Metronidazole Prophylaxis Research Articles

Porphyromonas gingivalis systemic infection is associated with calcific aortic valve stenosis through IL-1-dependent signaling pathways

Abstract Background Calcific aortic valve stenosis (CAVS) is characterized by inflammation mediated valvular calcification. Porphyromonas gingivalis, a keystone pathogen for periodontitis, has been associated with various chronic inflammatory diseases. We assessed the impact of intravenous inoculation with P. gingivalis on the progression of CAVS. Methods Wide-type (WT) C57BL/6, ApoE deficient (ApoE-/-), and IL1B deficient (IL-1β-/-) mice were fed with normal chow or high-fat diet (HFD). A series of metagenomic, morphometric, and molecular signaling experiments, including 16S rRNA gene sequencing, RNA sequencing (RNA-Seq), quantitative real-time polymerase chain reaction (qPCR), immunostaining, and western blotting, were conducted. Valvular calcification and aortic stenosis were evaluated by Alizarin red staining, and mice echocardiography, respectively. Results By using 16S rRNA gene sequencing and qPCR, we found that P. gingivalis was the 3rd most significantly enriched bacterial species in aortic valves from CAVS patients compared with controls. Morphometric assays showed predominant P. gingivalis infiltration inside of human aortic valves. Intravenous inoculation of P. gingivalis in either WT or ApoE-/- mice resulted in increased bacterial infiltration in aortic valves, irrespective of chow- or HFD. Alizarin red staining and echocardiographic evaluation further revealed that P. gingivalis bacteremia markedly enhanced valvular calcification, leading to hemodynamically significant aortic stenosis in the murine models, which were ameliorated by intraperitoneal metronidazole prophylaxis. RNA-Seq and qPCR validation showed that the gene expression of IL1B, RUNX2, and BMP2 was upregulated in P. gingivalis-stimulated valvular interstitial cells (VIC). Similar changes on IL1B were observed in aortic valves form P. gingivalis-challenged WT and ApoE-/- mice, and in valvular specimens from CAVS patients. qPCR and Alizarin red staining showed that IL1B knockdown decreased P. gingivalis-induced RUNX2 and BMP2 expression, and attenuated calcification in VICs. Consistently, P. gingivalis-induced changes on bacterial infiltration, valvular calcification, and hemodynamically significant aortic stenosis were markedly blunted in IL-1β-/- mice. Furthermore, the level of serum IL-1β and SAA were increased in response to P. gingivalis challenge in ApoE-/- mice, but not in WT or IL-1β-/- mice. Conclusions This study demonstrated, for the first time, that P. gingivalis infiltration in aortic valves promoted IL-1β-mediated local inflammation and valvular calcification, thus resulting in the progression of CAVS.Central Illustration: Pg promotes CAVS

The effect of prophylaxis with ertapenem versus cefuroxime/metronidazole on intestinal carriage of carbapenem-resistant or third-generation-cephalosporin-resistant Enterobacterales after colorectal surgery

ObjectivesCompared to cephalosporin-based prophylaxis, ertapenem prophylaxis lowers the risk of surgical site infection among carriers of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PEs) undergoing colorectal surgery. We aimed to determine whether ertapenem prophylaxis leads to increased postoperative colonization with carbapenem-resistant Enterobacterales (CREs) and third-generation-cephalosporin-resistant Enterobacterales (3GCR-Es). MethodsThis study was nested within a quality improvement study of prophylaxis for ESBL-PE carriers undergoing colorectal surgery. Patients were screened 4–6 days after surgery for carriage of ESBL-PEs or other 3GCR-Es and CREs. When CREs were detected, pre- and postsurgical clones were compared using Fourier-transform infrared (FT-IR) spectroscopy. ResultsThe sample consisted of 56 patients who carried ESBL-PEs before surgery and received cefuroxime/metronidazole prophylaxis (Group 1), 66 who carried ESBL-PEs before surgery and received ertapenem (Group 2), and 103 ESBL-PE non-carriers who received cefuroxime/metronidazole prophylaxis (Group 3). CRE carriage was detected postoperatively in one patient (1.5%) in Group 2 versus eight patients (14.3%) in Group 1 (RD –12.8%; 95%CI –22.4% to –3.1%). For seven out of nine patients, preoperative ESBL-PE and postoperative CRE isolates were compared; in five of them, the pre- and postoperative clones were identical. Postoperative 3GCR-E carriage was detected in 37 patients (56.1%) in Group 2 versus 46 patients in Group 1 (82.1%) (aRD –20.7%, 95%CI –37.3% to –4.1%). ConclusionsAmong ESBL-PE carriers undergoing colorectal surgery, detection of short-term postsurgical colonization by CREs and 3GCR-Es was significantly lower among patients who received ertapenem prophylaxis than those who received cephalosporin–metronidazole prophylaxis. Resistance development in a colonizing bacterial clone, rather than carbapenemase acquisition, was the major mechanism of carbapenem resistance.

Subcapsular Hematoma: An Unusual Complication of ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) developed in 1968 is a minimally invasive procedure for diagnosis and treatment of biliary and pancreatic disease. Complications include cholangitis, perforation, bleeding and pancreatitis. They occur in 2.5-8% of cases with mortality rates ranging 0.5-1.0%. Hepatic hematoma post ERCP is an exceedingly rare complication with only a limited number of cases described in the literature. Presented is a case of a subcapsular hematoma following ERCP. A 39-year-old female presented with acute, diffuse abdominal pain associated with non-bloody, non-bilious vomiting one day after ERCP for elevated liver tests. ERCP showed a 3cm stricture in the mid common bile duct (CBD) with proximal dilation of the biliary tree and CBD to 14mm. A 7 Fr x 7mm CBD stent was placed. Sphincterotomy was not performed. On admission, vital signs were within normal limits. Labs were significant for total bilirubin 2.4 mg/dL, alkaline phosphatase 215 U/L, AST 208 U/L, ALT 496 U/L, lipase 2730 U/L, Hgb 12.9 g/dL. CT abdomen showed a 5.8 x 5.6 x 18cm collection in relation to the right lobe of the liver concerning for subcapsular hematoma. Due to persistent abdominal pain, repeat CT was performed showing expansion now measuring 12 x 6.8 x 21cm. A right hepatic arteriogram was performed by IR revealing a pseudoaneurysm arising from a peripheral branch of the right hepatic artery that was embolized. She had ultrasound-guided drainage of the subcapsular hematoma with 500cc of blood drained. She completed 5 days of ceftriaxone and metronidazole for prophylaxis and was discharged on hospital day 8. Subcapsular hematoma is a rare complication that requires early identification and intervention. Presentation with severe abdominal pain and/or hypotension with associated nausea and/or vomiting should raise concern for a subcapsular hematoma. Symptoms often occur within the first 24 hours but can present as late as 2 weeks post-ERCP. A decreasing hemoglobin or hematocrit is the only laboratory finding that may raise suspicion in certain cases. Hematomas can occur as a result of incidental rupture of small caliber intrahepatic vessels due to advancement of the ERCP guide wire. Post ERCP diagnostic imaging consists of abdominal ultrasound, CT or MRI. In our case, due to an active bleeding vessel, embolization was warranted, but in a majority of cases conservative measures were the treatment of choice.1947_A Figure 1. CT Abdomen performed on admission showing a 5.8 x 5.6 x 18cm collection.1947_B Figure 2. CT Abdomen performed 12 hours after admission showing a 12 x 6.8 x 21cm collection.

Efficacy of preoperative antimicrobial prophylaxis in patients undergoing pancreatoduodenectomy: a multicentre retrospective analysis

Introduction: Most common complications following pancreaticoduodenectomy (PD) are infectious, despite the standard use of cefazolin and metronidazole prophylaxis. Preoperative biliary drainage (PBD) is a well-known risk factor for infectious complications. The objective was to identify the most common pathogens in intraoperative bile cultures in patients undergoing PD - with and without PBD - to determine the optimal antimicrobial prophylaxis regimen. Methods: Patients, who underwent PD between 2009 and 2016, were retrospectively identified in 3 major teaching hospitals in The Netherlands. The use of PBD and the type of perioperative antimicrobial prophylaxis were registered. All organisms isolated from intraoperative bile cultures including their susceptibility pattern were studied. If pathogen coverage by standard prophylaxis was incomplete, the most appropriate alternative regimen was determined. Results: A large multicentre cohort of 352 patients was analyzed, of which 198 (56%) underwent PBD and 154 (44%) did not. In the PBD group 175 patients (87.9%) had positive bile cultures compared with 49 (31.8%) in the non PBD group. Most commonly isolated microorganisms were Enterococcus species (42.4% and 3.9% respectively), Streptococcus species (31.8% and 9.1%), Klebsiella species (56% and 14%) and Enterobacter species (26.3% and 5.8%). Cefazolin and metronidazole was appropriate in 71% (PBD 55.6% and non PBD 88.3%) of patients. Adding gentamicin would provide complete coverage in 99% of PBD and 100% of non PBD patients. Conclusion: Our data confirm that PBD prior to PD leads to microbial colonization and antibiotic resistance. To potentially prevent infectious complications, gentamicin may be added to the standard antimicrobial prophylaxis.

Prophylactic Use of Metronidazole during Major Gynaecological Operation to Prevent Wound Infection: A Randomized Control Trial

Background: Prophylactic medication of major gynaecological operations is very important for the reduction of bad surgical outcomes. Objective: This randomized control trial was conducted to determine whether the metronidazole prophylaxis in conventional therapy was effective in controlling postoperative wound infection in major gynaecological infection. Methodology: The study was carried out at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, during .the period from August 2002 to January 2003. One hundred and fifty consecutively admitted patients for gynecological operation were randomly assigned to receive either metronidazole and ampicillin/amoxicillin (group A) or only ampicillin/amoxicillin (group B) just after operation and continued for 7 days. After operation, daily follow-up with observation of the wound was done till their discharge. All the outcome data were collected, compiled and statistically analyzed using SPSS programme with the consultation of the statistician. Result: A total number of one hundred and forty patients were referred of which 70 patients from group A and 70 from group B. Wound infection was observed in 4(5.7%) patients of group A and 6(8.6%) patients of group B. There was no significant difference (P>0.747) in only considering abdominal wound infection and also in including vaginal wound infections (P>0.747). Conclusion: The study findings show that metronidazole prophylaxis in conventional therapy is an extremely effective agent in controlling anaerobic wound infection after gynaecological surgery.Bangladesh Journal of Infectious Diseases 2017;4(1):10-14

Efficacy of Pre-Operative Antimicrobial Prophylaxis in Patients Undergoing Pancreatoduodenectomy: A Multi-Center Retrospective Analysis.

The most common complications after pancreaticoduodenectomy (PD) are infectious, despite the standard use of cefazolin and metronidazole prophylaxis. Pre-operative biliary drainage (PBD) is a well-known risk factor for infectious complications. The objective was to identify the pathogens in intra-operative bile cultures in patients undergoing PD-with and without PBD-to determine the optimal antimicrobial prophylaxis regimen. Patients who underwent PD between 2009 and 2016 were identified retrospectively in three major teaching hospitals in The Netherlands. Organisms isolated from intra-operative bile cultures were studied. If pathogen coverage by standard prophylaxis was incomplete, the most appropriate alternative regimen was determined. Of this large cohort of 352 patients, 56% underwent PBD and 44% did not. Positive bile cultures were found in 87.9% in the PBD group, compared with 31.8% in the non-PBD group. The micro-organisms isolated most commonly were Enterococcus, Streptococcus, and Klebsiella species. Cefazolin and metronidazole were appropriate in only 71% of patients. Adding gentamicin would provide complete coverage in 99% of PBD and 100% of non-PBD patients. Our data confirm that PBD prior to PD leads to microbial colonization and antibiotic resistance. To potentially prevent infectious complications, gentamicin may be added to the standard antimicrobial prophylaxis.

Metronidazole in the prevention of antibiotic-associated diarrhoea and Clostridium difficile infection in high-risk hospitalised patients

Abstract Background In-hospital diarrhoea has a high impact on morbidity and mortality rates among hospitalised patients. Chemoprophylaxis with antibiotics in selected patients could be a cost-effective tool for prevention. Methods A prospective randomised, open-label study was conducted in a tertiary hospital in Mexico City, selecting patients at high risk of acquiring in-hospital diarrhoea and assigning them to a group taking metronidazole 500 mg orally every 8 h for seven days or an observation group. The primary endpoint was the presence of antibiotic-associated diarrhoea and Clostridium difficile (C. difficile) infection during the seven days of evaluation. The study was approved by the institutional ethics committee. Registration number (11.2017) of 14 March 2017. Results Of the 116 patients who met the inclusion criteria, 96 were analysed, 41 in the intervention group and 55 in the observation group: 4.9% of patients in the intervention group and 16.4% in the observation group developed antibiotic-associated diarrhoea (odds ratio [OR] 0.26 (0.05–1.29); P = 0.109). 0% of patients in the intervention group and 9.1% in the observation group developed C. difficile infection (odds ratio [OR] 0.91 (0.84–0.99); P = 0.069). Conclusions Metronidazole prophylaxis did not result in a reduction in antibiotic-associated diarrhoea. It could, however, be an effective measure for preventing C. difficile infection in selected high-risk patients. This was the first prospective study designed for this purpose. New studies that involve a larger number of patients are required in the future.

Use and Effectiveness of Peri-Operative Cefotetan versus Cefazolin Plus Metronidazole for Prevention of Surgical Site Infection in Abdominal Surgery Patients.

Current practice guidelines for antimicrobial prophylaxis in surgery recommend a cephamycin or cefazolin plus metronidazole for various abdominal surgeries. In February 2016, cephamycin drug shortages resulted in a change in The Johns Hopkins Hospital's (JHH) recommendation for peri-operative antibiotic prophylaxis in abdominal surgeries from cefotetan to cefazolin plus metronidazole. The primary objective of this study was to quantify the percentage of abdominal surgeries adherent to JHH peri-operative antibiotic prophylaxis guidelines. A sub-group analysis investigated whether prophylaxis with cefazolin plus metronidazole was associated with a lower rate of surgical site infections (SSIs) versus cefotetan. This retrospective cohort study included adult inpatients who underwent an abdominal surgery at JHH in September 2015 (Study Period I: cefotetan) or February to March 2016 (Study Period II: cefazolin plus metronidazole). Two hundred abdominal surgery cases were included in the primary analysis. A subset of 156 surgical cases were included in the sub-group analysis. The overall adherence rate to JHH guidelines was 75% in Study Period I versus 17% in Study Period II (p < 0.001). The largest difference in adherence was attributed to pre-operative administration time (87% vs. 23%, p < 0.001), primarily because of the longer infusion time required for metronidazole. Surgical site infections occurred in 14% (12/83) of surgeries with cefotetan versus 8.2% (6/73) with cefazolin plus metronidazole for prophylaxis (p = 0.19). Adherence to an institution-specific peri-operative antibiotic prophylaxis guideline for abdominal surgeries was limited primarily by the longer infusion time required for pre-operative metronidazole. A higher percentage of SSIs occurred among abdominal surgeries with cefotetan versus cefazolin plus metronidazole for prophylaxis.

Cefazolin alone versus cefazolin, gentamicin, and metronidazole for prophylaxis in women undergoing caesarean section: a randomised controlled trial

BackgroundProphylactic antibiotic regimens for women undergoing caesarean section are useful for prevention of maternal morbidity, and antibiotic misuse can give rise to antimicrobial resistance. The aim of this study was to compare a single preoperative dose of cefazolin with the current standard practice of cefazolin, gentamicin, and metronidazole three times daily after the caesarean section until patient discharge. MethodsIn this randomised, unmasked, parallel-group controlled trial, we enrolled women (aged 18–45 years) who were undergoing a caesarean section at the Al-Helal Al-Emirati Hospital in Rafah, Gaza Strip, occupied Palestinian territory. Using manual-blocks formation based on the rolling of a die, recruited women were randomly assigned to either 1000 mg intravenous cefazolin 30–60 min before the caesarean section (cefazolin group) or 1000 mg cefazolin, 80 mg gentamicin, and 500 mg metronidazole three times daily after the caesarean section until hospital discharge (triple antibiotic group). Outcome measures included readmission to the hospital because of wound infection, registered post-caesarean complications, duration of the caesarean section procedure, and length of hospital stay. Data were analysed with SPSS. Groups were compared using student's t test or χ2 test. The study was approved by the Ministry of Health of the Gaza Strip and done in accordance with the Declaration of Helsinki. Women provided verbal informed consent before participation in the trial and before undergoing the caesarean section. FindingsBetween Jan 1, 2013, and July 31, 2013, we screened 329 women and enrolled 313 (mean age 31·2 years [SD 6·5]). We excluded 26 women because of previous infections (n=12), history of drug allergy (n=5), and missing data (n=9). 158 women were assigned to the cefazolin group, and 155 women assigned to the triple antibiotic group. Four women were readmitted to the hospital because of wound infections (three [2%] women from the cefazolin group, one [1%] from the triple antibiotic group; p=0·375). Mean duration of the caesarean section procedure was 35·86 min (SD 7·77) in the cefazolin group and 36·70 min (7·40) in the triple antibiotic group (p=0·511). Mean length of hospital stay after the caesarean section was 39·62 h (SD 11·19) in the cefazolin group and 40·48 h (13·07) in the triple antibiotic group (p=0·672). No cases of endometritis, urinary tract infections, or febrile morbidities were reported. InterpretationPre-caesarean, single-dose cefazolin was as effective as the combination of cefazolin, gentamicin, and metronidazole in preventing post-caesarean infections. We therefore recommend that cefazolin is used pre-operatively to prevent post-caesarean infection. FundingNone.

Efficacy of Oral Vancomycin, Oral Metronidazole, or IV Metronidazole Prophylaxis at Reducing the Risk of Clostridium difficile Recurrence

BackgroundSecondary prophylaxis (SP) for Clostridium difficile infection (CDI) with oral vancomycin or oral/IV metronidazole when initiating antibiotics is common, though few studies are available to support this practice. The purpose of this study was to assess the efficacy of prophylaxis within a year of index CDI.MethodsThis retrospective chart review looks at subsequent courses of antibiotics and CDI in patients with initial positive CDI testing in 2013–16. A positive CDI test within 90 days of antibiotics was a recurrence. The use of antibiotics for SP was noted, along with other factors associated with CDI relapse. Non-parametric and exact tests were used for univariate analysis. These variables were included in a multivariate proportional hazards model.ResultsWe found 597 antibiotic episodes in 230 patients. 130 episodes (21.8%) received SP. The difference of recurrence rates with and without antibiotics, 9.2 % vs 10.7%, was not statistically significant. No difference was seen when metronidazole was used, but vancomycin SP reduced the rate to 7.5% (6/80, P = 0.45). Probiotics were associated with a higher rate of recurrence (16.7 vs. 8.9%, P = 0.025). Proton pump inhibitors were also associated with a slightly higher rate of CDI recurrence (13.0% vs. 8.4%). The rate of relapse fell significantly with increasing time since the index case of CDI by logistic regression (P = 0.011). In multivariate regression, relapse was associated with shorter time from index CDI, shorter durations of antibiotics, and the use of probiotics.ConclusionThis retrospective study does not support the routine use of metronidazole in subsequent antibiotic courses following CDI. The use of probiotics paradoxically increased the rate of CDI relapse in this study. The limitations of this retrospective study do not eliminate the possibility of utility of vancomycin as prophylaxis, but this requires further evaluation.Disclosures All authors: No reported disclosures.

Control of Multidrug Resistant Pseudomonas Aeruginosa through Hospital Construction Design and Extensive Environmental and Clinical Surveillance in an Allogeneic Transplantat Unit

▪Introduction: Immunocompromised patients are increasingly threatened by multidrug resistant bacterial strains. Following allogeneic stem cell transplantation (SCT), patients are especially at risk for multidrug resistant Pseudomonas aeruginosa (MRPA) which as a pathogen can be the cause of life-threatening septicemias. A possible reservoir and source of nosocomial infections are biofilms in shower drains, sinks, and toilets. For this reason, substantial targeted renovation was performed in the bathrooms of our SCT unit. We subsequently performed extensive surveillance of patients status as carriers and took numerous environmental samples.Methods: Renovation/ conversion works of our transplant unit (2 wards with 20 HEPA filtered patients rooms, all equipped with separate shower baths) began in 2011 and included the installation of Pall-Aquasafe water filters (Pall Cooperation, Port Washington, NY) on all faucet and shower heads. Washbasins were equipped with Biorec Disinfection siphons (MoveoMed, Radebeul, Germany), which use UV and temperature together with frequent vibration and a bactericidal coating for disinfection. In addition, the toilets were replaced with rimless toilet basins and a system was developed to supply the flushing water with disinfectant at appropriate concentrations. The shower outlet drains were modified and covered by a heavy metal lid that cannot be easily removed and prevents aerosol formation. All renovation work was completed in April 2014. Cleaning and disinfection takes place once a day and the removable metal devices of the showers are sterilized once a week as well as every time a patient is discharged. In addition, extensive training of all personal in infection prevention was performed and the work of the cleaning personal was supervised closely. Environmental sampling was performed monthly in every room. Patients were screened upon admission and weekly during their treatment on the SCT unit by either anal swabs or stool cultures. Standard antibiotic prophylaxis consisted of ciprofloxacin and metronidazole for patients undergoing allogeneic SCT. Metronidazole prophylaxis was omitted in August 2013.Results: Peri-renovation environmental sampling detected MRPA in 22,6% of swabs from the toilets and 11,8% of swabs from the shower outlets in 2012. The rate decreased to 15,1% from the toilets and 4,4% from the shower outlets in 2013 and reached 10,1% from the toilets and 0,6% from the shower outlets in the first six months of 2014. In 2012, 15 out of 197 patients (7.6%), receiving an allogeneic SCT or treatment for severe post-transplant complications (mainly GvHD) were affected by MRPA. This number decreased to 13 out of 206 (6.3%) in 2013 and 2 out of 95 (2.1%) in the first half in 2014. Overall 18 patients (3.6%) were colonized only and 12 patients (2.4%) developed bacteremia from MRPA.Discussion: Environmental sources must be taken into consideration for the prevention of nosocomial infections. The implemented measures in our transplant unit can serve as an example for the reduction of biofilm, which can act as a reservoir for MRPA. Because of inconsistent local conformity of environmental and clinical isolates it still remains unclear whether the reason for colonisation and infection lays in environmental contamination and / or antibiotic selection in already precolonized patients. Further investigations will employ MRPA genotyping to determine genetic relationships between isolates from patients and environmental isolates. DisclosuresNo relevant conflicts of interest to declare.

Metronidazole prophylaxis for elective large bowel surgery in children: A prospective trial

In a controlled trial in children aged 2 days to 16 years undergoing large bowel surgery a group of 15 patients had preoperative mechanical bowel preparation and oral neomycin while a second group of 15 patients was similarly prepared but also had preoperative and postoperative metronidazole medication. Five of the 9 postoperative infections in the first group involved Bacteroides spp. but no anaerobe was found in the 3 wound infections in the metronidazole group.

Metronidazole prophylaxis to prevent infections after total abdominal hysterectomy

Metronidazole prophylaxis to prevent infections after total abdominal hysterectomy

Infection after radical abdominal hysterectomy and pelvic lymphadenectomy: prevention of infection with a two-dose peri-operative antibiotic prophylaxis.

Surgical site-related infections occurred in 21% of 87 consecutive patients undergoing radical hysterectomy with pelvic lymphadenectomy (RHPL) without planned peri-operative prophylaxis. A prospective, randomized double-blind, placebo-controlled study was conducted in 68 consecutive RHPL patients. In the 32 available patients with two-dose cefuroxime and metronidazole prophylaxis no surgical site-related infections developed as opposed to a rate of 14% in the 28 patients in the placebo group (P < 0.05). In a prospective, randomized double-blind study two two-dose antibiotic prophylactic regimens were compared in 105 consecutive patients. Surgical site-related infections developed in one (2%) patient in the cefuroxime plus metronidazole group, and in six (12%) patients in the moxalactam group. This difference did not achieve statistical significance. The mean length of the postoperative hospital stay of the patients with scheduled surgical prophylaxis was significantly shorter (P < 0.01) than that of the patients operated on without surgical prophylaxis. A two-dose antibiotic regimen is recommended, because levels of antibiotics assayed in samples collected during the course of the operation indicated a rapid clearance of the antibiotics from the operative site, most likely due to the high volume of peri-operative blood loss.

Mastoidectomy packs: Xeroform® or BIPP?

A retrospective study comparing adverse events using bismuth iodoform paraffin paste (BIPP) and Xeroform as dressings for newly fashioned mastoid cavities after mastoidectomy was undertaken. There were 20 patients in each group. Adverse events were defined as offensive packs, mastoid cavity infections and systemic signs of infection. There were no adverse events using BIPP packs whether or not prophylactic antibiotics were used. Xeroform packs were associated with a significantly higher incidence of adverse events compared to BIPP when using no antibiotic prophylaxis (P less than 0.005) or amoxycillin (P less than 0.005). Adverse events with Xeroform packs were abolished using ciprofloxacin and metronidazole prophylaxis. We conclude that BIPP is the mastoid dressing of choice.

Lokale Applikation von Metronidazol vor Hysterektomie - Einfluß auf infektiöse Morbidität

A prospective clinical trial was designed to examine the influence of a local application of metronidazole on postoperative infectious morbidity in 134 women undergoing vaginal and in 108 women undergoing abdominal hysterectomy. 116 patients received on the evening before hysterectomy a vaginal suppository of metronidazole (500 mg). The control group (126 patients) had no metronidazole prophylaxis. All patients, who underwent vaginal hysterectomy, were given additionally a single-shot prophylaxis with 1500 mg cefuroxim. With regard to febrile morbidity, urinary tract infection and abdominal wound or pelvic infection, there was a significant decrease in infectious morbidity. In women undergoing vaginal hysterectomy the infectious morbidity was reduced from 35.7% to 20.3% (p less than 0.05) in spite of systemic prophylaxis. In cases with abdominal hysterectomy, we saw a decrease from 64.3% to 26.9% (p less than 0.001). There was no effect on the incidence of urinary tract infections. Local prophylaxis with metronidazole in abdominal hysterectomy and additional to a systemic prophylaxis in vaginal hysterectomy reduces the infectious morbidity in our patients.

A comparison between imipenem and metronidazole prophylaxis against sepsis following appendicectomy

A single preoperative dose of imipenem/cilastatin was compared with metronidazole for the prevention of infectious sequelae following emergency appendicectomy. Patients with established sepsis received in addition 72 h of either intravenous imipenem or ampicillin, gentamicin and metronidazole postoperatively. Two hundred and sixty-eight patients were studied. Wound infection rate in low-risk patients was 9% for metronidazole and 8% for imipenem. When sepsis was already established intraperitoneally the wound infection rate was 24% for the triple therapy regimen and 8% for imipenem. There was no statistically significant difference between the infection rates in the two groups of treatment whatever the state of the appendix, but there was a trend in favour of imipenem in those patients with a perforated appendix.

A prospective randomized trial to compare triple dose mezlocillin with triple dose cefuroxime plus metronidazole as prophylaxis in colorectal surgery

The results of a prospective randomized clinical trial to compare three dose regimens of mezlocillin with cefuroxime plus metronidazole for prophylaxis in emergency and elective colorectal surgery are reported. Severe wound infection occurred in five patients (10%) receiving mezlocillin and in four patients (7%) receiving cefuroxime and metronidazole. There were two episodes of septicaemia, each in the mezlocillin group. The total number of surgically related infections was less with cefuroxime plus metronidazole (n = 10) compared with mezlocillin (n = 17), but this was not statistically significant ( P > 0·1).

A multicentre study to compare piperacillin with the combination of netilmicin and metronidazole for prophylaxis in elective colorectal surgery undertaken in district general hospitals

We have conducted a multicentre randomized study to compare piperacillin with the combination of netilmicin and metronidazole in patients undergoing elective colorectal surgery. There was no significant difference in the incidence of operation-related infection, chest or urinary tract infection. Major life-threatening sepsis occurred in 6% and the overall incidence of operation-related infection was 24%. Organisms which normally inhabit the bowel lumen were cultured from most of the postoperative infections; however, Staphylococcus aureus was isolated as a causative organism in nine patients in the piperacillin group compared with none in the netilmicin and metronidazole group. We are concerned at the high incidence of infection in both groups, and we believe that other factors in addition to prophylactic antibiotics need to be evaluated if the incidence of infection is to be reduced further.

Metronidazole prophylaxis in acute mural appendicitis: failure of a single intra-operative infusion to reduce wound infection

The efficacy of a single 500 mg intravenous intra-operative dose of metronidazole in the prevention of postoperative wound infection, following appendicectomy for acute mural appendicitis, was studied in a prospective randomized placebo controlled trial. Fourteen of the 96 patients (14·6%) in the metronidazole group and 13 of the 94 in the placebo group (13·8%) developed postoperative wound infection. Late sepsis was noted in 4 out of the 96 patients in the metronidazole group and in one of the 94 patients in the placebo group. This study suggests that a single intra-operative dose of metronidazole does not reduce the incidence of postoperative wound infection following appendicectomy for acute mural appendicitis.