Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle

Infective endocarditis and litigation for compensation on healthcare-associated infections: An Italian sample analysis

BACKGROUND

Litigation related to Healthcare-Associated Infections (HAIs) in Italy represent a growing field of interest in establishing the medico-legal link between infection and the healthcare environment and practices for compensation; it is little explored in the cardiovascular surgery regarding infective endocarditis (IE).

METHODS

We retrospectively analysed the civil judgements on infective endocarditis in the Italian region Emilia-Romagna from 2016 to July 2024 using Ministry of Justice national official database. The search was conducted on the online database on July 31, 2024, using the free word "endocarditis". Two authors independently analysed the full-text judgements: , those IE without relevance in the reason for the claim were excluded. Main items were the timeline and outcome, with complaint motivation and liability ascertainment. In-court confirmation of healthcare causal link was reported.

RESULTS

Twenty-five judgments were retrieved. After screening for inclusion, nineteen judgements (11 of first instance and 8 of appeal) were included, for overall 15 cases of infective endocarditis. Of the fifteen cases, median age 60.5 years, 73 % males, median time for claim 6 years, for judgement 10 years and, if appealed, 16.5 years. Annual distribution of the claims was linear over time. Eleven (67 %) infective endocarditis were confirmed as healthcare-associated in trial. The prevalent reason for liability was improper or delayed diagnosis and/or treatment of the IE. Valvular surgery resulted in 40 %, while the more frequent pathogens were Staphylococcus aureus (40 %) and epidermidis (30 %). Of fifteen cases, 73 % was decided in favour of the patient-claimant, with an average cost of €289.872, plus an additional €55.296 in case of appeal. Only in 25 % the appeal's judge changed decision. In all cases, technical advisors were appointed.

CONCLUSIONS

This sample provides an initial insight into litigation for compensation related to infective endocarditis, highlighting specific characteristics compared to HAIs management in court. Medico-legal reasoning should be integrated into infection prevention and control policies and overall clinical risk management strategies.

Temporal Patterns and Treatment Associations in Complications Following Hip Arthroplasty

Background and Objectives: Hip arthroplasty is commonly performed to enhance mobility and quality of life in patients with severe joint degeneration. However, post-surgery complications such as infections, dislocations, and mechanical failures remain prevalent and vary over time. This study examines the relationship between time intervals post-surgery and the occurrence of complications and explores the associations between specific treatment modalities and complications. It also investigates temporal patterns of infectious and mechanical complications to inform more effective post-surgery care. Materials and Methods: A retrospective cohort study was conducted on hip arthroplasty patients to analyze the occurrence and distribution of complications across medium-term (1-5 years) and long-term (≥6 years) intervals. Treatment modalities, including joint debridement, lavage, antibiotics, and mechanical interventions, were analyzed for their association with complications. Chi-Square tests were used, with significance set at p < 0.05. Results: A significant association was found between time intervals and complications (χ2 = 58.149, df = 19, p < 0.001). Infections were more prevalent in the medium-term, while mechanical complications such as dislocation, implant loosening, and periprosthetic fractures were more common in the long-term. Antibiotics were strongly linked to infectious complications (χ2 = 279.000, p < 0.001), and mechanical treatments were associated with fractures and dislocations. Conclusions: The study confirms that the timing of complications post-surgery plays a critical role in their occurrence. Specific complications become more prevalent at different intervals, emphasizing the need for tailored treatment strategies. Antibiotics for infections and mechanical interventions for fractures and dislocations should be adjusted based on timing. These findings highlight the importance of time-specific post-surgery care and suggest areas for further research on long-term strategies and risk factors.

Epidemiological analysis of intra-abdominal infections in Italy from the Italian register of complicated intra-abdominal infections-the IRIS study: a prospective observational nationwide study

BACKGROUND

Intra-abdominal infections (IAIs) are common and severe surgical emergencies associated with high morbidity and mortality. In recent years, there has been a worldwide increase in antimicrobial resistance associated with intra-abdominal infections, responsible for a significant increase in mortality rates. To improve the quality of treatment, it is crucial to understand the underlying local epidemiology, clinical implications, and proper management of antimicrobial resistance, for both community- and hospital-acquired infections. The IRIS study (Italian Register of Complicated Intra-abdominal InfectionS) aims to investigate the epidemiology and initial management of complicated IAIs (cIAIs) in Italy.

MATERIAL AND METHOD

This is a prospective, observational, nationwide (Italy), multicentre study. approved by the coordinating centre ethic committee (Local Research Ethics Committee of Pisa (Prot n 56478//2019). All consecutively hospitalized patients (older than 16 years of age) with diagnosis of cIAIs undergoing surgery, interventional drainage or conservative treatment have been included.

RESULTS

4530 patients included from 23 different Italian hospitals. Community Acquired infection represented the 70.9% of all the cases. Among appendicitis, we found that 98.2% of the cases were community acquired (CA) and 1.8% Healthcare-associated (HA) infections. We observed that CA represented the 94.2% and HA 5.8% of Gastro Duodenal perforation cases. The majority of HA infections were represented by colonic perforation and diverticulitis (28.3%) followed by small bowel occlusion (19%) and intestinal ischemia (18%). 27.8% of patients presented in septic shock. Microbiological Samples were collected from 3208 (70.8%) patients. Among 3041 intrabdominal sample 48.8% resulted positive. The major pathogens involved in intra-abdominal infections were found to be E.coli (45.6%). During hospital stay, empiric antimicrobial therapy was administered in 78.4% of patients. Amoxicillin/clavulanate was the most common antibiotic used (in 30.1% appendicitis, 30% bowel occlusion, 30.5% of cholecystitis, 51% complicated abdominal wall hernia, 55% small bowel perforation) followed by piperacillin/tazobactam (13.3% colonic perforation and diverticulitis, 22.6% cholecystitis, 24.2% intestinal ischemia, 28.6% pancreatitis). Empiric antifungal therapy was administered in 2.6% of patients with no sign of sepsis, 3.1% of patients with clinical sign of sepsis and 4.1% of patients with septic shock. Azoles was administered in 49.2% of patients that received empiric antifungal therapy. The overall mortality rate was 5.13% (235/4350). 16.5% of patients required ICU (748/4350). In accordance with mortality, it is important to highlight that 35.7% of small bowel perforation, 27.6% of colonic perforation and diverticulitis, 25.6% of intestinal ischemia and 24.6% of gastroduodenal complications required ICU.

CONCLUSION

Antibiotic stewardship programs and correct antimicrobial and antimycotic prescription campaigns are necessary to ulteriorly improve the adequacy of drug usage and reduce the resistances burden. This will help in improving the care and the cure of the next generations.

Point Prevalence Survey of Antibiotic Use in Level 1 hospitals in Zambia: Future Prospects for Antimicrobial Stewardship Programs

Introduction

The inappropriate prescribing and use of antibiotics have contributed to the emergence and spread of antimicrobial resistance (AMR). In Zambia, there is a paucity of information on the prescribing patterns and use of antibiotics among hospitalized patients in level 1 hospitals. This study investigated antibiotic use in five level 1 hospitals in Lusaka, Zambia.

Methods

This cross-sectional study utilized the World Health Organization (WHO) Point Prevalence Survey (PPS) methodology among in-patients admitted in level 1 hospitals before 08:00 a.m. on the survey day in August 2024. Data were analysed using IBM SPSS version 23.0.

Results

The prevalence of antibiotic use among inpatients was 59.0%, with ceftriaxone being the most prescribed. Antibiotics were prescribed mainly for paediatrics and male inpatients. This study found that 53.0% of prescribed antibiotics were from the Access group while 38.2% were from the Watch group of the World Health Organization Access, Watch, and Reserve (AWaRe) classification. Adherence to national treatment guidelines was 36.0%, with most antibiotics prescribed empirically without evidence of culture and sensitivity tests.

Conclusion

This study found a high use of antibiotics and low adherence to treatment guidelines in level 1 hospitals in Lusaka, Zambia. The findings of this study demonstrate the need to establish and strengthen antimicrobial stewardship programs and strengthen laboratory capacity to aid clinicians in diagnosing, treating, and managing patients across level 1 hospitals in Zambia.

Synthesizing evidence to guide the design and implementation of effective strategies for discontinuing postoperative antibiotic prophylaxis in surgical settings: an umbrella review post-WHO 2018 recommendations

BACKGROUND

Postoperative antibiotic prophylaxis (PAP) involves using antibiotics after surgery to prevent surgical site infections (SSIs). However, studies have shown that PAP offers no additional benefits compared to discontinuation after surgical incision closure, prompting its de-implementation to prevent unnecessary antibiotic use that may contribute to antibiotic resistance. We conducted this review to synthesize evidence for guiding the design and implementation of effective strategies for discontinuing PAP practice and optimizing antibiotic use in surgical settings.

METHODS

This umbrella review searched for articles from PubMed/MEDLINE and Scopus, focusing on reviews conducted on human subjects on PAP to prevent SSIs, published in English language from 2019 to 5th July 2024. This review followed guidelines from PRISMA-P and PRIOR. The risk of bias (methodological quality) was assessed using AMSTAR-2. The pooled risk ratio (RR) was estimated using a fixed-effects model (Mantel-Haenszel method), while I2 was used to assess the heterogeneity between reviews. This review was registered with PROSPERO (CRD42024566124).

RESULTS

In our umbrella review, we screened 1156 articles, with 28 review articles found eligible for final analysis, involving over 457 primary studies. About 80,483 patients were involved in 9 meta-analysis reviews, which were used to estimate the pooled RR. We found no significant benefits to patients from continuing PAP beyond 24-h post-surgery compared to immediate discontinuation, RR: 1.07 (95% CI: 0.97-1.17, I2: 25%, p-value: 0.22). Strategies such as regularly assessing and refining guidelines to fit specific surgical settings and patients' characteristics, multidisciplinary collaboration, availability of resources needed for best practices, education and training healthcare workers on SSI prevention and antibiotic stewardship, and patient education in SSI prevention and proper antibiotic use were recommended to improve best practices in surgical settings.

CONCLUSIONS

Prolonging antibiotic prophylaxis beyond 24-h post-surgery did not show significant protective benefits against SSIs. Our findings support the 2018 WHO recommendation for the immediate discontinuation of PAP following surgical incision closure in clean and clean-contaminated procedures. Further de-implementation research studies are needed to guide the effective discontinuation of PAP practice.

Comparison of the Efficacy of Cephalosporins and Non-cephalosporins in Preventing Surgical Site Infections in Colorectal Surgery Patients: An Updated Systematic Review and Meta-Analysis

OBJECTIVE

This study aims to compare the efficacy of cephalosporin and non-cephalosporin antibiotics in preventing surgical site infections (SSIs) in patients undergoing colorectal surgery, providing a scientific basis for the selection of perioperative antibiotics through systematic review and meta-analysis.

METHODS

Adhering to the PRISMA guidelines, this research employed an extensive literature search strategy across multiple databases to identify relevant studies, including randomized controlled trials (RCTs) and observational studies. Inclusion criteria were studies on adults undergoing colorectal surgery who received preoperative prophylaxis with either cephalosporin or non-cephalosporin antibiotics. Exclusion criteria included preoperative diagnosis of infectious diseases and preoperative use of antimicrobial agents. Meta-analysis was conducted using RevMan 5.3 software to assess the effectiveness of both antibiotic classes in preventing SSIs, including subgroup analyses.

RESULTS

Eight studies met the inclusion criteria, comprising 872 patients. Meta-analysis revealed that the incidence of SSI in the cephalosporin group was lower than in the non-cephalosporin group (14.8% vs 25.1%), with statistical significance (OR = 1.94, 95% CI: 1.38-2.74, PP = =0.0001). However, no significant difference in SSI risk was observed between the groups within 30 days (OR = =1.92, 95% CI: 1.08-3.42). Subgroup analysis indicated that higher-quality studies were associated with larger effect sizes.

CONCLUSION

This study suggests that cephalosporin antibiotics may be superior to non-cephalosporins in preventing SSIs following colorectal surgery, especially in the short term. However, their long-term efficacy in SSI prevention may be similar. The selection of perioperative antibiotics should consider factors such as the antimicrobial spectrum, pharmacokinetic properties, and bacterial resistance.

Oral Antibiotics Alone versus Oral Antibiotics Combined with Mechanical Bowel Preparation for Elective Colorectal Surgery: A Propensity Score-Matching Re-Analysis of the iCral 2 and 3 Prospective Cohorts

The evidence regarding the role of oral antibiotics alone (oA) or combined with mechanical bowel preparation (MoABP) for elective colorectal surgery remains controversial. A prospective database of 8359 colorectal resections gathered over a 32-month period from 78 Italian surgical units (the iCral 2 and 3 studies), reporting patient-, disease-, and procedure-related variables together with 60-day adverse events, was re-analyzed to identify a subgroup of 1013 cases (12.1%) that received either oA or MoABP. This dataset was analyzed using a 1:1 propensity score-matching model including 20 covariates. Two well-balanced groups of 243 patients each were obtained: group A (oA) and group B (MoABP). The primary endpoints were anastomotic leakage (AL) and surgical site infection (SSI) rates. Group A vs. group B showed a significantly higher AL risk [14 (5.8%) vs. 6 (2.5%) events; OR: 3.77; 95%CI: 1.22-11.67; p = 0.021], while no significant difference was recorded between the two groups regarding SSIs. These results strongly support the use of MoABP for elective colorectal resections.

Hospital prescribing patterns of antibiotics in Zambia using the WHO prescribing indicators post-COVID-19 pandemic: findings and implications

Background

Antimicrobial resistance (AMR) is a global public health problem that is fuelled by the inappropriate prescribing of antibiotics, especially those from the 'watch' and 'reserve' antibiotic lists. The irrational prescribing of antibiotics is particularly prevalent in developing countries, including Zambia. Consequently, there is a need to better understand prescribing patterns across sectors in Zambia as a basis for future interventions. This study evaluated the prescribing patterns of antibiotics using the WHO prescribing indicators alongside the 'access, watch and reserve' (AWaRe) classification system post-COVID pandemic at a faith-based hospital in Zambia.

Methods

A cross-sectional study was conducted from August 2023 to October 2023 involving the review of medical records at St. Francis' Mission Hospital in Zambia. A WHO-validated tool was used to evaluate antibiotic prescribing patterns alongside the AWaRe classification tool.

Results

Out of 800 medical records reviewed, 2003 medicines were prescribed. Each patient received an average of 2.5 medicines per prescription. Antibiotics were prescribed in 72.3% of encounters, of which 28.4% were injectable. The most frequently prescribed antibiotics were amoxicillin (23.4%-access), metronidazole (17.1%-access), ciprofloxacin (8%-watch) and ceftriaxone (7.4%-watch), with 77.1% overall from the 'access' list. Encouragingly, 96.5% of the medicines were prescribed by their generic names and 98% were from the Zambia Essential Medicines List.

Conclusions

There were high rates of antibiotic prescribing, including injectable antibiotics, which needs addressing going forward. It is crucial to implement targeted measures, including antimicrobial stewardship programmes, to improve future antibiotic prescribing in Zambia and reduce the risk of AMR.