Administration Of Perioperative Antibiotic Prophylaxis Research Articles

Perioperative antibiotic prophylaxis in skin surgery - Position paper of the Antibiotic Stewardship working group of the German Society for Dermatologic Surgery (DGDC), Part 2: Special indications and situations.

In addition to prevention of surgical site infections after skin surgery, perioperative antibiotic prophylaxis (PAP) aims to prevent the occurrence of other postoperative infectious complications, especially bacterial endocarditis and hematogenous joint prosthesis infections. This article discusses specific indications for the use of PAP. For example, patients who have undergone any type of heart valve replacement, including transcatheter valve replacement or use of prosthetic material to correct the heart valve, or patients who have experienced bacterial endocarditis, require PAP during skin surgery on mucosal membranes or ulcerated tumors. The use of PAP in special situations such as secondary wound healing, septic dermatosurgery or ulcer surgery is also presented and discussed in detail in this paper based on the current scientific literature. This paper represents the second part of the position paper of the Antibiotic Stewardship Working Group of the German Society for Dermatologic Surgery (DGDC) and summarizes evidence-based recommendations for the administration of PAP during skin surgery for special indications and situations. This is particularly important because, as detailed in Part 1 of this position paper, PAP can and usually should be avoided in skin surgery.

Efficacy of perioperative antibiotic prophylaxis in elective soft-tissue-only wrist arthroscopy

Wrist arthroscopy is a standard procedure in hand surgery for diagnosis and treatment of wrist injuries. Even though not generally recommended for similar procedures, general administration of perioperative antibiotic prophylaxis (PAP) is still widely used in wrist arthroscopy. A clinical ambispective dual-centre study was performed to determine whether PAP reduces postoperative infection rates after soft tissue-only wrist arthroscopies. Retrospective and prospective data was collected at two hospitals with departments specialized in hand surgery. During the study period, 464 wrist arthroscopies were performed, of these 178 soft-tissue-only interventions met the study criteria and were included. Signs of postoperative infection and possible adverse drug effects (ADEs) of PAP were monitored. Additionally, risk factors for surgical site infection (SSIs), such as diabetes mellitus and BMI, were obtained. The overall infection rate of SSI was zero. Neither in the PAP group (n = 69) nor in the control group (n = 109) were signs of postoperative infection observed. Observed symptoms of ADEs were three-times higher in the PAP group when compared to the control-group (16.3 vs 5.5%; p = 0.043). No major ADEs were observed, but one in ten patients in the PAP group reported mild to severe intestinal or hypersensitivity symptoms. We demonstrate that the number needed to treat (NNT) with PAP to prevent one postoperative infection in soft-tissue arthroscopies of the wrist is > 109. Conversely, symptoms of ADEs were reported by one out of ten patients given PAP. Considering the high NNT to prevent postoperative infection and the large number of ADEs caused by PAP, we recommend not to use PAP routinely in soft-tissue arthroscopies of the wrist. Subsequent large-scale studies should be conducted to substantiate these results.

Post-percutaneous Nephrolithotomy Urosepsis: Does Stone Culture Add Value?

Introduction: Percutaneous Nephrolithotomy (PCNL) is the most commonly performed intrarenal surgery worldwide for the management of renal stones. Despite the administration of perioperative antibiotic prophylaxis, a significant number of patients develop Systemic Inflammatory Response Syndrome (SIRS), and several research articles have reported post-PCNL sepsis in 0.4-3% of cases. Despite having a sterile preoperative urine culture, the incidence of sepsis mentioned above could possibly be attributed to the presence of organisms in the stone. These organisms may enter the bloodstream during surgery and manifest as urosepsis. Aim: To determine whether the microbial spectrum of preoperative urine and postoperative stone culture can serve as predictors of urosepsis. Materials and Methods: A prospective observational study was conducted at the Department of Urology at Bharati Medical College and Hospital, Pune, Maharashtra, India involving all patients (sample size=167) undergoing PCNL between August 2019 and July 2021. The PCNL procedure was performed according to standard guidelines. To obtain a renal stone culture, authors followed the technique described by Nemoy NJ and Stamey TA. Postoperatively, patients were closely monitored for signs of systemic inflammatory response. Demographic and continuous variables were summarised using mean and standard deviation, while categorical variables (such as urine culture and stone culture, organisms isolated) were summarised using frequency and percentage. Statistical analysis was performed using unpaired t-test for quantitative variables and Chi-square test for qualitative variables, with a significance level set at 5%. Results: The mean age of the study participants was 39 years. Although the spectrum of organisms differed in many cases, E.coli (11.4% versus 12.6%) was more prevalent in stone cultures compared to Enterococcus (9% versus 7.2%). Staphylococcus saprophyticus (66.6%) was isolated from stone cultures, while E.coli (66.6%) was predominant in urine cultures. Sepsis/SIRS was effectively managed with antibiotic treatment based on stone culture (p=0.001) rather than urine culture (p=0.047). Conclusion: Routine stone culture not only helps in better prediction of potential sepsis but also guides the appropriate choice of antibiotics for sepsis management.

Impact of duration of perioperative antibiotic prophylaxis on development of fracture-related infection in open fractures.

Infection is a common complication of open fractures potentially leading to nonunion, functional loss, and even amputation. Perioperative antibiotic prophylaxis (PAP) is standard practice for infection prevention in the management of open fractures. However, optimal duration of PAP remains controversial. The objectives were to assess whether PAP duration is independently associated with infection in open fractures and if administration of PAP beyond the commonly-recommended limit of 72h has any effect on the infection rate. Over a 14-year period from 2003 to 2017, 530 skeletally-mature patients with operatively-treated, non-pathologic, long-bone open fractures were treated at one institution. Twenty-eight patients were excluded because of death or loss to follow-up and the remaining 502 patients (with 559 open fractures) who completed a 24-month follow-up were included in this retrospective study. The outcome was fracture-related infection (FRI), defined by the criteria of a recent consensus definition. A logistic generalized estimating equations regression model was conducted, including PAP duration and variables selected by a least absolute shrinkage and selection operator (LASSO) method, to assess the association between PAP duration and FRI. Propensity score analysis using a 72-h cut-off was performed to further cope with confounding. PAP duration, adjusted for the LASSO selected predictors, was independently associated with FRI (OR: 1.11 [95%CI, 1.04-1.19] for every one-day increase in PAP duration, p = 0.003). PAP duration longer than 72h did not significantly increase the odds for FRI compared to shorter durations (p = 0.06, analysis adjusted for propensity score). This study found no evidence that administration of prophylactic antibiotics beyond 72h in patients with long-bone open fractures is warranted. Analyses adjusted for known confounders even revealed a higher risk for FRI for longer PAP. However, this effect cannot necessarily be considered as causal and further research is needed.

Local Application of a Gentamicin-Loaded Hydrogel Early After Injury Is Superior to Perioperative Systemic Prophylaxis in a Rabbit Open Fracture Model.

Open fractures are at significant risk of developing a fracture-related infection, despite the routine administration of perioperative antibiotic prophylaxis. Early application of antibiotic prophylaxis is known to reduce infection rates; however, most international guidelines focus on postoperative duration rather than prehospital administration. We compared conventional perioperative prophylaxis against early prehospital prophylaxis either as a systemic single shot of cefuroxime or a locally applied gentamicin-loaded hydrogel in a laboratory animal model. Thirty New Zealand white rabbits underwent a first surgical procedure to create an open wound, bone damage and contamination with Staphylococcus aureus. After a 4-hour observation period mimicking the time-to-treatment, the animals underwent a second procedure to irrigate the wound and apply a fracture fixation device. The 5 groups (n = 6 per group) received (1) no treatment; (2) conventional 24-hour cefuroxime; (3) an early single shot of cefuroxime 15 minutes after trauma; (4) a combined early and standard systemic prophylaxis; and (5) early application of a gentamicin-loaded hydrogel that was removed during irrigation. Untreated animals displayed high numbers of bacteria in irrigation fluid and were all highly culture positive at euthanasia. Three of 6 animals were culture positive at euthanasia after conventional prophylaxis. Early systemic prophylaxis reduced bacterial burden in irrigation fluid by up to 100-fold, but 5/6 animals were culture positive at euthanasia. The combined prophylaxis displayed greater efficacy with only 1/6 rabbits culture positive at euthanasia. Local application of the gentamicin-loaded hydrogel reduced bacteria recovered by irrigation to just above our detection limit, and at euthanasia, all animals were culture negative at euthanasia. Early systemic antibiotic administration can significantly reduce bacterial burden in the operative field and reduce culture positivity at euthanasia when continued for 24 hours after injury. The early application of a gentamicin-loaded hydrogel that was removed during irrigation displayed superior efficacy to early systemic therapy alone and postoperative conventional gold standard 24-hour systemic therapy alone. These experimental results highlight the importance of early antibiotic administration in fracture care.

Infections following arthroscopic rotator cuff repair: incidence, risk factors, and prophylaxis.

The primary aim of the present study was to determine the incidence of infections following arthroscopic rotator cuff repair in a single department over a 10-year period. Secondary goals included the evaluation of potential risk factors for infections and to investigate the efficacy of perioperative antibiotic prophylaxis in the reduction of infectious complications. A retrospective evaluation of 3294 all-arthroscopic rotator cuff repairs performed between 2004 and 2014 at a single institution was conducted to determine the rate of infection in all-arthroscopic rotator cuff repairs. Detailed data including demographics, co-morbidities, initial surgical procedure, time from index surgery to infection, clinical presentation, isolated pathogens, and subsequent treatment were recorded of patients with infections. Univariate logistic regression was performed, and a multivariate model was developed to identify variables that were predictive of infections following arthroscopic rotator cuff repair. The rate of infection was 8.5/1000 in whom rotator cuff repairs were performed (95% CI 0.58-1.23%) during the study period. The most commonly identified pathogen was Staphylococcus epidermidis (n=11, 39.3%), followed by Propionibacterium acnes (n=8, 28.6%) and Staphylococcus aureus (n=2, 7.1%). Patients presented at our institution with signs of infection an average of 28.9±14.7days after the index surgery. The leading symptom that was present in all patients was diffuse or localized shoulder pain, followed by local signs of infection in 19 (67.9%), secretion in 14 (50%), and fever in 9 (32.1%) patients, respectively. Univariate and multivariate analyses identified the male gender, age over 60, and duration of surgery over 90min as predictive factors for infection. Administration of perioperative antibiotic prophylaxis was an independent mitigating factor for postoperative infection and reduced the infection rate from 1.54% (95% CI 0.98-2.30%) to 0.28% (95% CI 0.10-0.67%). The overall incidence of infection was 8.5/1000 arthroscopic rotator cuff repairs over a 10-year period. Gender, age, and length of surgery were identified as predictive factors for infection. The administration of perioperative antibiotic prophylaxis significantly reduced the overall risk of infection and is therefore recommended in all-arthroscopic rotator cuff repairs. However, current prophylactic treatment strategies were not equally efficient for all types of pathogens. Retrospective comparative study, Level III.

May the drain be a way in for microbes in surgical infections?

Surgical site infection (SSI) is among the most frequent hospital-acquired infections occurring in surgical patients and leads to increased morbidity, mortality, and costs. We aimed to identify risk factors for SSI in patients undergoing surgical procedures, with a particular attention to the use of drains. This study includes all patients undergoing abdominal surgical procedures in 2 surgical wards in a teaching hospital in central Italy. Collected data included patient's demographic and clinical characteristics, procedure characteristics, administration of perioperative antibiotic prophylaxis, and microorganism isolated. The outcome of interest was SSI. A total of 872 abdominal surgery procedures were surveyed during the study period. Drains were placed in 37.0% of cases. SSI rate was 6.4% globally and 13.6% among the patients with drains, versus 2.4% in those without a drain (P < .001). In 72.1% of cases antibiotic prophylaxis was administered. The logistic regression analysis (P < .001) shown insertion of a drain (odds ratio [OR], 5.14; 95% confidence interval [CI], 2.63-10.08), prolonged surgery (OR, 1.98; 95% CI, 1.09-3.59), and American Society of Anesthesiologists score equal to 3 (OR, 6.13; 95% CI, 2.33-16.11) as independent risk factors for SSI, whereas antibiotic prophylaxis was protective (OR, 0.53; 95% CI, 0.29-0.99). This study revealed surgical drains as a risk factor for SSI, pointing out the need of a clearer understanding of drain role in the dynamics of SSI occurrence, with the purpose of decreasing infection risk through targeted preventive interventions.

A standardized protocol for perioperative antibiotic prophylaxis is associated with improvement of timing and reduction of costs

The objectives of this study were to implement a uniform guideline for perioperative antibiotic prophylaxis (PAP) and to measure the impact on timing and costs of PAP. The effects of implementation of the new guideline describing the application of PAP were measured by comparing the choice of agents and their timing in a random sample of procedures before and after implementation. Before the intervention, 153 procedures from different specialties were observed; eight different antibiotics in different dosages were used and in 20% of the procedures, PAP was given after the incision. Two months after the intervention, 147 procedures were observed; three different antibiotics were given and all were used in the correct dosage. There was a significant reduction of administration of PAP after the incision from 20 to 7% (P=0.002). Besides the quality improvements, the modified PAP protocol resulted in a net annual savings of at least 112,000 US dollars. This study shows that the implementation of a uniform, simple and clear protocol for PAP is associated with improved dosing and timing. The costs of PAP were also reduced.

Prophylaxis and treatment of implant-related infections by antibiotic-coated implants: a review

Implant-related infection is a feared complication in orthopedic and trauma surgery with tremendous consequences for the patient. To reduce this risk, administration of perioperative antibiotic prophylaxis is a routine procedure in orthopedic surgery. A local delivery system for antibiotics based on a polymer implant coating has been developed to optimize the prophylaxis. In an animal experiment, the efficacy of local prophylaxis of gentamicin was compared to a systemic single shot of gentamicin and to a combination of both administrations. The medullary cavities of rat tibiae were contaminated with Staphylococcus aureus and titanium K-wires were implanted into the medullary canals. For local antibiotic therapy, the implants were coated with poly(D,L-Lactide) (PDLLA) loaded with gentamicin. All the animals not treated with local and systemic application of the antibiotic developed osteomyelitis and all cultures of the implants tested positive for S. aureus. Onset of infection was prevented in 80-90% of animals treated with gentamicin-coated K-wires, with and without systemic prophylaxis. Gentamicin-coated intramedullary tibial nails are CE-certified for Europe and Canada and several patients have already been treated for implant-related infection. Up to now, eight patients with open tibia fractures have been treated with an unreamed tibial nail (UTN) coated with PDLLA and gentamicin. In the 1-year follow up, none of the patients developed an infection. A prospective randomized clinical documentation is currently in progress. So far, the results suggest that a local application of gentamicin from PDLLA-coated implants might support systemic antibiotic prophylaxis in preventing implant-associated osteomyelitis.

Systemic versus local application of gentamicin in prophylaxis of implant-related osteomyelitis in a rat model

Administration of perioperative antibiotic prophylaxis is a routine procedure in orthopedic surgery. Besides systemic prophylaxis, only few techniques are established for local application of antibiotics to reduce infection related to orthopedic implants. The aim of this study was to evaluate the efficacy of locally versus systemically applied gentamicin in a rat model ( n = 60). For local application, the antibiotic was delivered from a biodegradable poly( d, l-lactide) (PDLLA) coating of titanium implants. The efficacy of local prophylaxis was compared to a systemic single shot application of gentamicin as well as a combination of both administrations. Half of the animals received a weight-adopted single shot application of gentamicin 30 min prior to surgery. At surgery, the medullary cavities of the tibiae were contaminated with Staphylococcus aureus (10 2 colony forming units /CFU) and titanium Kirschner wires were implanted into the medullary canals. The implants were either uncoated, PDLLA coated, or coated with PDLLA + 10% w/w gentamicin. The animals were followed up for 42 days. X-ray examinations were performed; body weight, temperature, and the clinical condition were determined. After sacrifice, infection was evaluated by histological and microbiological analysis. All animals treated with uncoated or PDLLA-coated Kirschner wires without systemic application of the antibiotic developed osteomyelitis and all cultures of implants were tested positive on S. aureus. Implant-related osteomyelitis could be prevented by prophylaxis of systemically applied gentamicin in 15% of animals. In contrast, local application of gentamicin delivered from a PDLLA coating was more effective. Onset of infection could be prevented in 90% of animals treated with gentamicin coated Kirschner wires, and in 80% of the animals that were treated with a combination of local and systemic application. The local application from PDLLA-coated implants might support systemic antibiotic prophylaxis in preventing implant-associated osteomyelitis.