Randomized, double-blind comparison of the efficacies, costs, and vaginal flora alterations with single-dose ceftriaxone and multidose cefazolin prophylaxis in vaginal hysterectomy

Cefazolin as surgical antimicrobial prophylaxis in hysterectomy: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Current practice guidelines recommend cefazolin, cefoxitin, cefotetan, or ampicillin-sulbactam as first-line antibiotic prophylaxis in hysterectomy. We undertook this systematic review and meta-analysis of randomized controlled trials (RCTs) to determine whether cefazolin, with limited antianaerobic spectrum, is as effective in preventing surgical site-infection (SSI) as the other first-choice antimicrobials that have more extensive antianaerobic activity.

METHODS

We searched PubMed, Scopus, Web of Science, Cochrane Central, and EMBASE for relevant randomized controlled trials (RCT) in any language up to January 23, 2018. We only included trials that measured SSI (our primary outcome) defined as superficial, deep, or organ space. We excluded trials of β-lactams no longer in clinical use.

RESULTS

In terms of SSI incidence, cefazolin use was not inferior to its comparator in 12 of 13 individual RCTs included in the analysis. The meta-analysis summary estimate showed a significantly higher SSI risk with cefazolin versus cefoxitin or cefotetan (risk ratio, 1.7; 95% CI, 1.04-2.77; P = .03). However, most studies included nonstandardized dosing and duration of antimicrobial prophylaxis, had indeterminate or high risk of bias, did not include patients with gynecological malignancies, and/or were older RCTs not reflective of current clinical practices.

CONCLUSION

Due to inherent limitations associated with old RCTs with limited relevance to contemporary surgery, an RCT of cefazolin versus regimens with significant antianaerobic spectrum is needed to establish the optimal choice for SSI prevention in hysterectomy.

Postpartum infective endocarditis with Enterococcus faecalis in Japan: a case report

Background

The clinical characteristics of infective endocarditis include the presence of predisposing cardiac disease, a history of illegal drug use, and high morbidity in the elderly. Only a few cases of the disease after delivery have been reported in the literature. We describe here a first case of enterococcal postpartum infective endocarditis without underlying disease in Japan.

Case presentation

We report the case of a 31-year-old Japanese woman with postpartum infective endocarditis by Enterococcus faecalis. She had no significant medical history or any unusual social history. After emergency surgery for severe mitral regurgitation and antimicrobial treatment for 6 weeks, she was discharged from our hospital and is now being monitored at an out-patient clinic.

Conclusions

We encountered a case of Enterococcus faecalis infective endocarditis that occurred in the native valve of a postpartum healthy woman. Although the pathogenesis of this case remains unclear, it could be due to bacteremia arising from the administration of prophylactic broad-spectrum antibiotics used for cesarean section. Previous use of cefotiam and urinary catheter insertion may be risk factors for nosocomial enterococcal bacteremia in this case.

Clostridium difficile infection following systemic antibiotic administration in randomised controlled trials: a systematic review and meta-analysis

Antibiotics have been the most important risk factor for Clostridium difficile infection (CDI). However, only data from non-randomised studies have been reviewed. We sought to evaluate the risk for development of CDI associated with the major antibiotic classes by analysing data from randomised controlled trials (RCTs). The PubMed, Cochrane and Scopus databases were searched and the references of selected RCTs were also hand-searched. Eligible studies should have compared only one antibiotic versus another administered systemically. Inclusion of studies comparing combinations of antibiotics was allowed only if the second antibiotic was the same or from the same class or if it was administered in a subset of the enrolled patients who were equally distributed in the two arms. Only a minority of the selected RCTs (79/1332; 5.9%) reported CDI episodes. Carbapenems were associated with more CDI episodes than fluoroquinolones [risk ratio (RR) = 2.44, 95% confidence interval (CI) 1.32-4.49] and cephalosporins (RR = 2.24, 95% CI 1.46-3.42), but not penicillins (RR = 2.53, 95% CI 0.87-7.41). Cephalosporins were associated with more CDIs than penicillins (RR = 2.36, 95% CI 1.32-4.23) and fluoroquinolones (RR = 2.84, 95% CI 1.60-5.06). There was no difference in CDI frequency between fluoroquinolones and penicillins (RR = 1.34, 95% CI 0.55-3.25). Finally, clindamycin was associated with more CDI episodes than cephalosporins and penicillins (RR = 3.92, 95% CI 1.15-13.43). In conclusion, data from RCTs showed that clindamycin and carbapenems were associated with more CDIs than other antibiotics.

Ceftriaxone versus Other Antibiotics for Surgical Prophylaxis

OBJECTIVE

To investigate possible differences in prophylaxis with ceftriaxone compared with other antimicrobial agents for surgical-site infections and remote infections such as respiratory tract infections (RTIs) and urinary tract infections (UTIs).

METHODS

The efficacy of ceftriaxone was compared with that of other antibiotics in the perioperative prophylaxis of local (surgical wound) and remote (RTIs and UTIs) infections in a meta-analysis of randomised controlled trials published between 1984 and 2003. The analysis was based on a 2 x 2 contingency table with classification by treatment and number of infections obtained from individual studies.

RESULTS

Evaluations were performed on 48 studies, for a total of 17 565 patients. Overall, 406 patients (4.8%) in the ceftriaxone group and 525 (6.3%) in the comparator group developed a surgical-site infection (log odds ratio [OR] -0.30 [CI -0.50 to -0.13]; p < 0.0001). RTIs were observed in 292 (6.01%) patients in the ceftriaxone group and in 369 (7.6%) patients in the comparator group, (log OR -0.30 [CI -0.55 to -0.09]; p = 0.0013). UTIs were reported for 2.2% of the ceftriaxone prophylaxis patients compared with 3.74% of the comparator group patients (log OR -0.54 [CI -1.18 to -0.16]; p < 0.0001). Overall, in clean surgery 195 (5.1%) and 234 (6.2%) patients developed a surgical site infection in the ceftriaxone and comparator groups, respectively (log OR -0.22 [CI -0.51 to 0.01]; p = 0.0476). RTIs were prevented for all but 1.57% of patients in the ceftriaxone group and 2.62% of patients in the comparator group (p = 0.01) in clean surgery, and for 9.54% of the ceftriaxone group versus 11.6% of the comparator group (p = 0.01) in clean-contaminated surgery. While results observed in clean surgery did not show statistically significant superiority of ceftriaxone in preventing UTI insurgence (log OR -0.21 [CI 0.0-0.65]; p = 0.7702), this was clearly shown in the clean-contaminated surgery. In fact, 4.47% of patients in the ceftriaxone group versus 7.52% of patients in the comparator group developed a UTI (log OR -0.56 [CI -1.25 to -0.16]; p < 0.0001). Adverse events were observed in a similar proportion in the ceftriaxone prophylaxis and the comparator groups (0.35% and 0.23%, respectively). Duration of prophylaxis did not influence outcome of infection.

CONCLUSIONS

The meta-analysis showed that ceftriaxone is statistically superior to other antibiotics in preventing both local and remote postoperative infections.

Single dose ceftriaxone versus single dose cefuroxime plus metronidazole for preventing febrile morbidity and urinary tract infection in vaginal hysterectomy

OBJECTIVE

To compare the prophylactic efficacy of 1 g ceftriaxone with 1.5 g cefuroxime + 0.5 g metronidazole for febrile morbidity and urinary tract infection in patients undergoing vaginal hysterectomy.

STUDY DESIGN

A prospective, randomized, comparative, non-blinded study with at least 100 patients on each side. The two-sample t-test was used for testing equality of two means and the chi 2 test was used for pair differences.

RESULTS

Single dose cefuroxime + metronidazole and ceftriaxone were equally effective in preventing febrile morbidity postoperatively. Additionally ceftriaxone was more effective in sterilizing pre-operatively existing bacteriuria.

[Antibiotic prophylaxis in gynecologic surgery]

Hysterectomies are contaminated procedures; surgical wound related sepsis ranges from 10 to 25%. Several randomised controlled studies demonstrated a significant benefit with prophylactic antibiotics. The study results were more controversial for abdominal hysterectomies. Ureidopenicillins, cephamycins and other antibacterial agents active on Gram negative rods and anaerobes can be recommended as a preoperative flash at anaesthesia induction, followed by a second injection whenever the procedure duration exceeds 3 hours. In case of extended hysterectomy for cancer, broad spectrum antibiotic prophylaxis is usual; some recent studies demonstrated the efficacy of a short duration antibacterial agent use. Mastectomies are at low risk for postoperative infection. Antibacterial prophylaxis is common, especially in plastic surgery.