Dose Of Prophylactic Antibiotics Research Articles

Exposed Subcutaneous Implantable Devices

Background: Implantable venous and electrical devices are prone to exposure and infection. Indications for management are controversial, but—especially if infected—exposed devices are often removed and an additional operation is needed to replace the device, causing a delay in chemotherapy and prolonging healing time. We present our protocol for device salvage, on which limited literature is available. Methods: Between 2007 and 2013, 17 patients were treated (12 venous access ports, 3 cardiac pacemakers, and 2 subcutaneous neural stimulators). Most patients were operated within 7 days from exposure. All patients received only a single perioperative dose of prophylactic antibiotic. In cases of gross infection (n = 1), the device was immediately replaced. In the absence of clinical signs of infection: Complete capsulectomy and aggressive cleaning with an n-acetylcysteine solution and saline solution. Primary exposure of venous ports with sufficient skin coverage (n = 10): the device was covered with local skin flaps. Recurrent cases, cases with insufficient skin coverage or big devices (n = 7): the device was moved to a subpectoral pocket. Mean follow-up was 19 months. Results: Sixteen devices were saved. Only one grossly infected pacemaker was removed and replaced immediately. Only in 1 case, exposure of a venous port recurred after 18 months and was successfully moved to a subpectoral pocket. Chemotherapy was always restarted as scheduled and electrical devices remained functional. Conclusions: This protocol allows—with a straightforward operation and simple measures—to save exposed devices even several days after exposure. Submuscular placement or immediate replacement is indicated only in selected cases.

Exposed subcutaneous implantable devices: an operative protocol for management and salvage.

Background:Implantable venous and electrical devices are prone to exposure and infection. Indications for management are controversial, but—especially if infected—exposed devices are often removed and an additional operation is needed to replace the device, causing a delay in chemotherapy and prolonging healing time. We present our protocol for device salvage, on which limited literature is available.Methods:Between 2007 and 2013, 17 patients were treated (12 venous access ports, 3 cardiac pacemakers, and 2 subcutaneous neural stimulators). Most patients were operated within 7 days from exposure. All patients received only a single perioperative dose of prophylactic antibiotic. In cases of gross infection (n = 1), the device was immediately replaced. In the absence of clinical signs of infection:Complete capsulectomy and aggressive cleaning with an n-acetylcysteine solution and saline solution.Primary exposure of venous ports with sufficient skin coverage (n = 10): the device was covered with local skin flaps.Recurrent cases, cases with insufficient skin coverage or big devices (n = 7): the device was moved to a subpectoral pocket.Mean follow-up was 19 months.Results:Sixteen devices were saved. Only one grossly infected pacemaker was removed and replaced immediately. Only in 1 case, exposure of a venous port recurred after 18 months and was successfully moved to a subpectoral pocket. Chemotherapy was always restarted as scheduled and electrical devices remained functional.Conclusions:This protocol allows—with a straightforward operation and simple measures—to save exposed devices even several days after exposure. Submuscular placement or immediate replacement is indicated only in selected cases.

English

BACKGROUND: The incidence of caesarean section has increased. Maternal morbidity has also increased. Inadvertent use of antibiotics many drug resistant microbial strains have emerged. Management of post caesarean wound infection becoming difficult. Attempts have been made to bring down such infections by taking all aseptic precautions and use of minimal possible effective dose of prophylactic antibiotic or antibiotics post operatively. The purpose of this study to evaluate the effectiveness of single dose antibiotic in uncomplicated caesarean section. OBJECTIVES: To evaluate the effectiveness of single dose of ceftriaxone prophylaxis to that of ampicillin, gentamicin and metronidazole for 5 days post-operatively with regard to post-operative complications in uncomplicated caesarean sections. MATERIAL & METHODS: Hundred registered patients were selected among the pregnant women who underwent caesarean section in Obstetrics & Gynaecology department in Bharati Hospital, Sangli for a period of 1 year from December 2013 to November 2014. This study compares the drug efficacy of prophylactic single dose injection of ceftriaxone 1gm given intravenously 30 minutes prior to caesarean section with the control group of injection Ampicillin, + Gentamicin, Metronidazole given routinely for 5 days post operatively to prevent postoperative infection. In single dose antibiotic 50 patients and in control group 50 patients were studied. RESULT: Failure rate in single dose antibiotic was 2.0% (1 out of 50) and failure rate in multiple dose antibiotics was 6.0% (3 out of 50). Average duration of hospital stay was about 7 to 8 days. In all failure patients antibiotic were given according to culture and sensitivity report. CONCLUSION: Prophylactic single dose antibiotic is effective in reducing infective morbidity in low risk patients and also reduces chances of drug resistant in future.

Antibiotic prophylaxis for preventing infectious complications in orthognathic surgery.

Orthognathic surgery (OS) is a term that refers to many elective surgical techniques to correct facial deformity; the associated malocclusion and functional disorders related to the stomatognathic system. Whilst such surgery is classed as "clean-contaminated", the usefulness of and the most appropriate regimen for antibiotic prophylaxis in these patients are still debated. To assess the effects of antibiotic prophylaxis for preventing surgical site infection (SSI) in people undergoing orthognathic surgery. In June 2014, we searched the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We also searched Google Scholar and performed manual searches in journals relevant to the topic, conference proceedings and lists of references of potentially included articles. We did not restrict the search and study selection with respect to language, date of publication or study setting. We included randomised controlled trials (RCTs) involving people undergoing orthognathic surgery comparing one regimen of antibiotic prophylaxis with any other regimen or placebo. The primary outcome was SSI, and secondary outcomes were systemic infections, adverse events, duration of hospital stay and health-related quality of life. Two review authors screened articles independently. Data were abstracted independently by two review authors, and agreement was checked. Risk of bias was assessed using the Cochrane risk of bias tool. Antibiotic regimens were classified as preoperative (one dose before surgery), short-term (before or during surgery and/or during the same day of surgery) and long-term (before or during surgery and longer than one day after surgery) antibiotic prophylaxis. Random-effects meta-analyses using inverse variance methods were undertaken when possible. We report risk ratios (RRs) and their corresponding 95% confidence intervals (CIs). A total of 11 trials were included in this review. Most of the studies had an unclear risk of bias prompting us to downgrade the quality of evidence for our outcomes. Seven of these trials provided evidence for the main comparison and the primary outcome and these were pooled. Overall, long-term antibiotic prophylaxis probably reduces the risk of SSI (plausible effects range between a 76% to a 0.26% relative reduction in SSI with long-term antibiotic prophylaxis) (472 participants; RR 0.42, 95% CI 0.24 to 0.74; moderate-quality evidence). There is uncertainty surrounding the relative effects of short-term antibiotics compared with a single dose (220 participants; RR 0.34, 95% CI 0.09 to 1.22; low-quality evidence). No reports described adverse effects associated with the drugs in those trials that reported in this outcome. None of these trials assessed or reported data regarding other outcomes, and information was insufficient to show whether a specific antibiotic is better than another. For people undergoing orthognathic surgery, long term antibiotic prophylaxis decreases the risk of SSI compared with short-term antibiotic prophylaxis and the is uncertainty of whether short-term antibiotic prophylaxis decreases SSi risk relative to a single pre-operative dose of prophylactic antibiotics.

Special issues concerning thyroid surgery

Thyroid surgery is classified as a clean procedure and is associated with a low incidence of wound infections (0.3%). The majority of international guidelines do not recommend the use of systemic prophylactic antibiotic treatment in clean procedures. Antibiotic prophylaxis is not indicated in total thyroidectomy with or without neck dissection and should only be used in high-risk patients or when the operation is expected to last more than three hours (Ia,A). A single preoperative dose of prophylactic antibiotics must be administered 30 minutes prior to the induction of anaesthesia and should be re-administered only during the operation and if the latter exceeds three hours (Ia,A) Preoperative treatment with Lugol solution for 10 days blocks the release of thyroid hormone and significantly decreases the vascularity of the thyroid gland. Some endocrine surgeons administer Lugol solution 10 days preoperatively in order to decrease thyroid gland vascularity. However, the available studies are mostly based on empirical or indirect evaluations, such as the surgeon’s observations; consequently, objective results of the effects of Lugol solution on the thyroid gland are still difficult to achieve. The use of Lugol Solution in the preoperative preparation of patients with Grave’s Disease is acceptable (III,B). The development of DVT/PE complications in thyroidectomy has a low incidence when compared with the general surgical population. The operation is relatively short and allows immediate postoperative patient mobilization. Pharmacological prophylaxis against DVT is not necessary in thyroid surgery as the risk of postoperative bleeding is significantly greater than the risk of thromboembolism (Ib,A). Pharmacological prophylaxis against DVT is advised in high-risk patients (Ia,A). Mechanical prophylaxis against DVT is recommended in all patients as it demonstrates similar efficacy and risk reduction with pharmacological methods but without bleeding complications (Ia,A)

Surgical site infections after posterior spinal fusion for neuromuscular scoliosis: a thirty-year experience at a single institution.

Surgical site infection is a serious complication of posterior spinal fusion for neuromuscular scoliosis, with a reported prevalence of 6% to 24%. A single-institution experience over a thirty-year period was reviewed to determine the prevalence of surgical site infection after posterior spinal fusion for neuromuscular scoliosis, and to identify patient and treatment-related risk factors. Our retrospective review included all patients treated with posterior spinal fusion (alone or in combination with an anterior procedure) for neuromuscular scoliosis from 1980 to 2009 and followed for a minimum of two years. Univariate and multivariate statistical analysis was performed to identify significant risk factors for occurrence of deep surgical site infection (p < 0.05). The study included 428 patients with an average duration of follow-up of 4.9 years. The mean Cobb angle was 74.3°. Most (74%) were treated with posterior spinal fusion alone. Deep infection developed in forty-four patients (10.3%); 57% of the infections occurred within three months after the surgery and 73%, within twelve months. Nearly half (45%) of the infections were polymicrobial; 59% of the organisms were gram-positive and 41% were gram-negative. Implant removal was required in 58% of the patients. Surgical site infection was more frequent from 1980 to 1989 (20.3%) than it was from 1990 to 2009 (8.4%) (odds ratio [OR] = 2.8, p = 0.01 in univariate analysis). Surgical site infection was more common in patients with spina bifida (21.5%) than in those with other diagnoses (8.3%) (OR = 3.0, p = 0.001). Other patient factors associated with surgical site infection were a body mass index (BMI) of >25 kg/m(2) (OR = 2.4, p = 0.04) and incontinence (OR = 2.4, p = 0.009). Treatment factors associated with surgical site infection were inadequate prophylactic antibiotic dosing (cefazolin ≤ 20 mg/kg) (OR = 3.3, p = 0.0002), length of fusion (p = 0.002), pelvic fixation (OR = 2.4, p = 0.04), length of hospital stay (p = 0.005), and other complications (OR = 3.2, p = 0.0003). Drain output (p = 0.04) and lower hemoglobin levels (p = 0.008) were significantly associated with surgical site infection in patients with spina bifida, and drain use (superficial to the fascia) was protective in those without spina bifida (OR = 0.5, p = 0.046). This study identified modifiable factors, especially antibiotic dosing and drain use, associated with surgical site infection in patients with neuromuscular scoliosis.

Obesity and the challenges of caesarean delivery: Prevention and management of wound complications

Caesarean section in obese patients is associated with an increased risk of surgical wound complications, including haematoma, seroma, abscess and dehiscence. This review focusses on the available strategies to decrease wound complications in this population, and on the clinical management of these situations. Appropriate dose of prophylactic antibiotics, closure of the subcutaneous tissue, and avoidance of subcutaneous drains reduce the incidence of wound complications associated with caesarean section in obese patients. For treatment of superficial wound infection associated with dehiscence, there are data from general surgery patients to suggest that the use of vacuum-assisted devices leads to faster healing and that surgical reclosure is preferable to healing by secondary intention, when there are no signs of ongoing infection. There is a need for stronger evidence regarding the prevention and management of wound complications for caesarean section in obese women.

Description of a multidisciplinary initiative to improve SCIP measures related to pre-operative antibiotic prophylaxis compliance: a single-center success story.

BackgroundThe Surgical Care Improvement Project (SCIP) was launched in 2005. The core prophylactic perioperative antibiotic guidelines were created due to recognition of the impact of proper perioperative prophylaxis on an estimated annual one million inpatient days and $1.6 billion in excess health care costs secondary to preventable surgical site infections (SSIs). An internal study was conducted to create low cost, standardized processes on an institutional level to improve compliance with prophylactic antibiotic administration.MethodsWe assessed the impact of auditing and notifying providers of SCIP errors on overall compliance with inpatient antibiotic guidelines and on net financial gain or loss to a large tertiary center between March 1st 2010 and September 31st 2013. We hypothesized that direct physician-to-physician feedback would result in significant compliance improvements.ResultsThrough physician notification, our hospital was able to significantly improve SCIP compliance and emphasis on patient safety within a year of intervention implementation. The hospital earned an additional $290,612 in 2011 and $209,096 in 2012 for re-investment in patient care initiatives.ConclusionsProvider education and direct notification of SCIP prophylactic antibiotic dosing errors resulted in improved compliance with national patient improvement guidelines. There were differences between the anesthesiology and surgery department feedback responses, the latter likely attributed to diverse surgical department sub-divisions, frequent changes in resident trainees and supervising attending staff, and the comparative ability. Provider notification of guideline non-compliance should be encouraged as standard practice to improve patient safety. Also, the hospital experienced increased revenue for re-investment in patient care as a secondary result of provider notification.

REPEAT ANTIBIOTIC DOSING IN PROLONGED PAEDIATRIC SURGERY—DO WE? SHOULD WE?

AimTo evaluate the current practice of intra-operative repeat dosing of antibiotics during prolonged paediatric surgery.MethodThe proportion of procedures that lasted longer than four hours were identified from anaesthetic records over...

Description of a multidisciplinary initiative to improve SCIP measures related to pre-operative antibiotic prophylaxis compliance: a single-center success story

BackgroundThe Surgical Care Improvement Project (SCIP) was launched in 2005. The core prophylactic perioperative antibiotic guidelines were created due to recognition of the impact of proper perioperative prophylaxis on an estimated annual one million inpatient days and $1.6 billion in excess health care costs secondary to preventable surgical site infections (SSIs). An internal study was conducted to create low cost, standardized processes on an institutional level to improve compliance with prophylactic antibiotic administration.MethodsWe assessed the impact of auditing and notifying providers of SCIP errors on overall compliance with inpatient antibiotic guidelines and on net financial gain or loss to a large tertiary center between March 1st 2010 and September 31st 2013. We hypothesized that direct physician-to-physician feedback would result in significant compliance improvements.ResultsThrough physician notification, our hospital was able to significantly improve SCIP compliance and emphasis on patient safety within a year of intervention implementation. The hospital earned an additional $290,612 in 2011 and $209,096 in 2012 for re-investment in patient care initiatives.ConclusionsProvider education and direct notification of SCIP prophylactic antibiotic dosing errors resulted in improved compliance with national patient improvement guidelines. There were differences between the anesthesiology and surgery department feedback responses, the latter likely attributed to diverse surgical department sub-divisions, frequent changes in resident trainees and supervising attending staff, and the comparative ability. Provider notification of guideline non-compliance should be encouraged as standard practice to improve patient safety. Also, the hospital experienced increased revenue for re-investment in patient care as a secondary result of provider notification.

The Chitranjan Ranawat Award: Should prophylactic antibiotics be withheld before revision surgery to obtain appropriate cultures?

Preoperative antibiotics are known to be critical for decreasing the risk of periprosthetic joint infection (PJI) in primary THA and TKA. However, antibiotics often are withheld before revision surgery, as there is concern that even a single dose of prophylactic antibiotics may affect intraoperative cultures. In this prospective randomized controlled trial, we determined the effect of a single dose of prophylactic antibiotics on cultures obtained at the time of revision arthroplasty. We randomized 65 patients with known PJI after 37 TKAs and 28 THAs at three centers. Patients were included in the trial if they had a culture-positive aspiration and had not taken antibiotics within 2 weeks of the procedure. Patients were randomized to receive prophylactic antibiotics either before the skin incision or after a minimum of three sets of intraoperative cultures were obtained. Preoperative and intraoperative cultures were then compared. Results between patients who did and did not receive antibiotics were compared using an equivalence test for proportion differences (two one-sided t-tests [TOST]) with a 0.2 margin. Intraoperative cultures yielded the same organisms as preoperative cultures in 28 of 34 patients (82%) randomized to receive antibiotics before the skin incision compared to 25 of 31 patients (81%) randomized to receive antibiotics after obtaining operative cultures (statistically equivalent by TOST estimate: p = 0.0290). In this randomized controlled trial, there was no effect on the results of cultures obtained intraoperatively when prophylactic antibiotics were administered before skin incision. Given the known benefits of prophylactic antibiotics in preventing PJI, preoperative prophylaxis should not be withheld in revision surgery for fear of affecting cultures.

Timing of prophylactic antibiotic administration in an orthopedic hospital in a developing country

Background: Appropriate timing of administration is crucial to the effectiveness of prophylactic antibiotics in preventing surgical site infection. Poor adherence to perioperative antibiotic prophylaxis recommendations has been documented from developed countries, but there is a paucity of data on this subject from Nigeria. The aim of this study was to assess the timeliness of administration of the first dose of prophylactic antibiotics in orthopedic surgery. Materials and Methods: In this observational study in an orthopedic practice, administration of antibiotics in operations done over a 6-month period was investigated. The main outcome measure was timing of antibiotic administration in relation to skin incision and tourniquet application. Optimum timing was defined as prophylactic antibiotic administration 15-60 min before skin incision or tourniquet application. Univariate analysis was performed using CDC-Epi Info TM Version 3.5.1 (August 2008). Results: There were 102 procedures out of which 95 (93.1%) were performed without a tourniquet. Of these 95 procedures, antibiotics were given before skin incision in 53 (55.8%) procedures and administration was optimum only in 16 (16.8%) procedures. The median induction-incision interval was 19 min (range: 3-45 min). Conclusion: Timing of perioperative antibiotic administration was inadequate. Routine administration at induction of anesthesia may promote optimum timing and can be considered as in any practice where no written perioperative antibiotic protocol exists.

A Comprehensive Intervention Associated With Reduced Surgical Site Infections Among Pediatric Cardiovascular Surgery Patients, Including Those With Delayed Closure.

Surgical site infections (SSIs) cause significant morbidity and mortality in patients undergoing cardiovascular (CV) surgery. Following an increase in SSIs in this population, driven by a high rate in those with delayed closure, we implemented an intervention to reduce these infections and assessed the intervention using both population- and patient-level analyses. An intervention drawing from existing guidelines and targeting preoperative preparation of the patient, prophylactic antibiotics, and postoperative incision care was implemented. Special attention was paid to standardizing the care of the incision of patients with delayed closure. National Healthcare Safety Network criteria were used to prospectively identify SSIs. Population-level intervention effect was assessed using interrupted time series. To assess intervention adherence and effect in our patient population, retrospective chart review was performed on a cohort of patients undergoing cardiac procedures pre- and postintervention. Multivariate analysis was used to assess risk of SSI at the patient level. Timely preoperative prophylactic antibiotic dosing increased from 60% preintervention to 92% postintervention, and redosing during prolonged surgeries increased from 5% to 79% (both, P<.001). At the population-level, a decrease of 6.7 infections per 100 surgeries per 6 months was observed directly following the intervention (P=.002). The SSI rate decreased from 40% to 0.8% (P<.001) in patients with delayed closure and from 4.3% to 1.8% (P=.02) in patients with immediate closure. In multivariate analyses, surgery prior to the intervention was the strongest predictor for SSI (incidence rate ratio, 3.98; 95% confidence interval, 1.59 to 9.97). Our intervention decreased SSIs in pediatric CV surgery patients, particularly those with delayed closures.

Preoperative vaginal preparation with povidone-iodine on post-caesarean infectious morbidity

SummaryThe commonest complication associated with caesarean section is infection. The aim of this study is to investigate the effect of vaginal preparation with povidone-iodine on post-caesarean infection. In this clinical trial, 568 patients were selected for two groups: a treatment group and a control group, each with 284 patients. A vaginal scrub was performed before the routine abdominal scrub, with two 4 × 4 cm sponge sticks saturated with povidone-iodine solution, rotated in the vagina for about 30 s. In the control group, only the abdominal scrub was performed. Patients received a single dose of prophylactic antibiotics, and were reviewed for 6 weeks to look for predefined variables. Post-caesarean endometritis occurred less frequently in the treatment group than in the control group (2.5% vs 1.4%). There was no significant difference for febrile morbidity and wound infection in the two groups. The adjusted odds ratio for endometritis after vaginal preparation was 0.03 (95% CI: 0.008–0.7). Vaginal preparation with povidone-iodine may decrease the risk of post-caesarean endometritis.

The Impact of Antibiotics Prophylaxis in Elective Laparoscopic Cholecystectomy: A Prospective Randomized Study

To determine the necessity of a single dose prophylactic antibiotic in preventing the postoperative infective complications in patients undergoing elective laparoscopic cholecystectomy. All consecutive patients who underwent laparoscopic cholecystectomy (LC) at King Saud Medical City from 1 January 2010 to 1 May 2011 were considered for this prospective randomized controlled study. Patients who were included in this study were prospectively randomized into two groups: those receiving single dose of intravenous Cefuroxime 1.5 gm, 30 minute before surgery (group A) and those not receiving any preoperative antibiotic (group B). Postoperative infective complications were recorded and compared for both groups. One hundred and twelve patients received antibiotics (group A), and 109 patients did not received any antibiotics (group B). In group A, 3 patients developed umbilical port site infection whereas in group B, 5 patients developed infection (four in the umbilical port site and one in the epigastric port site). The differences in the infection rate between the two groups were not significant. Intraoperative gallbladder perforation and positive bile culture was not found to increase the rate of surgical site infection. The elimination of prophylactic antibiotics in patients undergoing elective LC increase the incidence of postoperative infective complications but not to a statistically significant degree.

Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy and Risk Factors for Surgical Site Infection: A Randomized Controlled Trial

The aim of this clinical trial was to determine whether prophylactic antibiotics could prevent surgical site infection (SSI) after laparoscopic cholecystectomy and to identify any risk factors for infection. The study included 100 patients undergoing laparoscopic cholecystectomy. They were randomized to receive either a single dose of ceftriaxone (Group A; n = 50) or physiologic saline as placebo (Group B; n = 50) after the induction of anesthesia. Patient demographics and clinical and surgical outcomes were recorded. The incidence of SSI was similar in the two groups: 2 patients in group A and 4 patients in group B (chi(2) = 0.71; p = 0.40). None of the factors studied was associated with surgical site infection statistically, as shown by binary logistic regression analysis. A single dose of prophylactic antibiotic failed to decrease the likelihood of SSI after laparoscopic cholecystectomy.

Inadequate timing of prophylactic antibiotics in orthopedic surgery. We can do better

Background and purpose There are rising concerns about the frequency of infection after arthroplasty surgery. Prophylactic antibiotics are an important part of the preventive measures. As their effect is related to the timing of administration, it is important to follow how the routines with preoperative prophylactic antibiotics are working.Methods In 114 consecutive cases treated at our own university clinic in Lund during 2008, the time of administration of preoperative prophylactic antibiotic in relation to the start of surgery was recorded from a computerized operation report. In 291 other cases of primary total knee arthroplasty (TKA), randomly selected from the Swedish Knee Arthroplasty Register (SKAR), the type and dose of prophylactic antibiotic as well as the time of administration in relation to the inflation of a tourniquet and to the start of surgery was recorded from anesthetic records.Results 45% (95% CI: 36–54) of the patients operated in Lund and 57% (CI: 50–64) of the TKAs randomly selected from the SKAR received the preoperative antibiotic 15–45 min before the start of surgery. 53% (CI: 46–61) received antibiotics 15–45 min before inflation of a tourniquet.Interpretation The inadequate timing of prophylactic antibiotics indicates that the standards of strict antiseptic and aseptic routines in arthroplasty surgery are falling. The use of a simple checklist to ensure the surgical safety may be one way of reducing infections in arthroplasty surgery.

Risk Factors for Surgical Site Infection after Major Breast Operation

Understanding surgical site infection (SSI) risk factors after breast operation is essential to develop infection-prevention strategies and improve surgical outcomes. We performed a retrospective case-control study with subjects selected from a cohort of mastectomy, breast reconstruction, and reduction surgical patients between January 1998 and June 2002 at a university-affiliated hospital. SSI cases within 1 year after operation were identified using ICD-9-CM diagnosis codes for wound infection and complication or positive wound cultures, or both. Medical records of 57 patients with breast SSI and 268 randomly selected uninfected control patients were reviewed. Multivariate logistic regression was used to identify independent risk factors for SSI. Significant independent risk factors for breast incisional SSI included insertion of a breast implant or tissue expander (odds ratio [OR] = 5.3; 95% CI, 2.5 to 11.1), suboptimal prophylactic antibiotic dosing (OR = 5.1; 95% CI, 2.5 to 10.2), transfusion (OR = 3.4; 95% CI, 1.3 to 9.0), mastectomy (OR = 3.3; 95% CI, 1.4 to 7.7), previous chest irradiation (OR = 2.8; 95% CI, 1.2 to 6.5), and current or recent smoking (OR = 2.1; 95% CI, 0.9 to 4.9). Local infiltration of an anesthetic agent was associated with substantially reduced odds of SSI (OR = 0.4; 95% CI, 0.1 to 0.9). Suboptimal prophylactic antibiotic dosing is a potentially modifiable risk factor for SSI after breast operation. SSI risk was increased in patients undergoing mastectomy and in patients who had an implant or tissue expander placed during operation. This information can be used to develop a specific risk stratification index to predict SSI and infection-preventive strategies tailored for breast surgery patients.

Single- Versus Multiple-Dose Antibiotic Prophylaxis in the Surgical Treatment of Closed Fractures: A Meta-Analysis

The use of prophylactic antibiotics in the surgical treatment of closed long bone fractures is well established. The duration and dosage of prophylaxis, however, vary significantly among surgeons. A systematic review and meta-analysis were performed to determine if multiple-dose perioperative antibiotic prophylaxis is more effective than a single preoperative dose in the prevention of surgical wound infections during the treatment of closed long bone fractures. Articles were identified by searching the following medical databases: Medline, Medline In Process & Other Non-indexed Citations, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews. Relevant conference proceedings and the reference section of selected manuscripts were also searched for additional studies. Studies were included if they were prospective randomized controlled trials of patients with closed fractures treated with surgical fixation or arthroplasty. The interventions must have directly compared a single preoperative prophylactic dose to a multiple-dose perioperative strategy. Studies were excluded if they involved open fractures. The demographic information, prophylaxis strategy, wound infection rate, and risk ratio were extracted from each article. Seven trials and 3,808 patients were pooled using a random effects model. When compared to a regimen of multiple doses of prophylactic antibiotics, administration of a single preoperative dose has a risk ratio of 1.24 (95% CI 0.60-2.60). The pooled risk difference between the 2 strategies is 0.005 (95% CI -0.011-0.021). Neither result is significant. In the setting of closed long bone fractures, the pooled results failed to demonstrate superiority of multiple-dose prophylaxis over a single-dose strategy. The pooled estimates suggest that surgical wound infections are relatively rare events and that any potential difference in infection rates between prophylaxis strategies is likely quite small. However, because the confidence interval surrounding the pooled risk ratio spans 1.0 by such a large amount, we are unable to definitively recommend a preferred dosing regimen to prevent surgical wound infections. Although future research is required to ensure our prophylaxis decisions continue to be evidence based and cost-effective, it is unlikely that a single clinical trial will be able to provide the answer. The use of other quantitative methods, such as cost-effectiveness analysis, may be helpful in modeling an optimal prophylaxis strategy.

Inadequate antimicrobial prophylaxis during surgery: a study of β-lactam levels during burn debridement

To determine how long single-dose prophylactic antibiotic regimens for burns surgery maintained plasma concentrations above the MICs for target organisms during surgery. We monitored antibiotic plasma concentrations in 12 patients (mean +/- SD 43 +/- 12% total burn surface area) throughout debridement surgery after administration of the standard prophylactic antibiotic dosing regimens of either 1 g of intravenous cefalotin or 4.5 g of intravenous piperacillin/tazobactam. The eschar debridement and grafting procedures ranged in duration from 2.25 to over 8.5 h. The duration of total plasma cefalotin concentration above an MIC of 0.2 mg/L for Staphylococcus aureus was 6.49 +/- 2.85 h, whereas the mean duration of total plasma piperacillin concentration above an MIC of 64 mg/L for Pseudomonas aeruginosa was only 1.15 +/- 0.59 h. None of the patients dosed with piperacillin/tazobactam was adequately protected for the duration of their surgery and adequate prophylaxis was only evident in four of the nine patients administered cefalotin. These results suggest a need to review antibiotic prophylaxis dosage regimens for burns surgery and the adoption of regimens that will minimize the risk of infection in this high-risk patient group. It is suggested that the antibiotic prophylaxis guideline for burn debridement surgery be modified to include re-dosing or a continuous infusion of beta-lactam antibiotics.