Intraoperative Antibiotic Prophylaxis Research Articles

Midurethral sling infectious complications: A systematic review

BackgroundThe French Health Authority (Haute Autorité de santé) and French scientific societies (Collège national des gynécologues et obstétriciens français) recommend the use of midurethral slings as the surgical treatment of choice for stress incontinence due to urethral hypermobility and failure of hygienic diet and pelvic rehabilitation. Within a year of implantation, almost 90% of patients no longer experience stress urinary incontinence. Despite their recognized efficacy, retropubic and/or trans-obturator midurethral sling can expose patients to potentially severe infectious complications. MethodsA comprehensive literature review using Pubmed, Medline, Embase and Cochrane: “stress urinary incontinence”, and/or the following keywords “complications”, “infections”, “abscess”, “prosthetic exposures”, “fistula”, “erosion”, “cellulitis”, “fasciitis” in association with the keywords “midurethral slings”, “suburethral sling”, “tension free vaginal tape” and “trans-obturator tape. In the 330 articles, 61 really dealt with infectious complications following the implantation of synthetic midurethral slings in women. ResultsPreoperative urinalysis and intraoperative antibiotic prophylaxis were rarely reported (n=1 and n=11, respectively). We recorded thirty-six cases of abscess, twenty-one cases of cellulitis, sixteen cases of fistula and forty-one cases of prosthetic exposure. In 95.5% of cases, patients were treated with broad-spectrum antibiotics. Total explantation of the prosthesis was performed in 56% of patients at the initial management, with two-stage explantation performed in 23% of cases, partial explantation was carried out in 12% of cases, and the prosthesis was left in place in 9% of cases. No deaths were recorded. ConclusionTo limit the risk of urinary tract infections and potential prosthetic infections, a prophylactic approach should be adopted by performing a preoperative urinalysis and administering intraoperative antibiotic prophylaxis should be discussed. In the event of prosthetic and/or surgical site infection, broad-spectrum probabilistic antibiotic therapy should be initiated as early as possible until targeted antibiotic therapy. Total explantation of the prosthesis appears to be the most appropriate surgical strategy.

PURULENT-INFLAMMATORY COMPLICATIONS AND POSTOPERATIVE HERNIAS AFTER CESAREAN SECTION

Any surgical intervention on the abdominal cavity, including caesarean section, is accompanied by several postoperative purulent-inflammatory complications, especially in patients with concomitant diseases. The most common purulent complications occur in the laparotomy area. They are suppuration of surgical wounds, necrotizing fasciitis, phlegmon and abdominal abscess. There are different opinions on the predictors of purulent complications. The most frequently mentioned are leukocyte count, C-reactive protein, procalcitonin, ferritin, and endocervical culture. Unfortunately, peritonitis and sepsis rates have not reduced recently. Still, these complications negatively affect treatment outcome. The paper discisses the effectiveness of drainage and lavage of the abdominal cavity during cesarean section. In this regard, preventive measures reducing the number and severity of purulent-inflammatory complications becomes relevant. First of all, this concerns intraoperative antibiotic prophylaxis, which should be carried out taking into account risk factors and the individual sensitivity of genital tract microorganisms to antimicrobial drugs. Obstetricians do not have a particular pattern to follow this technique. There is also ambiguous opinion on choosing an operative approach to reduce the number of postoperative ventral hernias. Both longitudinal and transverse laparotomies have certain advantages and disadvantages. Until now, the choice of postoperative ventral hernia repair, especially in the hypogastrium, is determined by many factors, which should be taken into account. These problems reveal the need for optimal measures aimed at reducing negative consequences of cesarean delivery. Articles from Cyberleninka, e-Library, disserCat, ResearchGate, JSTOR, PubMed, and Google Scholar were analyzed for the study.

Comparison of Three Antibiotic Prophylaxis Protocols for Preventing Postoperative Infection in Tibial Plateau Fractures

Background: The aim of this study was to compare the impact of three different types of intraoperative antibiotic prophylaxis on the risk of postoperative surgical site infection (SSI). Material and Methods: Single-center retrospective cohort study. Patients who underwent surgery for osteosynthesis of a tibial plateau fracture (January 2009–November 2018) in Hospital Clinic i Provincial de Barcelona were included. Three types of prophylaxis during the study period were used: group A (cefuroxime single-dose treatment), group B (meropenem + teicoplanin), and group C (ceftriaxone + teicoplanin). Demographics, co-morbidity, type of fracture, need for external fixation, microbiology data, surgical time, and outcome were recorded. Failure was defined as the need for reintervention due to postoperative surgical site infection. Results: From a total of 148 patients included, 20 cases developed SSI, 8 from group A, 8 from group B, and 4 from group C. Higher ASA scores, Schatzker II classification, need for external fixation, and a prolonged surgical time were associated with a significantly (p < 0.005) increased incidence of SSI. Group C showed the overall highest survival and lowest cumulative risk, but differences were not statistically significant. Conclusions: Group C showed the lowest incidence of infection in this sample. It is necessary to confirm these findings with larger studies.

Prolonged efficacy of cefazolin in intraosseous regional prophylaxis for total knee arthroplasty: a rabbit model study

BackgroundA novel approach known as intraosseous regional administration (IORA) has emerged as a technique for delivering prophylactic antibiotics, and it results in higher tissue concentrations around the knee. It is hypothesized that IORA of cefazolin for antibiotic prophylaxis during total knee arthroplasty will result in sustained effective levels for a longer duration. The aim of the current study was to investigate temporal changes in peri-knee cefazolin blood concentrations after IORA of cefazolin.MethodsTwelve rabbits were randomly divided into two groups, with six rabbits in each group. In control group a single intravenous bolus injection of cefazolin (10 mL, 100 mg) was administered into the marginal ear vein. In experimental groupexperimental group the same dose of cefazolin was injected into the left tibial marrow cavity after tourniquet inflation at the base of the left thigh. Blood samples were collected periodically at different timepoints, and cefazolin concentrations were determined.ResultsThe intraosseous treatment resulted in significant differences in plasma cefazolin concentrations at all timepoints. Experimental group exhibited higher plasma cefazolin concentrations than control group.ConclusionsCefazolin in intraosseous regional prophylaxis exhibits effectiveness in intraoperative antibiotic prophylaxis by maintaining concentrations above the minimum inhibitory concentration for extended durations, rather than relying solely on high concentrations.

Antibiotic prophylaxis and surgical site infections in orthognathic surgery – a retrospective analysis

BackgroundThis study was conducted to determine surgical site infection (SSI) rates and potential risk factors as well as to evaluate antibiotic prophylaxis in orthognathic surgery.MethodsThis retrospective observational study included patients who received orthognathic surgery. SSIs and their management were assessed for up to one year post-operatively. The applied antibiotic regime and other possible influencing factors (smoking, age, site of infection, drainage, duration of surgery, displacement distances, craniofacial malformations) were assessed.ResultsIn total 291 patient met the inclusion criteria (56.7% female). The mean age at surgery was 25.5 ± 8.5 years. Fifty-four patients (18.6%) were diagnosed with a craniofacial malformation. Relevant previous surgeries were documented in about one quarter of included patients (n = 75). Ninety-two percent of patients (n = 267) received intraoperative single-dose antibiotic prophylaxis. Surgical site infections occurred in 12.4% (n = 36) of patients. There was a significant association between postoperative infections and type of surgery (P = .037) as well as type of drainage (P = .002). Statistical analyses also revealed a higher prevalence of smokers (P = .036) and previous surgically assisted rapid palatal expansion (SARPE) (P = .018) in the infection group. Furthermore, no significant relationships were observed between postoperative infections and various co-factors (i.e. antibiotic regime, age at surgery, gender, associated craniofacial malformations, surgery duration, displacement distances, mandibular setback vs. advancement).ConclusionLow rates of SSIs occurred following an intraoperative single-dose antibiotic regime. None of the SSIs had a significant effect on the final surgical outcome. Present data do not warrant escalation of the antibiotic regimen. Postoperative smoking and capillary drainage should be avoided.

Managing early complications in total hip arthroplasty: the safety of immediate revision

PurposeImmediate revision refers to a reoperation that involves resetting, draping, and exchanging the implant, after wound closure in total hip arthroplasty. The purpose of this study is to investigate the impact of immediate revision after total hip arthroplasty on subsequent infection and complication rates.MethodsA total of 14,076 primary total hip arthroplasties performed between 2010 and 2020 were identified in our institutional database, of which 42 underwent immediate revision. Infection rates were determined 2 years after the index arthroplasty. The cause and type of revision, duration of primary and revision surgeries, National Nosocomial Infections Surveillance score, implant type, changes in implants, complications, and preoperative and intraoperative antibiotic prophylaxis were all determined.ResultsNo infections were observed within 2 years after the index arthroplasty. Leg length discrepancy (88%, n = 37) and dislocation (7.1%, n = 3) were the main causes of immediate revision. In most cases of discrepancy, the limb was clinically and radiologically longer before the immediate revision. The mean operative time was 48 ± 14 min for the primary procedure and 23.6 ± 9 min for the revision. The time between the first incision and last skin closure ranged from 1 to 3 h. None of the patients were extubated between the two procedures. Two patients had a National Nosocomial Infections Surveillance score of 2, 13 had a score of 1, and 27 had a score of 0.ConclusionImmediate revision is safe for correcting clinical and radiological abnormalities, and may not be associated with increased complication or infection rates.Study designRetrospective cohort study; level of evidence, 3.

MP46-18 SPECTRUM AND INCIDENCE OF URINARY TRACT INFECTIONS (UTI) IN PATIENTS UNDERGOING RADICAL CYSTECTOMY: RESULTS FROM A SINGLE CENTER STUDY AND PROPOSAL FOR ERAS PROTOCOL

You have accessJournal of UrologyCME1 Apr 2023MP46-18 SPECTRUM AND INCIDENCE OF URINARY TRACT INFECTIONS (UTI) IN PATIENTS UNDERGOING RADICAL CYSTECTOMY: RESULTS FROM A SINGLE CENTER STUDY AND PROPOSAL FOR ERAS PROTOCOL Vito Lorusso, Antoine Le Quellec, Claire Rion, Andrea Pacchetti, Laure Doisy, François Lannes, Davidson Sypre, Nicolas Branger, Thomas Maubon, Stanislas Rybikowski, Antonio Granata, Andrea Gregori, Geraldine Pignot, and Jochen Walz Vito LorussoVito Lorusso More articles by this author , Antoine Le QuellecAntoine Le Quellec More articles by this author , Claire RionClaire Rion More articles by this author , Andrea PacchettiAndrea Pacchetti More articles by this author , Laure DoisyLaure Doisy More articles by this author , François LannesFrançois Lannes More articles by this author , Davidson SypreDavidson Sypre More articles by this author , Nicolas BrangerNicolas Branger More articles by this author , Thomas MaubonThomas Maubon More articles by this author , Stanislas RybikowskiStanislas Rybikowski More articles by this author , Antonio GranataAntonio Granata More articles by this author , Andrea GregoriAndrea Gregori More articles by this author , Geraldine PignotGeraldine Pignot More articles by this author , and Jochen WalzJochen Walz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003292.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy (RC) has a high rate of postoperative complications. Our aim was to assess the spectrum of UTI and efficacy of our ERAS protocol. METHODS: We analyzed prospectively collect data from 206 patients (Pts) undergoing RC at our Institution from 2015 to 2020. A fully comprehensive ERAS protocol was applied. Urine cultures (UCs) were taken before surgery and Pts treated accordingly. One-shot intraoperative antibiotic (ABT) prophylaxis was used. UCs were collected from urinary drains (UD) at POD 4. Pts with positive UCs and Ileal conduit (IC) were not treated if asymptomatic whilst all Neobladder (NB) pts with positive UCs received ABT based on reports till complete removal of UDs (POD 10). Pts with NB and negative UCs received short-term ABT 24h prior and after neobladder catheter ablation. Rate of in-hospital UTIs was recorded, differentiated and defined as Systemic inflammatory Response Syndrome (SIRS) and Sepsis (SEP) according to Sepsis-3 Consensus Definitions. RESULTS: Clinicopathological characteristics are in Table 1. Pathogens are shown in Figure 1. Overall, 17/178 (9.4%) of Pts experienced SIRS, 18/178 (9.9%) sepsis whilst the remainder 147/178 (80.7%) did not have any UTI. In the IC group, occurred 7/75 (9.3%) and 8/75 (10.7%) cases of SIRS and SEP respectively. In same group, 56/75 (74.5%) had bacteriuria, of them 32/75 (57%) did not receive ABT as per protocol, resulting in only 1/75 (1%) case of UTI-SIRS. There was no significant difference in rate of SIRS (p=0.6) and SEP (p=0.4) in pts with UC+ and UC- for IC Pts. In the Neobladder (NB) group, there were 10/103 (9.7%) and 10/103 (9.7%) of SIRS and SEP respectively. 81/103 (78.6%) of NB pts had bacteria in at last one UD. There was no significant difference in rate of SIRS (p=0.6) and SEP (p=0.3) in Pts with UC+ and UC- for NB patients. No statistically significant difference (p>0.5) was observed in both groups in the rate of UTI considering surgical approach (Open vs Robotic). CONCLUSIONS: UTI-related complications represent a challenge after RC. Our protocol is safe and effective to maintain the rate of UTIs low allowing for effective use of ABT according to the principles of antimicrobial stewardship and ERAS. Our protocol seems to be effective for both urinary reconstructions. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e639 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vito Lorusso More articles by this author Antoine Le Quellec More articles by this author Claire Rion More articles by this author Andrea Pacchetti More articles by this author Laure Doisy More articles by this author François Lannes More articles by this author Davidson Sypre More articles by this author Nicolas Branger More articles by this author Thomas Maubon More articles by this author Stanislas Rybikowski More articles by this author Antonio Granata More articles by this author Andrea Gregori More articles by this author Geraldine Pignot More articles by this author Jochen Walz More articles by this author Expand All Advertisement PDF downloadLoading ...

Do Intrawound Antibiotics Reduce the Incidence of Surgical Site Infections in Pelvic and Lower-Limb Trauma Surgery? A Systematic Review and Meta-analysis.

To analyze the efficacy of intraoperative topical antibiotics in reducing the incidence of postoperative surgical site infections in pelvic and lower-limb trauma orthopaedic surgery. A search of Ovid MEDLINE, PubMed, and Embase was conducted for English language studies published from 1946 through September 3, 2021, using relevant keywords. Included studies were randomized controlled trials, cohort studies, or case-control studies reporting on the rate of surgical site infections in adult patients (age 16 and older) who underwent surgical fixation of lower-limb or pelvic traumatic fractures, including both open and closed fractures, with topical intraoperative antibiotics applied to the surgical site before wound closure. Studies were evaluated using the Joanna Briggs Institute Critical Appraisal Checklist for analytical cross-sectional studies. The risk of bias was assessed using the ROBINS-I and Cochrane risk-of-bias tools. A meta-analysis was conducted using the inverse variance method and random-effects model to assess effect significance and study heterogeneity. Seven studies were included in the systematic review. Results of the meta-analysis suggested a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intraoperative antibiotic powder compared with those managed with intravenous antibiotics alone (odds ratio 0.77, 95% confidence interval 0.52-1.13), although the results did not reach statistical significance. Further powered studies including randomized controlled trials would be of great value to validate the results suggested in this study and inform best practice intraoperative antibiotic prophylaxis in pelvic and lower-limb trauma surgery. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of Local Use of Rifampicin on the Development of Surgical Site Infection after Lumbar Microdiscectomy.

To investigate the effect of local use of rifampicin (RIF) on the development of postoperative surgical site infection (SSI) after lumbar microdiscectomy. Observational study. Van YuzuncuYil University Medical School Neurosurgery Clinic, between 2020 and 2022. This retrospective study reviewed the clinical and laboratory records of 178 patients who underwent lumbar microsurgery. After lumbar microsurgery, one ampoule of rifampicin (RIF) (250 mg) was locally injected into the surgical site in 62 patients (RIF group), while the remaining 116 patients (non-RIF group) received no injection into the surgical site after lumbar microsurgery. Normal distribution of data was analysed using Kolmogorov-Smirnov test. Continuous variables were compared using Mann-Whitney U test and categorical variables were compared using chi-square test or Fisher's exact test as needed. In the postoperative period, local infection developed in one patient in the RIF group, while local infection developed in 11 and deep infection developed in three of the patients in the non-RIF group. Moreover, the risk of local infection development was significantly higher in the non-RIF group compared to the RIF group. The rate of superficial SSI was lower in the RIF group compared to the non-RIF group. No significant difference was observed between the two groups with regard to the rate of deep SSI. Postoperative infection is an extremely important clinical condition manifesting in the form of superficial or deep SSI. The utmost care and necessary precautions should be taken to avoid postoperative infections. Intraoperative antibiotic prophylaxis is the most effective method in preventing postoperative spinal infections. Infection, Lumbar microdiscectomy, Rifampicin, Local infection, Deep infection.

Prophylactic Intraoperative Antibiotic Dosing in Head and Neck Surgery: Opportunities for Improvement and Future Study.

To investigate rates of Surgical Care Improvement Project (SCIP) guideline adherence with regard to intraoperative antibiotic prophylaxis in head and neck surgery with free tissue transfer. Retrospective case series. A single academic center. All patients who underwent mucosa-violating head and neck oncologic surgery with free tissue transfer between March 2017 and June 2019 were reviewed. Intraoperative antibiotic data included type, dosage, frequency of administration, and duration. Any deviation from SCIP recommendations was defined as nonadherence. Antibiotic type was categorized as ampicillin-sulbactam, cefazolin/metronidazole, clindamycin, and others. As a secondary exploratory analysis, postoperative infections were analyzed and stratified by adherent vs nonadherent and by antibiotic type. A total of 129 surgical procedures were included. The mean ± SD number of antibiotic doses during surgery was 3.16 ± 1.2. The mean number of missed doses was 1.86 ± 1.65. Adherence rate with first dosing recommendation was 100%, as compared with 41.7% for dose 2, 23.1% for dose 3, 13.7% for dose 4, 5.26% for dose 5, 2.56% for dose 6, and 0% for dose 7 (P < .001). Ampicillin-sulbactam (6.4%) had a significantly lower rate of average redosing adherence when compared with cefazolin/metronidazole (73.2%) and clindamycin (63.3%; P < .001). Significant opportunities exist in SCIP guideline adherence rates for intraoperative antibiotic prophylaxis. Cefazolin/metronidazole had a significantly higher rate of appropriate redosing when compared with ampicillin-sulbactam, which should be considered when choosing a prophylactic antibiotic regimen and performing antibiotic-based outcomes studies. More attention should be given to intraoperative antibiotic prophylaxis in head and neck surgery with free tissue transfer, as this presents an opportunity for quality improvement and future study heretofore not explored.

Femistina versus Canephron as a prevention of urinary tract infections after midurethral sling surgery – Non-inferiority study

ObjectiveUrinary tract infection (UTI) is relatively common post-operative complication following midurethral sling placement (MUS), even in cases where intraoperative antibiotic prophylaxis was given. The primary aim of this study was to investigate the non-inferiority of Femistina as compared with Canephron in reducing symptomatic UTI in first six months following surgery. Study designA sample size of 144 patients per group was established, to provide at least 90% power to demonstrate the non-inferiority of phytodrug Femistina versus Canephron as a prevention of post-MUS urinary tract infection. ResultsWomen suffering from stress urinary incontinence and mixed urinary incontinence (MUI) with predominant SUI symptoms as confirmed by urodymamics (n = 320) were randomized in a 1:1 ratio to Femistina (40 mg, oral, twice daily for 20 days) or Canephron (3 × 5 ml taken orally-three times daily for 4 weeks). Both groups were homogenous for age, type of operation (only TOT outside-in) and severity of illness as indicated by ICIQ-SF questionnaire. We found that symptoms of UTI were significantly lower in patients receiving Femistina. During first 6 months after surgery UTI was confirmed in only 10 patients receiving Femistina (6,25%) when compared to 25 (15,63%) subjects receiving Canephron, p < 0.007. ConclusionFemistina is not inferior to Canephron in preventing lower urinary tract infection after midurethral sling surgery.

Use of Antibiotic Prophylaxis for Polymicrobial Urine Culture before Urological Surgery: A Pilot Study

Introduction: Preoperative polymicrobial urine cultures are common, but the associated risk of nosocomial infection is currently unknown. We aimed to analyze the risk of postoperative infection in patients with preoperative polymicrobial urine cultures. Methods: This was a prospective cohort study conducted from November 2018 to October 2020. Polymicrobial urine cultures were defined by at least the presence of 3 bacteria without leukocyturia threshold on two consecutive samples in the month preceding the surgical procedure. Data on postoperative infections were collected during hospitalization until day 30. A postoperative infection was defined by the occurrence of clinical signs (fever, chills, and suppurated process on the surgical site) associated with the prescription of an antibiotic therapy. Results: Sixty-eight patients were included, and seven developed a postoperative infection with a microbe identified in blood or urine cultures. There was a significant association between leukocyturia ≥104 (p = 0.02) and the administration of intraoperative antibiotic prophylaxis (p < 0.001). In contrast, there was no significant association between postoperative infections for patients with polymicrobial preoperative urine cultures and having received or not an empirical antibiotic therapy. Conclusion: The rate of postoperative infection in patients with polymicrobial urine culture before urological procedure was 10.2%. Further studies are needed to assess the antibiotic prophylaxis to be used in this situation.

Bacterial bile duct colonization in perihilar cholangiocarcinoma and its clinical significance

Abdominal infections including cholangitis represent a major problem in patients with perihilar cholangiocarcinoma (pCCA). Thus, we investigated bacterial colonization of the bile ducts and determined its impact on postoperative outcome focusing on abdominal infections. A cohort of 95 pCCA patients who underwent surgery between 2010 and 2019 with available intraoperative microbial bile cultures were analyzed regarding bile duct colonization and postoperative abdominal infection by group comparisons and logistic regressions. 84.2% (80/95) showed bacterial colonization of the bile ducts and 54.7% (52/95) developed postoperative abdominal infections. Enterococcus faecalis (38.8%, 31/80), Enterococcus faecium (32.5%, 26/80), Enterobacter cloacae (16.3%, 13/80) and Escherichia coli (11.3%, 9/80) were the most common bacteria colonizing the bile ducts and Enterococcus faecium (71.2%, 37/52), Enterococcus faecalis (30.8%, 16/52), Enterobacter cloacae (25.0%, 13/52) and Escherichia coli (19.2%, 10/52) the most common causes of postoperative abdominal infection. Further, reduced susceptibility to perioperative antibiotic prophylaxis (OR = 10.10, p = .007) was identified as independent predictor of postoperative abdominal infection. Bacterial colonization is common in pCCA patients and reduced susceptibility of the bacteria to the intraoperative antibiotic prophylaxis is an independent predictor of postoperative abdominal infections. Adapting antibiotic prophylaxis might therefore have the potential to improve surgical outcome pCCA patients.

The effect of antibiotic prophylaxis on infection rates in mohs micrographic surgery: a single-institution retrospective study.

As data and recommendations regarding antibiotic prophylaxis in dermatologic surgery vary, we tried to describe the effect of antibiotic prophylaxis (AP) in Mohs micrographic surgery (MMS) on infective endocarditis, prosthetic joint infection, and surgical site infection using a single-institution retrospective cohort study of antibiotic use (pre-/intra-operative, post-operative or none) among 2,364 patient encouters treated with MMS. Bivariate logistic regression was evaluated for associations between patient and operative characteristics, antibiotic use, and infectious complications. 85.8% of patients received no AP, 10.0% received post-operative AP, and 4.1% received pre-/intra-operative AP. The overall surgical site infection (SSI) rate was 1.3%. SSI did not differ between patients who received pre-/intra-operative prophylaxis, post-operative prophylaxis or no antibiotics. One patient receiving pre-/intra-operative prophylaxis developed SSI. Repairs involving porcine xenografts and interpolation/pedicle flaps were associated with increased SSI. In addition, there were no patients who post-operatively experienced an infected joint or infective endocarditis. Limitations include selection bias, use of observational retrospective data, low infection rates, single institution analysis, and possible omission of explanatory variables or confounders. There was no difference in rates of SSI when comparing MMS patients who received pre-/intra-operative, post-operative or no AP. There were no cases of infective endocarditis or infected prosthetic joint.

Perioperative Management in Patients With Cleft Lip and Palate.

In cleft care, perioperative treatment strategies like ear nose and throat (ENT) diagnostics as well as postoperative antibiotics, feeding, and duration of inpatient stay are nonstandardized procedures varying between different centers. Likewise, intraoperative choice of suture materials and time of suture removal are performed inconsistently. Therefore, we wanted to collect information on protocols focusing on these topics to summarize and subsume currently approved treatment strategies of centers around the world. We ask members of international cleft centers for their respective treatment strategies and performed descriptive statistics.Absorbable suture material is used for reconstruction of the outer lip skin in 20 of 70 centers. Removal of skin sutures is conducted after 7.0 ± 1.5 days. Suturing of the orbicularis oris muscle, the enoral and nasal mucosa, as well as the palatal musculature is predominantly performed with absorbable suture materials. Intraoperative antibiotic prophylaxis is applied in 82.9% of the participating centers. In contrast, 31.9% of the departments do not apply any antibiotic postoperatively. Postoperative feeding is performed in 27 centers via a nasogastric tube for 4.6 ± 2.3 days on average. Mean length of postoperative inpatient stay is 4.1 ± 2.6 days in children after cleft lip surgery and 4.5 ± 2.7 days after cleft palate surgery. ENT consultation before surgery is routinely conducted in 52.8% of the centers and 82.9% of ENT colleagues investigate middle ear pathologies in the same operation in which cleft repair is performed.Closure of the lip skin is predominantly performed with nonabsorbable suture material followed by a suture removal after 1 week. Intraoperative antibiotic prophylaxis as well as inpatient hospital stay of 4 to 5 days in combination with oral feeding and a preoperative consultation and intraoperative cooperation with the ENT department seems to be well-proven concepts in cleft lip palate patient care. However, this analysis illustrated the variations and differing approaches in perioperative care emphasizing the need to verify perioperative management concepts in cleft surgery-preferably in the context of multicenter studies.

Microbiologic Changes Induced by Biliary Drainage Require Adapted Antibiotic Prophylaxis during Duodenopancreatectomy.

Background: Patients with periampullary tumors frequently undergo endoscopic biliary investigations and biliary drainage (BD) prior to surgery. Recent literature shows a shift of the biliary microbiome toward more resistant bacteria in patients having BD. This study aimed to evaluate the local microbiome and changes induced by BD and related antibiotic exposure and to consider the choice of antibiotic for peri-operative prophylaxis. Methods: A single-center retrospective cohort study included patients operated on for periampullary tumors between January 2013 and November 2017. All patients had intra-operative bile samples taken for culture and peri-operative antibiotic use as well as documentation of complications according to the Dindo-Clavien classification. Results: A total of 37 patients were included. All received pre-operative endoscopy, and 29 (78%) had BD preceded by administration of ceftriaxone or metronidazole. Intra-operative antibiotic prophylaxis consisted of cefuroxime (92%) or ceftriaxone (13%) combined with metronidazole (100%). Bacterial contamination of bile samples was more common in the BD group than in the no biliary drainage (NBD) group (93% vs 38%; p < 0.01). A shift was observed from bile containing mainly Escherichia coli and Streptococcus spp. toward Enterococcus faecalis (0 in the NBD group versus 44.8% in the BD group; p < 0.01), Enterococcus faecium (0 versus 23%; p = 0.3), and Candida albicans (0 versus 34.5%; p = 0.08). Post-operative antibiotic modifications were common. No difference was found regarding Dindo-Clavien complications, post-operative stay, or antibiotic use in the two groups, although one patient in the NBD group who had pre-operative biliary endoscopy with antibiotic prophylaxis developed a fatal septic clot caused by Escherichia coli resistant to cefuroxime. Conclusions: We observed a significant change toward colonization by enterococci and fungi in the microbiome of patients who had pre-operative biliary investigations or drainage with antibiotic prophylaxis. These findings indicate that bile samples should be obtained systematically during surgery for periampullary tumors to guide any post-operative antibiotic therapy and peri-operative antibiotic prophylaxis and might need adaptation to target the modified microbiome.

PREOPERATIVE AND POSTOPERATIVE ANTIBIOTIC PROPHYLAXIS IN GYNECOLOGICAL PATIENTS DEPENDING ON INDIVIDUAL RISK FACTORS

Pelvic inflammatory diseases as complications of invasive diagnostics and surgical treatment occur often enough in patients with gynecological disorders. The risk of infectious complications is always individual and depends on many factors. The implementation of a personified approach and optimization of antibacterial prophylaxis can decrease the incidence of inflammatory reactions and reduce the risk of infectious complications. Objective: to estimate the efficacy and tolerability of combiflox (ornidazole 500 mg + ofloxacin 200 mg) in long-term antibiotic prophylaxis after gynecological and oncological surgeries. Materials and methods. We assessed the results of a 7-day oral course of combiflox after intravenous intraoperative antibiotic prophylaxis (ciprofloxacin 500 mg + metronidazole 500 mg) in 73 women that underwent gynecological or oncological surgeries. All patients were monitored for postoperative complications, including any wound inflammation, low-grade hyperthermia, symptoms of postoperative vaginitis, endometritis, limited peritonitis, adnexitis. Results. We found that 43.8 % of patients were at high risk of developing postoperative inflammatory complications; in most of the cases, it was associated with obesity (body mass index &gt;30 kg/m2). Three out of 32 overweight patients (9.3 %) developed postoperative complications, whereas none of the 41 patients with minimal risk factors had such events. No combiflox-related adverse effects were observed during the study. All patients reported good tolerability and high convenience of the drug. Conclusion. The need for long-term antibiotic prophylaxis depends on the type of surgery and individual risks for infectious complications. Low-cost oral therapy with combiflox (ornidazole + ofloxacin) during the postoperative period reduces the risk of infectious complications, especially among patients with a body mass index &gt;30 kg/m2, since they are particularly prone to wound complications.

The enhanced recovery after surgery (ERAS) Greenie Board: a Navy-inspired quality improvement tool.

The United States Navy uses a visual feedback system for pilots, named 'the Greenie Board', to improve flight manoeuvres on aircraft carriers. Given that increased compliance with enhanced recovery after surgery protocols reduces postoperative complications, we decided to apply a similar feedback system to our institutional enhanced recovery programme. We undertook a prospective 12-month audit of 194 patients assigned to our enhanced recovery programme and evaluated adherence to the anaesthesia-related components of our protocol, before and after implementing a Greenie Board. A compliance score was calculated by summing points for adherence to: intra-operative antibiotic prophylaxis; temperature management; goal-directed intravenous fluid therapy; postoperative nausea and vomiting prophylaxis; and postoperative fluid restriction. The score for each patient was then colour-coded and anonymously displayed for each anaesthetist on a Greenie Board within the operating theatre suite. Protocol adherence improved significantly following introduction, with 'Green' scores (acceptable compliance) increasing from 33% to 72% of patients (p < 0.0001). The greatest improvement was seen with anti-emetic prophylaxis (49% to 70%, p = 0.004) with a consequent reduction in postoperative nausea and vomiting (OR 0.42, 95% CI 0.19-0.88, p = 0.021). We did not observe a decrease in other postoperative complications nor hospital length of stay. We conclude that this US Navy-inspired feedback system is an easily implemented, low-cost quality improvement tool that significantly improved adherence to intra-operative components of our enhanced recovery protocol. The system lends itself to global scaling to drive quality improvement in healthcare delivery and would be suited to institutions without electronic medical records, including low-resource countries.

Complication rates of external ventricular drain insertion by surgeons of different experience.

Introduction Insertion of external ventricular drain (EVD) is a widely accepted, routinely performed procedure for treatment of hydrocephalus and raised intracranial pressure. The purpose of this study was to investigate whether a surgeon's experience affects the associated complication rate. Methods This retrospective study included all adult patients undergoing EVD insertion at a single centre between July 2013 and June 2015. Medical records were retrieved to obtain details on patient demographics, surgical indication, risk factors for infection and use of anticoagulants or antiplatelets. Surgeon experience, operative time, intraoperative antibiotic prophylaxis, need for revision surgery and EVD associated infection were examined. Information on catheter tip position and radiological evidence of intracranial haemorrhage was obtained from postoperative imaging. Results A total of 89 patients were included in the study. The overall infection, haemorrhage and revision rates were 4.8%, 7.8% and 13.0% respectively, with no significant difference among surgeons of different experience. The mean operating time for patients who developed an infection was 22 minutes while for those without an infection, it was 33 minutes (p=0.474). Anticoagulation/antiplatelet use did not appear to increase the rate of haemorrhage. The infection rate did not correlate with known risk factors (eg diabetes and steroids), operation start time (daytime vs out of hours) or duration of surgery although intraoperative (single dose) antibiotic prophylaxis seemed to reduce the infection rate. There was also a correlation between longer duration of catheterisation and increased risk of infection. Conclusions This is the first study demonstrating there is no significant difference in complication rates between surgeons of different experience. EVD insertion is a core neurosurgical skill and junior trainees should be trained to perform it.

Comparison of Preoperative and Perioperative Antibiotic Prophylaxis Regimen in Compound Facial Fractures

Intraoperative antibiotics may be effective in elective surgery; there may be an advantage to starting antibiotics preoperatively when there is already an infective focus, such as compound facial fractures. The purpose of this study is to compare preoperative and intraoperative antibiotic prophylaxis in compound facial fractures. This is a prospective study conducted over a period of 2 years on 50 patients, who underwent open reduction and rigid internal fixation. The patients were assigned to two groups. The patients in group I received antibiotics at the time of admission. The patients in group II received antibiotics perioperatively at the time of induction of general anesthesia. Postoperatively, the patients were evaluated for the reduction of pain and the presence of infection by assessing the local presence of erythema, swelling, a rise in temperature, and purulent discharge, if any, on a predefined proforma. A total of 72 fractures were assessed in 50 patients. There was an overall reduction of pain in both the groups. Wound healing status was found to be satisfactory in both the groups. Wound status and infection rate were evaluated in patients of both the groups. In the study, there was no difference between the two groups on the predecided parameters whether the antibiotics were given either preoperatively or perioperatively. It is very essential to have a sound knowledge of the use of antibiotic therapy effectively to prevent the overuse of it and, thereby, help avoid developing resistance to antibiotics in patients.