affordable. Ongoing projects prove that this is feasible in Switzerland and elsewhere. International collaboration is vital to success. The next steps include the implementation of the SwissPedData core dataset in the clinical information systems of Swiss hospitals, the use of this data to address priority research questions, and the acquisition of sustainable funding to support a slim central infrastructure and local support in each hospital. This will lay the foundation for a national paediatric learning health system in Switzerland.
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Affiliation(s)
- Milenko Rakic
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Manon Jaboyedoff
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
- Service of Pediatrics, Department Women-Mother-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sara Bachmann
- University of Basel Children’s Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| | - Christoph Berger
- University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Manuel Diezi
- Service of Pediatrics, Department Women-Mother-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | | | - Urs Frey
- University of Basel Children’s Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| | - Oliver Fuchs
- Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alain Gervaix
- Department of Woman, Child and Adolescent, Children’s Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Amalia Stefani Gluecksberg
- Paediatric Department of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland and Università della Svizzera Italiana, Lugano, Switzerland
| | - Michael Grotzer
- University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ulrich Heininger
- University of Basel Children’s Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| | | | - Daniela Kaiser
- Children’s Hospital of Lucerne, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Matthias V. Kopp
- Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roger Lauener
- Children’s Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Thomas J. Neuhaus
- Children’s Hospital of Lucerne, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Paolo Paioni
- University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Klara Posfay-Barbe
- Department of Woman, Child and Adolescent, Children’s Hospital, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Gian Paolo Ramelli
- Paediatric Department of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland and Università della Svizzera Italiana, Lugano, Switzerland
| | - Umberto Simeoni
- Service of Pediatrics, Department Women-Mother-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Giacomo Simonetti
- Paediatric Department of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland and Università della Svizzera Italiana, Lugano, Switzerland
| | - Christiane Sokollik
- Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ben D. Spycher
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Claudia E. Kuehni
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
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Perceptions of surgeons on surgical antibiotic prophylaxis use at an urban tertiary hospital in Tanzania. PLoS One 2021; 16:e0256134. [PMID: 34437587 PMCID: PMC8389451 DOI: 10.1371/journal.pone.0256134] [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: 03/06/2021] [Accepted: 07/25/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Surgical Site Infections are a major cause of morbidity and mortality among operated patients. In spite of the accessibility of universal and national guidelines for surgical prophylaxis, recent studies surveying the present routine of prophylaxis have demonstrated overutilization of a wide range antibacterial medication for a single patient. Few studies have shown qualitatively factors influencing this and perceptions of surgeons on surgical antibiotic prophylaxis use. Unfortunately, none of these studies have been done in Tanzania. OBJECTIVE To describe the perceptions of surgeons on surgical antibiotic prophylaxis use at an urban tertiary hospital. METHODS A qualitative study involving in-depth interviews with surgeons was conducted in English by the primary investigator. The interviews were audio-recorded and transcribed verbatim. Systematic text condensation by Malterud was used for data analysis. FINDINGS Fourteen surgeons and obstetrics and gynaecologists participated. Their perceptions were summarized into three main categories: Inadequate data to support practice; one who sees the patient decides the antibiotic prophylaxis; prolonged antibiotic use for fear of unknown. The participants perceived that choice of antibiotic should be based on local hospital data for bacterial resistance pattern, however the hospital guidelines and data for surgical site infection rates are unknown. Fear of getting infection and anticipating complications led to prolonged antibiotics use. CONCLUSION The study provides an understanding of surgical antibiotic prophylaxis use and its implementation challenges. This was partly expressed by unavailability of local data and guidelines to enhance practice. To improve this, there is a need of guidelines that incorporates local resistance surveillance data and enhanced antibiotic stewardship programmes. A strong consideration should be placed into ways to combat the fears of surgeons for complications, as these significantly affect the current practise with use of surgical antibiotic prophylaxis.
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Conen A, Stortecky S, Moreillon P, Hannan M, Franzeck F, Jeger R, Widmer A. A review of recommendations for infective endocarditis prevention in patients undergoing transcatheter aortic valve implantation. EUROINTERVENTION 2021; 16:1135-1140. [PMID: 32207407 PMCID: PMC9725011 DOI: 10.4244/eij-d-19-00993] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is a new disease entity. The rate of IE after TAVI is similar to that after surgical aortic valve replacement (SAVR), but mortality and prevalence of Enterococcus spp. as causing pathogens are significantly higher. Guidelines on infection prevention measures before TAVI procedures are currently lacking. We performed a structured review of the available data to provide interim recommendations based on guidelines to prevent infections issued by the World Health Organization as well as guidelines by professional societies from Europe and the USA. Such interim recommendations based on expert opinions are probably justified until large randomised trials provide strong evidence for infection control in TAVI, because IE after TAVI is often related to the TAVI procedure itself and the associated mortality rate is high. Antibiotic prophylaxis should be adapted from an intravenous cephalosporin to, e.g., amoxicillin/clavulanic acid, to cover enterococci. In addition, infection control should follow operating room standards as far as is reasonable, even if the evidence for this recommendation is very low. These recommendations are endorsed by the International Society for Cardiovascular Infectious Diseases (ISCVID).
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Affiliation(s)
- Anna Conen
- Department of Infectious Diseases and Hospital Epidemiology, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Philippe Moreillon
- Department of Fundamental Microbiology, University of Lausanne, Lausanne, Switzerland
| | - Margaret Hannan
- Department of Clinical Microbiology, Mater Misericordiae University Hospital, University College Dublin, Dublin, Ireland
| | - Fabian Franzeck
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Raban Jeger
- Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Widmer
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
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Sommerstein R, Marschall J, Atkinson A, Surbek D, Dominguez-Bello MG, Troillet N, Widmer AF. Antimicrobial prophylaxis administration after umbilical cord clamping in cesarean section and the risk of surgical site infection: a cohort study with 55,901 patients. Antimicrob Resist Infect Control 2020; 9:201. [PMID: 33349269 PMCID: PMC7754587 DOI: 10.1186/s13756-020-00860-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/20/2020] [Indexed: 12/13/2022] Open
Abstract
Background The World Health Organization (WHO) recommends administration of surgical antimicrobial prophylaxis (SAP) in cesarean section prior to incision to prevent surgical site infections (SSI). This study aimed to determine whether SAP administration following cord clamping confers an increased SSI risk to the mother.
Methods Study design: Cohort. Setting: 75 participating Swiss hospitals, from 2009 to 2018. Participants: A total of 55,901 patients were analyzed. Main outcome measures: We assessed the association between SAP administration relative to incision and clamping and the SSI rate, using generalized linear multilevel models, adjusted for patient characteristics, procedural variables, and health-care system factors. Results SAP was administered before incision in 26′405 patients (47.2%) and after clamping in 29,496 patients (52.8%). Overall 846 SSIs were documented, of which 379 (1.6% [95% CI, 1.4–1.8%]) occurred before incision and 449 (1.7% [1.5–1.9%]) after clamping (p = 0.759). The adjusted odds ratio for SAP administration after clamping was not significantly associated with an increased SSI rate (1.14, 95% CI 0.96–1.36; p = 0.144) when compared to before incision. Supplementary and subgroup analyses supported these main results. Conclusions This study did not confirm an increased SSI risk for the mother in cesarean section if SAP is given after umbilical cord clamping compared to before incision.
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Affiliation(s)
- Rami Sommerstein
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland. .,Swissnoso, National Center for Infection Control, Bern, Switzerland.
| | - Jonas Marschall
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.,Swissnoso, National Center for Infection Control, Bern, Switzerland
| | - Andrew Atkinson
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Gynaecology, Bern University Hospital, University of Bern, Bern, Switzerland.,Swiss Society of Obstetrics and Gynaecology, Bern, Switzerland
| | - Maria Gloria Dominguez-Bello
- Department of Biochemistry and Microbiology, Rutgers School of Environmental and Biological Science, New Brunswick, NJ, USA
| | - Nicolas Troillet
- Swissnoso, National Center for Infection Control, Bern, Switzerland.,Service of Infectious Diseases, Central Institute, Valais Hospitals, Sion, Switzerland
| | - Andreas F Widmer
- Swissnoso, National Center for Infection Control, Bern, Switzerland. .,Department of Infectious Diseases, University Hospital Basel, Basel, Switzerland.
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Miranda D, Mermel LA, Dellinger EP. Perioperative Antibiotic Prophylaxis: Surgeons as Antimicrobial Stewards. J Am Coll Surg 2020; 231:766-768. [DOI: 10.1016/j.jamcollsurg.2020.08.767] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
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Rimmler C, Lanckohr C, Mittrup M, Welp H, Würthwein G, Horn D, Fobker M, Ellger B, Hempel G. Population pharmacokinetic evaluation of cefuroxime in perioperative antibiotic prophylaxis during and after cardiopulmonary bypass. Br J Clin Pharmacol 2020; 87:1486-1498. [PMID: 32959896 DOI: 10.1111/bcp.14556] [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: 02/11/2020] [Revised: 08/30/2020] [Accepted: 09/09/2020] [Indexed: 11/27/2022] Open
Abstract
AIMS The purpose of this study was to explore pharmacokinetic and pharmacodynamic aspects of a contemporary dosing scheme of cefuroxime as perioperative prophylaxis in cardiac surgery using cardiopulmonary bypass (CPB). METHODS Cefuroxime plasma concentrations were measured in 23 patients. A 1.5-g dose of cefuroxime was administered at start of surgery and CPB, followed by 3 additional doses every 6 hours postoperative. Drug levels were used to build a population pharmacokinetic model. Target attainment for Staphylococcus aureus (2-8 mg/L) and Escherichia coli (8-32 mg/L) were evaluated and dosing strategies for optimization were investigated. RESULTS A dosing scheme of 1.5 g cefuroxime preoperatively with a repetition at start of CPB achieves plasma unbound concentrations of 8 mg/L in almost all patients during surgery. The second administration is critical to provide this level of coverage. Simulations indicate that higher unbound concentrations up to 32 mg/L are reached by a continuous infusion rate of 1 g/h after a bolus of 1 g. In the postoperative phase, most patients do not reach unbound concentrations above 2 mg/L. To improve target attainment up to 8 mg/L, the continuous application of cefuroxime with infusion rates of 0.125-0.25 g/h is simulated and shown to be an alternative to bolus dosing. CONCLUSION Dosing recommendations for cefuroxime as perioperative antibiotic prophylaxis in cardiac surgery are sufficient to reach plasma unbound concentration to cover S. aureus during the operation. Target attainment is not achieved in the postoperative period. Continuous infusion of cefuroxime may optimize target attainment.
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Affiliation(s)
- Christer Rimmler
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Christian Lanckohr
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Miriam Mittrup
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Henryk Welp
- Department of Cardiac Surgery, University Hospital Muenster, Muenster, Germany
| | - Gudrun Würthwein
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Dagmar Horn
- Department of Pharmacy, University Hospital of Muenster, Muenster, Germany
| | - Manfred Fobker
- Center for Laboratory Medicine, University Hospital Muenster, Muenster, Germany
| | - Björn Ellger
- Department of Anesthesiology, Intensive Care and Pain Medicine, Klinikum Westfalen, Dortmund, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
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Mahmoudi L, Ghouchani M, Mahi-Birjand M, Bananzadeh A, Akbari A. Optimizing compliance with surgical antimicrobial prophylaxis guidelines in patients undergoing gastrointestinal surgery at a referral teaching hospital in southern Iran: clinical and economic impact. Infect Drug Resist 2019; 12:2437-2444. [PMID: 31496756 PMCID: PMC6689569 DOI: 10.2147/idr.s212728] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/09/2019] [Indexed: 12/16/2022] Open
Abstract
Background Antibiotic prophylaxis is one of the major approaches to prevent surgical site infection. Despite the availability of international guidelines on it, the practice of antibiotic prophylaxis is still far from optimal. This study aimed to assess the impact of guideline implementation on the rational use of prophylactic antibiotics and its cost-saving effect in gastrointestinal surgery by clinical pharmacist intervention. Methods A pre and post intervention study was carried out between October 2017 and June 2018 on patients who underwent gastrointestinal surgery in a major referral teaching hospital in Shiraz, southern Iran. The intervention phase consisted of revising the institutional guidelines for surgical antimicrobial prophylaxis, assigning a clinical pharmacist to the surgical department, and arranging several meetings with the surgical department regarding the appropriate utilization of antibiotics. Differences in antibiotic utilization in patients before and after the intervention phase were compared. Exposures were surgical antimicrobial prophylaxis timing and agents, and main outcomes were incidence of surgical site infection and length of hospital stay. Results A total of 430 patients were included in the post intervention phase, while 445 patients were included in the baseline evaluation. Promoting appropriate antibiotic use in the post intervention group had the potential to decrease medication costs by reducing unnecessary prescriptions and duration of antibiotic usage (P<0.001). In the pre intervention group, the mean cost of antibiotic prescriptions was 11.5 times that of the post intervention group. Mean hospitalization in the pre intervention group was greater than the post intervention group (P<0.001). Furthermore, our data revealed that the rate of postsurgery infection in the post intervention group was 3.03%, while this rate was 6.76% in the preintervention group (P=0.01). Conclusion This study provides evidence that adherence to surgical antimicrobial prophylaxis guidelines increased the rational use of prophylactic antibiotics, with substantial cost savings in patients who underwent surgery.
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Affiliation(s)
- Laleh Mahmoudi
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrdad Ghouchani
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Motahareh Mahi-Birjand
- Infectious Disease Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | | | - Ali Akbari
- Department of Anesthesiology, Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
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