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Jannati M. The value of prophylactic antibiotics in coronary artery bypass graft surgery: A review of literature. JOURNAL OF VASCULAR NURSING 2021; 39:100-103. [PMID: 34865718 DOI: 10.1016/j.jvn.2021.07.005] [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: 04/07/2020] [Revised: 05/15/2021] [Accepted: 07/21/2021] [Indexed: 11/30/2022]
Abstract
Infections have a significant impact on increasing both the morbidity and mortality rate of patients who have undergone coronary artery bypass graft (CABG) surgery. Infection after CABG imposes a clinical and economic burden on patients and health care organizations; therefore, prevention should be on the agenda. This review will focus on the value of using prophylactic antibiotics in coronary artery bypass graft surgery (CABG). Prophylactic antibiotics like cephalosporin and vancomycin are more commonly used antibiotics and are strongly associated with reduced infection risk in patients. The results showed that using antibiotics during the perioperative period and after CABG is an effective strategy for reducing post-infection problems without compromising the patients' clinical outcomes. Diabetic patients are prone to postoperative infection after CABG, however, prophylactic antibiotics should not be the only strategy used to reduce the risk of postoperative infection in diabetic patients. Perioperative glycaemic control is essential for diabetic patients undergoing CABG. Appropriate antibiotic prophylaxis has a great impact on preventing infection after CABG but duration and selecting appropriate antibiotic is important. Standardizing the use of antibiotic prophylaxis reduces the rate of infection and unwanted bacterial resistance, which could subsequently reduce economic costs to patients and public health.
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Affiliation(s)
- Mansour Jannati
- Department of Cardiovascular Surgery, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
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McFarland A, Reilly J, Manoukian S, Mason H. The economic benefits of surgical site infection prevention in adults: a systematic review. J Hosp Infect 2020; 106:76-101. [PMID: 32417433 DOI: 10.1016/j.jhin.2020.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/11/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) present a significant burden to healthcare and patients in terms of excess length of stay, distress, disability and death. SSI risk and the associated economic burden may be reduced through adherence to prevention guidelines although the irreducible minimum is unclear. AIM To evaluate the methods used to estimate the cost-effectiveness of prevention strategies for all SSIs. METHODS PubMed, Medline, CINAHL, and UK National Health Service Economic Evaluation Database were searched from inception to January 2020 to identify English language economic evaluation studies, embedded economic evaluations, and studies with some analysis in relation to cost and benefit in adult patients receiving surgical care in any setting. Risk of bias was assessed using two published checklists. FINDINGS Thirty-two studies involving 24,043 participants were included. Most studies evaluated SSI prevention in orthopaedic surgeries. Antibiotic prophylaxis, screening, treating, or decolonization of meticillin-resistant Staphylococcus aureus and surgical wound closure were the main methods evaluated. Methods ranged from cost-analyses to cost-effectiveness and cost-utility analyses. Synthesis of results was not possible due to heterogeneity. All studies reported some economic benefit associated with preventing SSI; however, measures of benefit were not reported consistently and the quality of studies was low to moderate. Limited evidence in relation to SSI impact on quality of life was identified. CONCLUSION Current evidence in relation to the economic benefits of SSI prevention is limited. Further robust studies that utilize sound economic and epidemiological methods are required to inform future investment decisions in SSI prevention.
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Affiliation(s)
- A McFarland
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.
| | - J Reilly
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - S Manoukian
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - H Mason
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
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Evaluation of Current Perioperative Antimicrobial Regimens for the Prevention of Surgical Site Infections in Breast Implant-based Reconstructive Surgeries. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2342. [PMID: 31942364 PMCID: PMC6952132 DOI: 10.1097/gox.0000000000002342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 05/15/2019] [Indexed: 11/26/2022]
Abstract
Several steps to reduce the rate of postoperative surgical site infections (SSIs) have been implemented. The use of prophylactic antimicrobials targeting patient’s microbial flora has been associated with a decrease in postoperative infections. We evaluated the relationship between perioperative antimicrobials, baseline microbial flora, and occurrence of SSIs.
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Alotaibi AF, Mekary RA, Zaidi HA, Smith TR, Pandya A. Safety and Efficacy of Antibacterial Prophylaxis After Craniotomy: A Decision Model Analysis. World Neurosurg 2017; 105:906-912.e5. [DOI: 10.1016/j.wneu.2017.05.126] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 05/21/2017] [Indexed: 10/19/2022]
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5
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Prevalence and risk factors for carriage of extended-spectrum β-lactamase-producing Enterobacteriaceae among patients prior to bowel surgery. Diagn Microbiol Infect Dis 2016; 85:377-380. [DOI: 10.1016/j.diagmicrobio.2016.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 01/03/2016] [Accepted: 04/05/2016] [Indexed: 11/23/2022]
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Saab S, Alper T, Sernas E, Pruthi P, Alper MA, Sundaram V. Hospitalized Patients with Cirrhosis Should Be Screened for Clostridium difficile Colitis. Dig Dis Sci 2015; 60:3124-9. [PMID: 25986524 DOI: 10.1007/s10620-015-3707-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/06/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is an important public health problem in hospitalized patients. Patients with cirrhosis are particularly at risk of increased associated morbidity, mortality, and healthcare utilization from CDI. AIM The aim of this study was to assess the pharmacoeconomic impact of CDI screening on hospitalized patients with cirrhosis. METHODS A Markov model was used to compare costs and outcomes of two strategies for the screening of CDI. The first strategy consisted of screening all patients for CDI and treating if detected (screening). In the second strategy, only patients found to have symptomatic CDI were treated (no screening). The probability of underlying CDI prevalence, symptomatic CDI infection, and likelihood of recurrent infection were varied in a sensitivity analysis. The costs of antibiotics and hospitalization were also assessed. Differences in outcome were expressed in ratio of the total costs associated with screening to the total costs associated without screening. RESULTS The results of our model showed that screening for CDI was consistently associated with improved healthcare outcomes and decreased healthcare utilization across all variables in the one- and two-way sensitivity analyses. Using baseline assumptions, the costs associated with the no screening strategy were 3.54 times that of the screening strategy. Moreover, the mortality for symptomatic CDI was lower in the screening strategy than the no screening strategy. CONCLUSION The screening strategy results in less healthcare utilization and improved clinical outcomes. Screening for CDI measures favorably.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. .,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA. .,Pfleger Liver Institute, 200 Medical Plaza, Suite 214, Los Angeles, CA, 90095, USA.
| | - Theodore Alper
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Ernesto Sernas
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Paridhima Pruthi
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Vinay Sundaram
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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7
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Miller LG, McKinnell JA, Vollmer ME, Spellberg B. Impact of Methicillin-Resistant Staphylococcus aureus Prevalence among S. aureus Isolates on Surgical Site Infection Risk after Coronary Artery Bypass Surgery. Infect Control Hosp Epidemiol 2015. [DOI: 10.1086/522269] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective.Cephalosporins are recommended for antibiotic prophylaxis to prevent cardiothoracic surgical site infections (SSIs) except in patients withβ-lactam allergy or in settings with a “high” prevalence of methicillin-resistantStaphylococcus aureus(MRSA) among S.aureusisolates (hereafter, “MRSA prevalence”); however, “high” remains undefined. We sought to identify the MRSA prevalence at which glycopeptide prophylaxis would minimize SSIs relative toβ-lactam prophylaxis.Methods.We developed a decision analysis model to estimate SSI likelihood when either glycopeptides orβ-lactams were used for prophylaxis in cardiothoracic surgery. Event probabilities were derived from a systematic literature review. A similar cost-minimization model was also developed.Results.At 0% MRSA prevalence, SSI probability was 3.64% with glycopeptide prophylaxis and 3.49% withβ-lactam prophylaxis. At MRSA prevalences of 10%, 20%, 30%, or 40%, SSI probabilities with glycopeptide prophylaxis did not change, but they were 3.98%, 4.48%, 4.97%, and 5.47% withβ-lactam prophylaxis. The threshold of MRSA prevalence at which glycopeptide prophylaxis minimized SSI probability and cost was 3%. In sensitivity analyses, variations in most model estimates only modestly affected the threshold.Conclusion.Glycopeptide prophylaxis minimizes the risk of SSIs and cost when MRSA prevalence exceeds 3%. At very low MRSA prevalence (between 3% and 10%), the SSI minimization provided by glycopeptide prophylaxis is small and may be within the error of the model. Given the current MRSA prevalence in most community and healthcare settings, clinicians should consider routine prophylaxis with vancomycin. Our findings may have important policy implications, as benefits in cardiothoracic surgery antibiotic prophylaxis must be weighed against the limitations of increased glycopeptide use.
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Glycopeptides Versus β-Lactams for the Prevention of Surgical Site Infections in Cardiovascular and Orthopedic Surgery. Ann Surg 2015; 261:72-80. [DOI: 10.1097/sla.0000000000000704] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Turcotte RF, Brozovich A, Corda R, Demmer RT, Biagas KV, Mangino D, Covington L, Ferris A, Thumm B, Bacha E, Smerling A, Saiman L. Health care-associated infections in children after cardiac surgery. Pediatr Cardiol 2014; 35:1448-55. [PMID: 24996642 DOI: 10.1007/s00246-014-0953-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 06/12/2014] [Indexed: 11/25/2022]
Abstract
Few recent studies have assessed the epidemiology of health care-associated infections (HAIs) in the pediatric population after cardiac surgery. A retrospective cohort study was performed to assess the epidemiology of several types of HAIs in children 18 years of age or younger undergoing cardiac surgery from July 2010 to June 2012. Potential pre-, intra-, and postoperative risk factors, including adherence to the perioperative antibiotic prophylaxis regimen at the authors' hospital, were assessed by multivariable analysis using Poisson regression models. Microorganisms associated with HAIs and their susceptibility patterns were described. Overall, 634 surgeries were performed, 38 (6 %) of which were complicated by an HAI occurring within 90 days after surgery. The HAIs included 7 central line-associated bloodstream infections (CLABSIs), 12 non-CLABSI bacteremias, 6 episodes of early postoperative infective endocarditis (IE), 9 surgical-site infections (SSIs), and 4 ventilator-associated pneumonias (VAPs). Mechanical ventilation (rate ratio [RR] 1.07 per day; 95 % confidence interval [CI] 1.03-1.11; p = 0.0002), postoperative transfusion of blood products (RR 3.12; 95 %, CI 1.38-7.06; p = 0.0062), postoperative steroid use (RR 3.32; 95 % CI 1.56-7.02; p = 0.0018), and continuation of antibiotic prophylaxis longer than 48 h after surgery (RR 2.56; 95 % CI 1.31-5.03; p = 0.0062) were associated with HAIs. Overall, 66.7 % of the pathogens associated with SSIs were susceptible to cefazolin, the perioperative antibiotic prophylaxis used by the authors' hospital. In conclusion, HAIs occurred after 6 % of cardiac surgeries. Bacteremia and CLABSI were the most common. This study identified several potentially modifiable risk factors that suggest interventions. Further studies should assess the role of improving adherence to perioperative antibiotic prophylaxis, the age of transfused red blood cells, and evidence-based guidelines for postoperative steroids.
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Affiliation(s)
- Rebecca F Turcotte
- Department of Pediatrics, Columbia University Medical Center, 3959 Broadway, CHN 10-24, New York, NY, 10032, USA,
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Hansen E, Belden K, Silibovsky R, Vogt M, Arnold WV, Bicanic G, Bini SA, Catani F, Chen J, Ghazavi MT, Godefroy KM, Holham P, Hosseinzadeh H, Kim KII, Kirketerp-Møller K, Lidgren L, Lin JH, Lonner JH, Moore CC, Papagelopoulos P, Poultsides L, Randall RL, Roslund B, Saleh K, Salmon JV, Schwarz EM, Stuyck J, Dahl AW, Yamada K. Perioperative antibiotics. J Arthroplasty 2014; 29:29-48. [PMID: 24355256 DOI: 10.1016/j.arth.2013.09.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Erik Hansen
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Katherine Belden
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Randi Silibovsky
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Markus Vogt
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - William V Arnold
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Goran Bicanic
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Stefano A Bini
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Fabio Catani
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jiying Chen
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mohammad T Ghazavi
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karine M Godefroy
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Paul Holham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Hamid Hosseinzadeh
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kang I I Kim
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Lars Lidgren
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jian Hao Lin
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jess H Lonner
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christopher C Moore
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Lazaros Poultsides
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - R Lor Randall
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Brian Roslund
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Khalid Saleh
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Julia V Salmon
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Edward M Schwarz
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jose Stuyck
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Annette W Dahl
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Koji Yamada
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Hansen E, Belden K, Silibovsky R, Vogt M, Arnold W, Bicanic G, Bini S, Catani F, Chen J, Ghazavi M, Godefroy KM, Holham P, Hosseinzadeh H, Kim KII, Kirketerp-Møller K, Lidgren L, Lin JH, Lonner JH, Moore CC, Papagelopoulos P, Poultsides L, Randall RL, Roslund B, Saleh K, Salmon JV, Schwarz E, Stuyck J, Dahl AW, Yamada K. Perioperative antibiotics. J Orthop Res 2014; 32 Suppl 1:S31-59. [PMID: 24464896 DOI: 10.1002/jor.22549] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Viola GM, Raad II, Rolston KV. Breast tissue expander-related infections: perioperative antimicrobial regimens. Infect Control Hosp Epidemiol 2013; 35:75-81. [PMID: 24334802 DOI: 10.1086/674390] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The rate of postmastectomy tissue expander (TE) infection remains excessively high, ranging between 2% and 24%. We hypothesized that current perioperative antimicrobial regimens utilized for breast TE reconstruction may be outdated as a result of recent changes in microflora and susceptibility patterns. DESIGN AND METHODS We reviewed the records of all patients who had a TE reconstructive procedure and developed a definite breast TE infection between 2003 and 2010 at MD Anderson Cancer Center. Antimicrobials were stratified into 3 groups: systemic perioperative, local irrigation, and oral immediate postoperative antimicrobials. These were considered discordant if they did not target the isolated organisms, while a breakthrough infection was defined as an infection that occurred despite concordant antimicrobial coverage. RESULTS Overall, 75 patients with a definite TE infection were identified. The most common organisms identified were methicillin-resistant Staphylococcus epidermidis (29%), methicillin-resistant Staphylococcus aureus (15%), and gram-negative rods (26%). The use of systemic perioperative antimicrobials was deemed discordant in 51% of the cases. Although 79% of the patients received broad-spectrum perioperative local antimicrobial irrigation, 63% developed a breakthrough infection. Even though 61% received oral postoperative prophylactic antimicrobials, 63% of the times they were deemed discordant. CONCLUSIONS Contrary to the proven effectiveness of a single dose of perioperative antibiotics, the common use of local antimicrobial irrigation and prolonged postoperative oral antibiotics appears to be an inadequate component of our preventive armamentarium. Also, because methicillin-resistant staphylococcal and pseudomonal infections occurred approximately 60% of the time, at institutions that have observed an increase of these organisms, it may be prudent that perioperative antimicrobials target these microorganisms.
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Affiliation(s)
- George M Viola
- Division of Medicine, Department of Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, Texas
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Crawford T, Rodvold KA, Solomkin JS. Vancomycin for Surgical Prophylaxis? Clin Infect Dis 2012; 54:1474-9. [DOI: 10.1093/cid/cis027] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Byrne C, Hazlerigg A, Khan W, Smitham P. The role of perioperative care in reducing rates of methicillin resistant Staphylococcus aureus. J Perioper Pract 2012; 21:410-7. [PMID: 22263319 DOI: 10.1177/175045891102101202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Methicillin resistant Staphylococcus aureus (MRSA) is defined as any strain of Staphylococcus aureus resistant to beta-lactam antibiotics, including the penicillins and cephalosporins. Over the past ten years the UK has seen a dramatic increase in MRSA prevalence in healthcare facilities and the community, with an estimated 30-50% of healthy adults thought to be colonised with MRSA. Surgical patients are among those at highest risk. With potential sequelae including septicaemia, septic shock, septic arthritis, osteomyelitis, meningitis, pneumonia or endocarditis, it is vital that all care facilities have up to date evidence-based guidelines to tackle this problem. The purpose of this review is to highlight the current evidence supporting some of the key perioperative measures which may be implemented in preventing MRSA.
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Miller LG, McKinnell JA, Vollmer ME, Spellberg B. Impact of methicillin-resistant Staphylococcus aureus prevalence among S. aureus isolates on surgical site infection risk after coronary artery bypass surgery. Infect Control Hosp Epidemiol 2011; 32:342-50. [PMID: 21460485 DOI: 10.1086/658668] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Cephalosporins are recommended for antibiotic prophylaxis to prevent cardiothoracic surgical site infections (SSIs) except in patients with β-lactam allergy or in settings with a "high" prevalence of methicillin-resistant Staphylococcus aureus (MRSA) among S. aureus isolates (hereafter, "MRSA prevalence"); however, "high" remains undefined. We sought to identify the MRSA prevalence at which glycopeptide prophylaxis would minimize SSIs relative to β-lactam prophylaxis. METHODS We developed a decision analysis model to estimate SSI likelihood when either glycopeptides or β-lactams were used for prophylaxis in cardiothoracic surgery. Event probabilities were derived from a systematic literature review. A similar cost-minimization model was also developed. RESULTS At 0% MRSA prevalence, SSI probability was 3.64% with glycopeptide prophylaxis and 3.49% with β-lactam prophylaxis. At MRSA prevalences of 10%, 20%, 30%, or 40%, SSI probabilities with glycopeptide prophylaxis did not change, but they were 3.98%, 4.48%, 4.97%, and 5.47% with β-lactam prophylaxis. The threshold of MRSA prevalence at which glycopeptide prophylaxis minimized SSI probability and cost was 3%. In sensitivity analyses, variations in most model estimates only modestly affected the threshold. CONCLUSION Glycopeptide prophylaxis minimizes the risk of SSIs and cost when MRSA prevalence exceeds 3%. At very low MRSA prevalence (between 3% and 10%), the SSI minimization provided by glycopeptide prophylaxis is small and may be within the error of the model. Given the current MRSA prevalence in most community and healthcare settings, clinicians should consider routine prophylaxis with vancomycin. Our findings may have important policy implications, as benefits in cardiothoracic surgery antibiotic prophylaxis must be weighed against the limitations of increased glycopeptide use.
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Affiliation(s)
- Loren G Miller
- Infectious Diseases Clinical Outcomes Research Unit (ID-CORE), Division of Infectious Diseases, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Los Angeles, California, USA.
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Semel ME, Resch S, Haynes AB, Funk LM, Bader A, Berry WR, Weiser TG, Gawande AA. Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals. Health Aff (Millwood) 2010; 29:1593-9. [PMID: 20820013 PMCID: PMC3069616 DOI: 10.1377/hlthaff.2009.0709] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Use of the World Health Organization's Surgical Safety Checklist has been associated with a significant reduction in major postoperative complications after inpatient surgery. We hypothesized that implementing the checklist in the United States would generate cost savings for hospitals. We performed a decision analysis comparing implementation of the checklist to existing practice in U.S. hospitals. In a hospital with a baseline major complication rate after surgery of at least 3 percent, the checklist generates cost savings once it prevents at least five major complications. Using the checklist would both save money and improve the quality of care in hospitals throughout the United States.
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Affiliation(s)
- Marcus E Semel
- Brigham and Women's Hospital, Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA.
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Patrick S, James C, Ali A, Lawson S, Mary E, Modak A. Vascular Surgical Antibiotic Prophylaxis Study (VSAPS). Vasc Endovascular Surg 2010; 44:521-8. [PMID: 20675336 DOI: 10.1177/1538574410373837] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This prospective, randomized study was performed at a single institution. Low-risk patients undergoing elective vascular procedures were enrolled (August 2007 to June 2009). Participants were randomized into 3 separate arms. They received cefazolin, cefazolin + vancomycin, or cefazolin + daptomycin prior to surgery. In total, 169 patients were included in the analysis. Mean age was 64 (range, 26-85), and the patients’ comorbidities were similar across all groups. Only Szilagyi II and III infections were analyzed. Any infection/methicillin-resistant Staphylococcus aureus (MRSA) infections was seen in 8 (12.9%)/2 (3.23%) in the cefazolin group, 7 (12.5%)/4 (7.14%) in the cefazolin + vancomycin group, and 2 (3.92%)/(0%) in the cefazolin + daptomycin group. In this study, population of low-risk patients undergoing elective vascular procedures, there was a trend toward fewer infectious complications in the cefazolin + daptomycin group. Adding anti-MRSA agents to the current standard prophylaxis regimen does not appear to reduce the incidence of MRSA infection in low-risk patients.
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Affiliation(s)
- Stone Patrick
- Charleston Division, Vascular Surgery, West Virginia University, WV, USA
| | | | - AbuRahma Ali
- Division of Surgery, West Virginia University, WV, USA
| | - Safley Lawson
- Division of Surgery, West Virginia University, WV, USA
| | - Emmett Mary
- Center for Health Services and Outcomes Research
| | - Asmita Modak
- Center for Health Services and Outcomes Research
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Elliott RA, Weatherly HLA, Hawkins NS, Cranny G, Chambers D, Myers L, Eastwood A, Sculpher MJ. An economic model for the prevention of MRSA infections after surgery: non-glycopeptide or glycopeptide antibiotic prophylaxis? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2010; 11:57-66. [PMID: 19669182 DOI: 10.1007/s10198-009-0175-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 07/09/2009] [Indexed: 05/28/2023]
Abstract
AIM Surgical site infection is commonly caused by Staphylococcus aureus. The multiresistant strains (MRSA) are resistant to most antibiotic prophylaxis regimens. Our aim was to explore whether there is a threshold of MRSA prevalence at which switching to routine glycopeptide-based antibiotic prophylaxis becomes cost-effective. METHODS An indicative model was designed to explore the cost-effectiveness of vancomycin, cephalosporin or a combination, in patients undergoing primary hip arthroplasty. RESULTS If the MRSA infection rate is equal to or above 0.25% and the rate of other infections with cephalosporin prophylaxis is equal to or above 0.2%, use of the combination antibiotic prophylaxis is optimal. DISCUSSION Modelling the cost-effectiveness of interventions for MRSA prevention is complex due to uncertainty around resistance and effectiveness of glycopeptides. CONCLUSIONS The indicative model provides a framework for evaluation. More work is needed to understand the impact of antibiotic resistance over time in these currently effective antibiotics.
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Affiliation(s)
- Rachel A Elliott
- Division of Social Research in Medicines and Health, School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK.
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Tacconelli E, Cataldo M, Albanese A, Tumbarello M, Arduini E, Spanu T, Fadda G, Anile C, Maira G, Federico G, Cauda R. Vancomycin versus cefazolin prophylaxis for cerebrospinal shunt placement in a hospital with a high prevalence of meticillin-resistant Staphylococcus aureus. J Hosp Infect 2008; 69:337-44. [DOI: 10.1016/j.jhin.2008.04.032] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Accepted: 04/25/2008] [Indexed: 11/30/2022]
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Lichtenfels E, Lucas ML, Webster R, d' Azevedo PA. Profilaxia antimicrobiana em cirurgia vascular periférica: cefalosporina ainda é o padrão-ouro? J Vasc Bras 2007. [DOI: 10.1590/s1677-54492007000400012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Nas cirurgias vasculares periféricas, as cefalosporinas têm seu uso consagrado como agente antimicrobiano profilático de escolha. Recentemente, observamos uma mudança nos padrões de colonização, prevalência de patógenos e suscetibilidade geral aos antimicrobianos. Os patógenos multirresistentes vêm se tornando cada vez mais freqüentes nas infecções de ferida cirúrgica vascular, demonstrando variações regionais e locais quanto à suscetibilidade aos antimicrobianos profiláticos utilizados na rotina cirúrgica. Os dados e a literatura disponível até o momento demonstram que não existe evidência suficiente para uma mudança na rotina profilática perioperatória. Entretanto, devemos levar em consideração os padrões regionais e institucionais de prevalência de patógenos resistentes e padrões de suscetibilidade aos antimicrobianos para estabelecer guias e orientações específicas para a utilização de antimicrobianos profiláticos alternativos.
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Affiliation(s)
- Eduardo Lichtenfels
- Hospital Moinhos de Vento; Fundação Faculdade Federal de Ciências Médicas de Porto Alegre
| | - Márcio L. Lucas
- Irmandade Santa Casa de Misericórdia de Porto Alegre; FFFCMPA
| | - Ronaldo Webster
- Fundação Faculdade Federal de Ciências Médicas de Porto Alegre; Irmandade Santa Casa de Misericórdia de Porto Alegre
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Perencevich EN, Stone PW, Wright SB, Carmeli Y, Fisman DN, Cosgrove SE. Raising standards while watching the bottom line: making a business case for infection control. Infect Control Hosp Epidemiol 2007; 28:1121-33. [PMID: 17933084 DOI: 10.1086/521852] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
While society would benefit from a reduced incidence of nosocomial infections, there is currently no direct reimbursement to hospitals for the purpose of infection control, which forces healthcare institutions to make economic decisions about funding infection control activities. Demonstrating value to administrators is an increasingly important function of the hospital epidemiologist because healthcare executives are faced with many demands and shrinking budgets. Aware of the difficulties that face local infection control programs, the Society for Healthcare Epidemiology of America (SHEA) Board of Directors appointed a task force to draft this evidence-based guideline to assist hospital epidemiologists in justifying and expanding their programs. In Part 1, we describe the basic steps needed to complete a business-case analysis for an individual institution. A case study based on a representative infection control intervention is provided. In Part 2, we review important basic economic concepts and describe approaches that can be used to assess the financial impact of infection prevention, surveillance, and control interventions, as well as the attributable costs of specific healthcare-associated infections. Both parts of the guideline aim to provide the hospital epidemiologist, infection control professional, administrator, and researcher with the tools necessary to complete a thorough business-case analysis and to undertake an outcome study of a nosocomial infection or an infection control intervention.
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Affiliation(s)
- Eli N Perencevich
- Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Atahan E, Gul M, Ergun Y, Eroglu E. Vascular Graft Infection by Staphylococcus aureus: Efficacy of Cefazolin, Teicoplanin and Vancomycin Prophylaxis Protocols in a Rat Model. Eur J Vasc Endovasc Surg 2007; 34:182-7. [PMID: 17481929 DOI: 10.1016/j.ejvs.2007.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2006] [Accepted: 03/03/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Prophylactic efficiencies of cefazolin, teicoplanin and vancomycin in a dacron graft infection model caused by methicillin-susceptible (MSSA) or -resistant Staphylococcus aureus (MRSA) were investigated. DESIGN Prospective, randomized, controlled animal study. MATERIALS AND METHODS Infections were established subcutaneously in the back of rats by implantation of Dacron prostheses followed by topical inoculation onto grafts of MSSA or MRSA. Experimental groups were as follows: Uncontaminated group (control), MSSA- or MRSA-contaminated and untreated groups, MSSA- or MRSA-contaminated groups treated with cefazolin, teicoplanin or vancomycin by one of three regimens (one day, two days, or three days regimen). Grafts were removed 7 days after the implantation and evaluated by using sonication and quantitative blood agar culture. RESULTS Contaminated groups demonstrated graft infections. Cefazolin, teicoplanin and vancomycin profoundly prevented the graft infections in MSSA- or MRSA-contaminated groups. For each antibiotic regimen, the most effective prevention was achieved by the drugs given as three days regimen. For MSSA and MRSA, the order of the effectiveness was as follows: teicoplanin>vancomycin>cefazolin. CONCLUSION As a prophylactic agent, teicoplanin seems to be more effective than vancomycin and cefazolin against vascular graft infections caused by MSSA and MRSA in rats.
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Affiliation(s)
- E Atahan
- Department of Cardiovascular Surgery, School of Medicine, Kahramanmaras Sutcu Imam University, 46100, Turkey.
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Kato Y, Shime N, Hashimoto S, Nomura M, Okayama Y, Yamagishi M, Fujita N. Effects of controlled perioperative antimicrobial prophylaxis on infectious outcomes in pediatric cardiac surgery. Crit Care Med 2007; 35:1763-8. [PMID: 17507823 DOI: 10.1097/01.ccm.0000269027.50834.fe] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine the efficacy of a protocol for the prophylactic use of antimicrobials in pediatric cardiac surgery. DESIGN Nonrandomized comparison of two groups of patients studied sequentially. SETTING Pediatric intensive care unit of university hospital. PATIENTS Infants and children <18 yrs of age who had undergone cardiac surgery. INTERVENTIONS Limitation of prophylactic antimicrobials to <48 hrs after operation and, in patients at high risk of methicillin-resistant Staphylococcus aureus, strong recommendation to use glycopeptides. MEASUREMENTS AND MAIN RESULTS No intervention was applied in 189 patients (control group) during the first 21 months, whereas the intervention was applied in 185 patients (intervention group) during the next 18 months. In the intervention group, prophylaxis was recommended to be discontinued <48 hrs postoperatively. As a result, antimicrobials were administered for a median of 4 days (range 2-14) in the intervention group, significantly shorter than 7 days (3-35) in controls. This was associated with a trend toward a lower frequency of postoperative infections, including at the surgical site, and with significantly lower costs of antimicrobial therapy and a significantly lower rate of newly acquired nasal colonization with antibiotic-resistant pathogens in the intervention group (8%) than in controls (17%).Since, in the intervention group, glycopeptides were strongly recommended for patients at high risk of methicillin-resistant S. aureus, the frequency of surgical-site infections (0% vs. 18%) and the frequency of all infections (11% vs. 39%) were significantly lower in the intervention group than in the control group. CONCLUSIONS Limiting the duration of prophylactic antimicrobials was cost-effective and reduced the risk of acquiring resistant pathogens without increasing the frequency of postoperative infections. The use of glycopeptides in properly selected patients at high risk of methicillin-resistant S. aureus infection can lower the risk of postoperative infections.
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Affiliation(s)
- Yuko Kato
- Department of Anesthesiology and Intensive Care, Kyoto Prefectural University, School of Medicine, Kyoto, Japan
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25
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Engelman R, Shahian D, Shemin R, Guy TS, Bratzler D, Edwards F, Jacobs M, Fernando H, Bridges C. The Society of Thoracic Surgeons practice guideline series: Antibiotic prophylaxis in cardiac surgery, part II: Antibiotic choice. Ann Thorac Surg 2007; 83:1569-76. [PMID: 17383396 DOI: 10.1016/j.athoracsur.2006.09.046] [Citation(s) in RCA: 253] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Revised: 09/02/2006] [Accepted: 09/14/2006] [Indexed: 12/31/2022]
Affiliation(s)
- Richard Engelman
- Baystate Medical Center, Division of Cardiac Surgery, 759 Chestnut St, Springfield, MA 01199, USA.
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Merrer J, Desbouchages L, Serazin V, Razafimamonjy J, Pauthier F, Leneveu M. Comparison of routine prophylaxis with vancomycin or cefazolin for femoral neck fracture surgery: microbiological and clinical outcomes. Infect Control Hosp Epidemiol 2006; 27:1366-71. [PMID: 17152036 DOI: 10.1086/509846] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Accepted: 12/16/2005] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess the impact of antibiotic prophylaxis on the emergence of vancomycin-resistant strains of Enterococcus faecium, Enterococcus faecalis, and Staphylococcus aureus and the incidence of surgical site infection (SSI) after vancomycin or cefazolin prophylaxis for femoral neck fracture surgery. DESIGN Prospective cohort study. SETTING A hospital with a high prevalence of methicillin-resistant S. aureus (MRSA) carriage. PATIENTS All patients admitted with a femoral neck fracture from March 1, 2004 through February 28, 2005 were prospectively identified and screened for MRSA and vancomycin-resistant (VRE) carriage at admission and at day 7. Deep incisional and organ/space SSIs were also recorded. RESULTS Of 263 patients included in the study, 152 (58%) received cefazolin and 106 (40%) received vancomycin. At admission, the prevalence of MRSA carriage was 6.8%; it was 12% among patients with risk factors and 2.2% among patients with no risk factors (P=.002). At day 7 after surgery, there were 6 patients (2%) who had hospital-acquired MRSA, corresponding to 0.7% in the cefazolin group and 5% in the vancomycin group (P=.04); none of the MRSA isolates were resistant to glycopeptides. The rate of VRE carriage at admission was 0.4%. Three patients (1%) had acquired carriage of VRE (1 had E. faecium and 2 had E. faecalis); all 3 were in the cefazolin group (2% of patients) and none in the vancomycin group (P=.27). Eight SSIs (3%) occurred, 4% in the cefazolin group and 2% in the vancomycin group (P=.47). CONCLUSIONS This preliminary study demonstrates that cefazolin and vancomycin prophylaxis have similar impacts on the emergence of glycopeptide-resistant pathogens. Neither MRSA infection nor increased rates of SSI with other bacteria were observed in the vancomycin group, suggesting that a larger multicenter study should be initiated.
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Affiliation(s)
- Jacques Merrer
- Unité de Lutte Contre les Infections Nosocomiales, Hôpital de Poissy / St Germain-en-Laye, Poissy, France.
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Karra R, McDermott L, Connelly S, Smith P, Sexton DJ, Kaye KS. Risk factors for 1-year mortality after postoperative mediastinitis. J Thorac Cardiovasc Surg 2006; 132:537-43. [PMID: 16935107 DOI: 10.1016/j.jtcvs.2006.04.037] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Revised: 03/29/2006] [Accepted: 04/11/2006] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Postoperative mediastinitis after median sternotomy is associated with disability and mortality. The aim of this study was to identify risk factors for mortality 1 year after postoperative mediastinitis diagnosis. METHODS Postoperative mediastinitis was defined as an organ-space infection involving the mediastinum and necessitating debridement. A total of 183 cases of postoperative mediastinitis were prospectively identified from infection control databases. By using univariate and multivariate analysis, clinical risk factors for 1-year mortality were identified. RESULTS Of 183 patients, 36 (19.7%) died within 3 months of the initial operation. Overall, 51 (33%) died during the study period (the median time to death from the date of diagnosis was 37 days [interquartile range, 11,139 days]). In multivariate analysis, independent predictors of 1-year mortality were a greater than 3-day delay in sternal closure after debridement (hazard ratio, 6.27; P < .001), age greater than 65 years (hazard ratio, 2.29; P = .015), serum creatinine level greater than 2 mg/dL before debridement (hazard ratio, 2.52; P = .019), stay in an intensive care unit before sternal debridement (hazard ratio, 5.56; P < .001), and postoperative mediastinitis due to methicillin-resistant Staphylococcus aureus (hazard ratio, 2.13; P = .02). Treatment with antibiotics with in vitro activity against the infecting pathogen within 7 days of initial debridement was associated with a decreased risk for mortality (hazard ratio, 0.40; P = .03). CONCLUSIONS Our data suggest that, to improve long-term survival, patients with postoperative mediastinitis should undergo sternal closure within 72 hours after sternal debridement and should receive effective antimicrobial therapy based on operative culture results.
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Affiliation(s)
- Ravi Karra
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA.
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Abstract
NOSOCOMIAL SURGICAL SITE INFECTIONS (SSIs), especially those caused by antibiotic-resistant organisms, are a major concern for perioperative nurses. Administering the correct antibiotic at its effective dose within the optimal time frame can help prevent SSIs. THE SIGNIFICANT RELATIONSHIP between microbial resistance and overuse of antibiotics justifies an examination of practices and a move away from widespread antibiotic administration. NEW ANTIBIOTIC GUIDELINES and research support recommendations for antibiotic administration for specific cardiac, colorectal, gynecologic, ophthalmologic, orthopedic, and urinary surgical procedures. Perioperative nurses can help protect their patients from nosocomial SSIs by using this clinical evidence.
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de With K, Bergner J, Bühner R, Dörje F, Gonnermann C, Haber M, Hartmann M, Rothe U, Strehl E, Steib-Bauert M, Kern WV. Antibiotic use in German university hospitals 1998-2000 (Project INTERUNI-II). Int J Antimicrob Agents 2005; 24:213-8. [PMID: 15325423 DOI: 10.1016/j.ijantimicag.2004.03.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2004] [Accepted: 03/11/2004] [Indexed: 11/24/2022]
Abstract
In a pilot study we established a hospital antibiotic use database from which estimates for antibiotic consumption in German hospitals (expressed as defined daily doses per 100 patient days, DDD/100) can be retrieved for both benchmarking and antibiotic use and resistance research purposes. Data from eight university hospitals (1998-2000) showed a mean antibiotic use density of 60.1 DDD/100 in the surgical and 79.3 DDD/100 in the medical services. Antibiotic use was higher in the intensive care units (surgery: 146 DDD/100, medicine: 187 DDD/100) than in haematology-oncology services (110.8 DDD/100) or in other surgical (51.6 DDD/100) and medical (66 DDD/100) service areas. There were major differences in the use of specific antibacterial drug classes between service areas. The established database allows detailed analysis in antibacterial drug use and can be linked to bacterial resistance surveillance databases.
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Affiliation(s)
- Katja de With
- Center for Infectious Diseases and Travel Medicine, University Hospital, Hugstetter Strass 55, D-79106 Freiburg, Germany
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Merrer J, Pisica-Donose G, Leneveu M, Pauthier F. Prevalence of methicillin-resistant Staphylococcus aureus nasal carriage among patients with femoral neck fractures: implication for antibiotic prophylaxis. Infect Control Hosp Epidemiol 2004; 25:515-7. [PMID: 15242202 DOI: 10.1086/502432] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Fifteen (8.4%) of 179 patients admitted with femoral neck fractures carried MRSA. Among 96 patients admitted from their homes, only 2 (2%) were carriers, whereas 13 (15.6%) of 83 patients from nursing or residential homes or long-term-care facilities were colonized (P = .001). Routine prophylaxis with vancomycin is recommended in the latter group.
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Affiliation(s)
- Jacques Merrer
- Department of Public Health, Infection Control Unit, Hôpital Intercommunal de Poissy/St. Germain-en-Laye, France
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Movahed MR, Kasravi B, Bryan CS. Prophylactic use of vancomycin in adult cardiology and cardiac surgery. J Cardiovasc Pharmacol Ther 2004; 9:13-20. [PMID: 15094964 DOI: 10.1177/107424840400900i103] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The recent appearance of Staphylococcus aureus and Staphylococcus epidermidis strains that have reduced susceptibility to vancomycin, and the spread of vancomycin-resistant enterococci, raise the specter of endovascular infections that will be difficult or impossible to cure with available drugs. We review issues concerning the prophylactic use of vancomycin in adult cardiology and cardiac surgery with special attention to dosing and indications. There is no indication for the routine use of prophylactic vancomycin in pacemaker implantations, cardiac catheterization, and transesophageal echocardiography. In institutions with a high incidence of methicillin-resistant S. aureus and S. epidermidis, vancomycin may be used for antibiotic prophylaxis in place of cephalosporins for pacemaker or defibrillator implantation. The strongest evidence in support of the prophylactic use of vancomycin is during cardiac surgeries, particularly valvular surgeries in institutions with a high prevalence of methicillin-resistant S. aureus and S. epidermidis. When vancomycin is used prior to open heart surgery, the dose should be 15 mg/kg rather than the standard 1 g dose that is often recommended in the literature and used by 85% of institutional pharmacists who responded to our survey. Cardiologists and cardiac surgeons should assume leadership roles in promoting its responsible use.
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Affiliation(s)
- Mohammad-Reza Movahed
- Department of Medicine, Division of Cardiology, University of California-Irvine Medical Center, Building 53, Route 81, Room 100, 101 The City Drive South, Orange, CA 92868-4080, USA.
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Zanetti G, Platt R. Antibiotic Prophylaxis for Cardiac Surgery: Does the Past Predict the Future? Clin Infect Dis 2004; 38:1364-6. [PMID: 15156471 DOI: 10.1086/383329] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2004] [Accepted: 01/26/2004] [Indexed: 11/03/2022] Open
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Bolon MK, Morlote M, Weber SG, Koplan B, Carmeli Y, Wright SB. Glycopeptides are no more effective than beta-lactam agents for prevention of surgical site infection after cardiac surgery: a meta-analysis. Clin Infect Dis 2004; 38:1357-63. [PMID: 15156470 DOI: 10.1086/383318] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2003] [Accepted: 12/21/2003] [Indexed: 01/28/2023] Open
Abstract
A meta-analysis was performed to investigate whether a switch from beta-lactams to glycopeptides for cardiac surgery prophylaxis should be advised. Results of 7 randomized trials (5761 procedures) that compared surgical site infections (SSIs) in subjects receiving glycopeptide prophylaxis with SSIs in those who received beta -lactam prophylaxis were pooled. Neither agent proved to be superior for prevention of the primary outcome, occurrence of SSI at 30 days (risk ratio [RR], 1.14; 95% confidence interval [CI], 0.91-1.42). In subanalyses, beta-lactams were superior to glycopeptides for prevention of chest SSIs (RR, 1.47; 95% CI, 1.11-1.95) and approached superiority for prevention of deep-chest SSIs (RR, 1.33; 95% CI, 0.91-1.94) and SSIs caused by gram-positive bacteria (RR, 1.36; 95% CI, 0.98-1.91). Glycopeptides approached superiority to beta-lactams for prevention of leg SSIs (RR, 0.77; 95% CI, 0.58-1.01) and were superior for prevention of SSIs caused by methicillin-resistant gram-positive bacteria (RR, 0.54; 95% CI, 0.33-0.90). Standard prophylaxis for cardiac surgery should continue to be beta-lactams in most circumstances.
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Affiliation(s)
- Maureen K Bolon
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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Engemann JJ, Carmeli Y, Cosgrove SE, Fowler VG, Bronstein MZ, Trivette SL, Briggs JP, Sexton DJ, Kaye KS. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis 2003; 36:592-8. [PMID: 12594640 DOI: 10.1086/367653] [Citation(s) in RCA: 639] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2002] [Revised: 11/26/2002] [Indexed: 11/03/2022] Open
Abstract
Data for 479 patients were analyzed to assess the impact of methicillin resistance on the outcomes of patients with Staphylococcus aureus surgical site infections (SSIs). Patients infected with methicillin-resistant S. aureus (MRSA) had a greater 90-day mortality rate than did patients infected with methicillin-susceptible S. aureus (MSSA; adjusted odds ratio, 3.4; 95% confidence interval, 1.5-7.2). Patients infected with MRSA had a greater duration of hospitalization after infection (median additional days, 5; P<.001), although this was not significant on multivariate analysis (P=.11). Median hospital charges were 29,455 dollars for control subjects, 52,791 dollars for patients with MSSA SSI, and 92,363 dollars for patients with MRSA SSI (P<.001 for all group comparisons). Patients with MRSA SSI had a 1.19-fold increase in hospital charges (P=.03) and had mean attributable excess charges of 13,901 dollars per SSI compared with patients who had MSSA SSIs. Methicillin resistance is independently associated with increased mortality and hospital charges among patients with S. aureus SSI.
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Affiliation(s)
- John J Engemann
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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Allen G. Perioperative prophylaxis; viral transmission; surgical scrubs; iodophors; hepatitis B vaccine. AORN J 2002. [DOI: 10.1016/s0001-2092(06)60949-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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