Periprocedural Antibiotics Research Articles

Initial Experience Performing In-office Ultrasound-guided Transperineal Prostate Biopsy Under Local Anesthesia Using the PrecisionPoint Transperineal Access System

To describe our procedural technique and initial outcomes performing in-office transperineal prostate biopsies using the PrecisionPoint Transperineal Access System (Perineologic, Cumberland, MD). Following institutional review board approval, we retrospectively reviewed the records of men who underwent an in-office transperineal prostate biopsy using the PrecisionPoint device. Records were reviewed for baseline characteristics, biopsy results, and postbiopsy complications. Between January 4, 2017 and August 23, 2017, 43 men underwent an in-office transperineal prostate biopsy using the PrecisionPoint Transperineal Access System. Patients had a median serum prostate specific antigen level of 6.1 ng/mL (range 0.8-32.9). Of the 43 biopsies, 12 (27.9%) were performed for active surveillance of low-risk prostate cancer and 31 (72.1%) were performed for cancer screening. Overall, 21 (48.8%) men were found to have prostate cancer. Among those on active surveillance, cancer was detected in 8 of 12 (66.7%) patients, with 2 of 12 (16.7%) found to have Gleason ≥3 + 4 = 7 prostate cancer. Additionally, cancer was detected in 13 of 31 (41.9%) patients undergoing a biopsy for prostate cancer screening, with 5 (16.1%) found to have Gleason ≥3 + 4 = 7 disease. In total, 3 (7.0%) patients experienced a postbiopsy complication: 2 (4.7%) with urinary retention and 1 (2.3%) with gross hematuria requiring catheterization. No patient experienced an infectious complication despite omission of periprocedural antibiotics in all cases. The PrecisionPoint device allowed for the successful performance of in-office transperineal prostate biopsies under local anesthesia without the need for periprocedural antibiotics. We observed an acceptable cancer detection rate with no infectious complications.

Diagnostic Yield of Micro Forceps Biopsies during Endoscopic Ultrasound Evaluation of Pancreatic Cystic Lesions

Introduction: Evaluation of pancreatic cystic lesions (PCLs) can be challenging and requires a combination of radiologic imaging, morphologic characteristics on endoscopic ultrasound (EUS), cyst fluid cytology, and cyst fluid analysis. Through-the-needle micro forceps (Moray micro forceps, US Endoscopy, Mentor, OH) are a recent addition to EUS armamentarium. These forceps allow tissue sampling from PCLs and may improve diagnostic yield. To date, scant data exists on the use of micro forceps biopsy for these lesions. The main aim of this study was to assess diagnostic yield and safety of EUS-guided micro forceps biopsy for PCLs. Methods: Our electronic endoscopy database was queried to identify patients who underwent EUS-FNA of PCLs and biopsies with the micro forceps, during the same procedure. Cysts were identified on EUS and punctured using 19-G FNA needle. All patients received peri-procedural antibiotics. Cyst fluid was collected for cytologic analysis, CEA and amylase levels, and wall of the cyst was biopsied using micro forceps through the 19-G needle. Adverse events were recorded per published ASGE criteria. Results: Twenty patients (mean age 64.2 years [range 34 -87]; 8/20 male [40%]) underwent EUS-FNA and micro-forceps biopsy of PCLs from 02/2016 to 05/2017. The mean cyst size was 34.4 mm (range 13 -70 mm), with 10 cysts in the pancreatic head/uncinate and 10 in the body/tail region. Micro forceps biopsies were technically successful in all cases, and provided a diagnosis of neoplasia in 11 cases (55%), benign tissue in 8 cases (40%) and insufficient quantity in 1 case. In 4 patients (20%), micro forceps biopsy results drastically changed patient management, providing diagnoses (1 Neuroendocrine tumor, 1 mucinous cystic neoplasm, and 2 IPMNs) otherwise not suggested by cytology or cyst fluid analysis. However, cytology provided a diagnosis of mucinous neoplasm in 3 cases not detected by micro forceps biopsies. No adverse events were noted. Conclusion: Micro forceps biopsies were associated with high yield and excellent safety profile. Biopsies provided a diagnosis of neoplasia not detected by cytology in a significant number of patients but also did not identify mucinous neoplasms in a few cases as suggested by cyst fluid cytology. Hence micro forceps biopsies may be a useful adjunctive tool for EUS guided assessment of PCLs, complementing existing EUS-FNA sampling protocols.

Reassessing the utility of routine urine culture with urodynamics: UTI incidence and risk factors

There is no consensus regarding use of periprocedural antibiotics or routine urine cultures during urodynamics study (UDS) in children. At our hospital, we historically have obtained urine cultures during UDS. However, even with positive cultures, few patients require treatment. Most are successfully managed with increased hydration and frequent bladder emptying. To evaluate clinical characteristics, antibiotic treatment, and outcomes in patients undergoing UDS to identify (1) risk factors for urinary tract infection (UTI) after UDS, and (2) patients who may benefit from routine urine culture. Retrospective review of 769 patients who underwent 1057 UDS between January 2013 and January 2015. Positive urine culture was defined as ≥104 colony forming units/ml. Afebrile UTI was defined as new symptoms within 7 days. Febrile UTI was new symptoms with fever (≥38.5 °C). Fisher's exact test was used for comparative analyses. Nearly all patients had a urine culture taken immediately prior to UDS (94%, 993/1057). Patients on clean intermittent catheterization (CIC) were more likely to be on pre-UDS antibiotics, 22.8% (106/464) vs. 17.9% of those not on CIC (106/593) (p = 0.04). Of patients who had a urine culture, it was positive in 40% (402/993) with more positive cultures in patients on CIC vs. not (72.0%, 316/439 vs. 15.5%, 86/554, p < 0.0001). Factors significantly associated with clinical/possible post-UDS UTI included clinical UTI within 30 days before UDS, immunosuppression, overnight Foley catheter use, febrile UTI as indication, and symptoms on day of procedure (Table). Fifteen patients (1.4%, 95% confidence interval 0.7-2.1%) developed a clinical/possible post-UDS UTI, of which 40% (6/15) were febrile, with one requiring hospitalization. Of patients with post-UDS UTIs, 33% (5/15) had negative cultures at the time of UDS. If urine cultures were obtained selectively based on our study findings, 78% of pre-UDS urine cultures could be eliminated, while "missing" clinically relevant cultures in only 0.4% (4/1057). Study limitations include the retrospective design. However, prospective data collection will now be possible by using standardized, templated UDS and post-UDS follow-up notes with extractable data elements that automatically populate a database. Post-UDS UTI is uncommon (1.4%), even in the setting of bacteriuria. This finding calls into question the utility of routine pre-UDS urine culture. Data from this study and a future prospective study will be used to refine a new working protocol, with the goal of targeting future urine cultures to a high-risk subset of patients.

Urinary tract infection after voiding cystourethrogram

Reported rates of post-procedural urinary tract infection (ppUTI) after voiding cystourethrogram (VCUG) are highly variable (0-42%). This study aimed to determine the risk of ppUTI after cystogram, and evaluate predictors of ppUTI. A retrospective cohort study of children undergoing VCUG or radionuclide cystogram (henceforth 'cystogram') was conducted. Children with neurogenic bladder who underwent cystogram in the operating room and without follow-up at the study institution were excluded. Incidence of symptomatic ppUTI within 7 days after cystogram was recorded. Predictors of ppUTI were evaluated using univariate statistics. A total of 1108 children (54% female, median age 1.1 years) underwent 1203 cystograms: 51% were on periprocedural antibiotics, 75% had a pre-existing urologic diagnosis (i.e., vesicoureteral reflux (VUR) or hydronephrosis; not UTI alone), and 18% had a clinical UTI within 30 days before cystogram. Of the cystograms, 41% had an abnormal cystogram and findings included VUR (82%), ureterocele (6%), and diverticula (6%). Twelve children had a ppUTI (1.0%; four girls, five uncircumcised boys, three circumcised boys; median age 0.9 years). Factors significantly associated with diagnosis of a ppUTI (Summary fig.) included: pre-existing urologic diagnosis prior to cystogram (12/12, 100% of patients with ppUTI), abnormal cystogram results (11/12, 92%), and use of periprocedural antibiotics (11/12, 92%). All 11 children with an abnormal cystogram had VUR≥Grade III. However, among all children with VUR≥Grade III, 4% (11/254) had a ppUTI. This is the largest study to date that has examined incidence and risk factors for ppUTI after cystogram. The retrospective nature of the study limited capture of some clinical details. This study demonstrated that the risk of ppUTI after a cystogram is very low (1.0% in this cohort). Having a pre-existing urologic diagnosis such as VUR or hydronephrosis was associated with ppUTI; therefore, children with moderate or high-grade VUR on cystogram may be at highest risk. Development of ppUTI after cystogram also highlighted the potential for a delay in diagnosis or oversight of a healthcare-associated infection due to several factors: 1) cystograms may be ordered, performed/interpreted, and followed up by multiple different providers; and 2) such infections are not captured by traditional healthcare-associated infection surveillance strategies. The risk of ppUTI after a cystogram is very low. Only children with pre-existing urologic diagnoses developed ppUTI in this study. This study's findings suggest that children undergoing a cystogram should not be given peri-procedural antibiotic prophylaxis for the sole purpose of ppUTI prevention.

Symptomatic Urinary Tract Infections in Renal Transplant Recipients after Cystoscopy for Ureteral Stent Removal

IntroductionSymptomatic urinary tract infection is a known complication of cystoscopy with ureteral stent removal. However, little is known about the incidence and risk factors for urinary tract infection after cystoscopy in renal transplant recipients, who likely represent a high risk cohort. In this study we determined the infection rate after cystoscopy with stent removal in this population and identified opportunities for care improvement. MethodsWe performed a retrospective cohort study of office cystoscopies with stent removal in renal transplant recipients performed at a single institution from April 2012 through May 2014. Strict criteria were used to determine the presence of symptomatic urinary tract infection within 1 month of the procedure. Fisher’s exact tests were completed to examine associations between patient characteristics and post-transplant outcomes with urinary tract infection. ResultsA total of 324 patients were included in the study. Mean age was 50.0 years (SD 13.1) and 187 patients (57.7%) were male. In this group 165 patients (52.5%) received an oral fluoroquinolone antibiotic before the procedure. Nine patients had symptomatic urinary tract infections (2.8%), of which 3 infections (33.3%) were due to quinolone-resistant organisms. Female sex but no other patient or postoperative characteristic was associated with symptomatic urinary tract infection (p=0.04), including the use of peri-procedural antibiotics. ConclusionsThe incidence of symptomatic urinary tract infection after cystoscopy with ureteral stent removal in renal transplant recipients is less than 3%, comparable to the risk of urinary tract infection after cystoscopy in the general population. Female sex is associated with symptomatic urinary tract infection. Further investigation is needed to identify the groups at greatest risk for urinary tract infection and other complications.

Feasibility and safety of Reveal LINQ insertion in a sterile procedure room versus electrophysiology laboratory

BackgroundInsertable cardiac monitors (ICMs) are increasingly utilized for diagnosis of unexplained syncope and arrhythmia monitoring. The Reveal LINQ is a novel miniaturized ICM with improved algorithms. The feasibility and safety of insertion outside the traditional electrophysiology laboratory is unknown. Here we compare outcomes of Reveal LINQ insertion in different environments. MethodsWe report on a prospective, single-centre, non-randomized, observational experience of consecutive Reveal LINQ implantation in the electrophysiology laboratory or a procedure room between October 2013 and October 2015. ResultsOf 178 consecutive patients who underwent LINQ device insertion, 80 were implanted in the electrophysiology laboratory and 98 in a procedure room. There were no significant differences in baseline patient characteristics. All implants were performed in the recommended manufacturer method with the exception of 1 which required suture closure. Only a minority received peri-procedural antibiotics with a greater number in the electrophysiology laboratory group (11 [14%] versus 1 [1%], p=0.007). Overall, there were 3 (1.7%) complications with no significant difference between the electrophysiology laboratory and the procedure room groups (2 [3%] versus 1 [1%], p=0.45). There was 1 superficial infection in the procedure room group and 1 superficial infection with device extrusion and 1 traumatic extrusion in the electrophysiology laboratory group. Procedure room implantation subjectively improved laboratory efficiency and patient flow. ConclusionReveal LINQ insertion can be safely performed outside of the cardiac laboratory provided a sterile technique is followed by the operator using manufacturer recommendations for insertion. These findings have significant resource implications for hospitals undertaking such procedures.

Antibiotic Prophylaxis for Patients with a History of Total Joint Replacement.

As the population ages and people remain active into the 7th and 8th decades of life, the frequency of total joint replacement is increasing. Following joint replacement surgery, patients inevitably require various invasive procedures as part of their routine health maintenance, including, but not limited to, dental care, colonoscopy, cystoscopy, and cardiac catheterization. There is scant evidence to support the use of periprocedural prophylactic antibiotics in the prevention of late total joint infection. The guidelines for the usage of periprocedural antibiotics have changed as knowledge of the pathophysiology of joint infection has evolved. We review the current recommendations from subspecialty academic organizations regarding antibiotic prophylaxis for patients undergoing routine urologic, gastrointestinal, dental, and cardiac procedures after total joint replacement.

MP26-15 SYMPTOMATIC URINARY TRACT INFECTIONS IN RENAL TRANSPLANT PATIENTS AFTER CYSTOSCOPY FOR URETERAL STENT REMOVAL

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Kidney & Bladder II1 Apr 2016MP26-15 SYMPTOMATIC URINARY TRACT INFECTIONS IN RENAL TRANSPLANT PATIENTS AFTER CYSTOSCOPY FOR URETERAL STENT REMOVAL Justin Gregg, Caroline Kang, Thomas Talbot, S. Duke Herrell, Roger Dmochowski, and Daniel Barocas Justin GreggJustin Gregg More articles by this author , Caroline KangCaroline Kang More articles by this author , Thomas TalbotThomas Talbot More articles by this author , S. Duke HerrellS. Duke Herrell More articles by this author , Roger DmochowskiRoger Dmochowski More articles by this author , and Daniel BarocasDaniel Barocas More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2952AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Symptomatic urinary tract infection (UTI) is a known complication of cystoscopy with ureteral stent removal. However, little is known about the incidence and risk factors for post-cystoscopy UTI in renal transplant recipients, who likely represent a high-risk cohort. Our aim was to determine the infection rate following cystoscopy with stent removal in this population and identify opportunities for care improvement. METHODS We performed a retrospective cohort study of office cystoscopies with stent removal in renal transplant recipients performed at a single institution from April 2012 through May 2014. Symptomatic UTI was defined as having a single symptom (fever, urgency, frequency, dysuria, prostate tenderness or suprapubic tenderness) with a culture of 10^5 or more colony-forming units (CFU) per high-power field, or two symptoms with other characteristics such as a positive urinalysis or physician-diagnosed UTI within one month of procedure. Fisher's exact tests were completed to examine associations between patient characteristics (age, race, diabetes, smoking history, prednisone use, and deceased or living donor) and post-transplant outcomes (time to stent removal, readmission, non-genitourinary tract infection, delayed graft function, acute cellular rejection, and post-procedure urinary leak). Use of pre-procedural antibiotics in addition to daily prophylactic trimethoprim/sulfamethoxazole or dapsone was also evaluated. RESULTS A total of 324 patients underwent outpatient cystoscopy with stent removal. Mean age was 50.0 (SD 13.1) years, and 187 (57.7%) patients were male. Within this group, 200 (61.7%) patients underwent stent removal within four weeks of transplant. 165 (52.5%) patients received a pre-procedural oral fluroquinolone antibiotic dose prior to the procedure. Nine patients had symptomatic UTIs (2.8%), of which three infections (33.3%) were due to quinolone-resistant organisms. Univariate analyses revealed that female sex (P =0.04), was associated with symptomatic UTI. No other patient characteristic or post-operative outcome was associated with symptomatic UTI, including the use of peri-procedural antibiotics. CONCLUSIONS The incidence of symptomatic UTI after cystoscopy with ureteral stent removal in renal transplant recipients is less than three percent and comparable to post-cystoscopy UTI risk in the general population. Female sex is associated with symptomatic UTI. Further investigation is needed to identify groups most at risk for UTI and other complications. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e359 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Justin Gregg More articles by this author Caroline Kang More articles by this author Thomas Talbot More articles by this author S. Duke Herrell More articles by this author Roger Dmochowski More articles by this author Daniel Barocas More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Routine Antibiotic Prophylaxis for Totally Implantable Venous Access Device Placement: Meta-Analysis of 2,154 Patients

PurposeTo provide a meta-analysis of currently available literature on the topic of antibiotic prophylaxis for totally implanted venous access device (TIVAD) placement. Materials and MethodsA systematic review of MEDLINE/PubMed was performed to identify studies that met Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria reviewing antibiotic prophylaxis in TIVAD placement. Four studies were identified that met criteria. The analysis included 2,154 patients undergoing TIVAD placement; 360 (16.7%) received antibiotic prophylaxis, and 1,794 (83.3%) received no periprocedural antibiotics. ResultsIn the period after TIVAD placement, 27 (1.25%) infections were identified. Of infections, five occurred in the antibiotic prophylaxis group (1.39%), and 22 occurred in the nonprophylaxis group (1.23%) with an odds ratio of 0.84 (CI = 0.29–2.35). ConclusionsThe odds ratio of infection was 0.85 with antibiotic use but one was contained within the confidence interval suggesting no significant difference in infection rate when antibiotics were used.

Endovascular management of symptomatic gastrointestinal complications associated with retrievable inferior vena cava filters.

With the increase in retrievable inferior vena cava (IVC) filter use, a higher than expected reported rate of pericaval tine penetration is observed. Symptomatic gastrointestinal (GI) complications associated with retrievable IVC filters have been documented; however, their management remains controversial. We describe a series of GI complications of retrievable IVC filters, detailing the spectrum of presenting symptoms and multiple treatment options, including the safety of endovascular retrieval. A retrospective chart review was performed to describe the presentation, diagnosis, and treatment of patients with symptomatic GI complications associated with retrievable IVC filters from 2008 to2014. Nine patients had symptomatic GI complications associated with a retrievable IVC filter (two G2 Recovery [Bard Peripheral Vascular, Tempe, Ariz], seven Celect [Cook Medical, Bloomington, Ind]; six women; age range, 17-81years). All patients had small bowel perforation on computed tomography scan, four confirmed by esophagogastroduodenoscopy. Concomitant aortic and vertebral penetration occurred in seven and five patients, respectively. Patients presented with various abdominal complaints; one patient presented in acute sepsis. Two patients underwent laparotomy without complications. The remaining seven patients had attempted endovascular retrieval, six of which were successful. One patient's IVC filter was unable to be retrieved, and he was managed medically. Of the six patients who had successful endovascular retrieval, all had resolution of their symptoms with no complications, except for transient sepsis in a single patient who was not receiving periprocedural antibiotics. A follow-up computed tomography scan was performed 48 to 72hours after endovascular retrieval and ruled out duodenal leak in all patients. Long-term follow-up demonstrated continued resolution of GI symptoms without further episodes of deep venous thrombosis or pulmonary embolism. GI complications of retrievable IVC filters are manifested with a wide spectrum of symptoms and frequent concomitant aortic and vertebral penetration. Endovascular retrieval can be safely used as a first-line therapy even in the setting of small bowel and aortic penetration.

4:51 PM Abstract No. 76 - Image-guided percutaneous abscess drain placement can be performed safely without routine administration of peri-procedural antibiotics

4:51 PM Abstract No. 76 - Image-guided percutaneous abscess drain placement can be performed safely without routine administration of peri-procedural antibiotics

Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries).

This review aims to answer the most common questions in routine surgical practice during the first 48 h of blunt chest trauma (BCT) management. Two authors identified relevant manuscripts published since January 1994 to January 2014. Using preferred reporting items for systematic reviews and meta-analyses statement, they focused on the surgical management of BCT, excluded both child and vascular injuries and selected 80 studies. Tension pneumothorax should be promptly diagnosed and treated by needle decompression closely followed with chest tube insertion (Grade D). All traumatic pneumothoraces are considered for chest tube insertion. However, observation is possible for selected patients with small unilateral pneumothoraces without respiratory disease or need for positive pressure ventilation (Grade C). Symptomatic traumatic haemothoraces or haemothoraces >500 ml should be treated by chest tube insertion (Grade D). Occult pneumothoraces and occult haemothoraces are managed by observation with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B). No sign of life at the initial assessment and cardiopulmonary resuscitation duration >10 min are considered as contraindications of Emergency Department Thoracotomy (Grade C). Damage Control Thoracotomy is performed for either massive air leakage or refractive shock or ongoing bleeding enhanced by chest tube output >1500 ml initially or >200 ml/h for 3 h (Grade D). In the case of haemodynamically stable patients, early video-assisted thoracic surgery is performed for retained haemothoraces (Grade B). Fixation of flail chest can be considered if mechanical ventilation for 48 h is probably required (Grade B). Fixation of sternal fractures is performed for displaced fractures with overlap or comminution, intractable pain or respiratory insufficiency (Grade D). Lung herniation, traumatic diaphragmatic rupture and pericardial rupture are life-threatening situations requiring prompt diagnosis and surgical advice. (Grades C and D). Tracheobronchial repair is mandatory in cases of tracheal tear >2 cm, oesophageal prolapse, mediastinitis or massive air leakage (Grade C). These evidence-based surgical indications for BCT management should support protocols for chest trauma management.

Quality indicators for EUS.

EUS has become integral to the diagnosis and staging of GI and mediastinal mass lesions and conditions. EUS-guided FNA (EUS-FNA) allows the endoscopist to obtain tissue or fluid for cytologic and chemical analysis, adding to the procedure's utility. Furthermore, the recent development of EUS-guided core biopsy techniques enables his-tologic sampling in selected cases and for obtaining tissue for molecular analysis in neoadjuvant and palliative settings. The clinical effectiveness of EUS and EUS-FNA depends on the judicious use of these techniques.

PTH-005 Laparoscopy-assisted Ercp Following Bariatric Gastric Bypass Surgery: Initial Experience At A Uk Tertiary Referral Centre

IntroductionBariatric gastric bypass surgery is being increasingly performed, but ERCP in these patients poses a unique challenge because of lack of per-oral access to the stomach. Small series suggest a...

Risk factors for post-traumatic pneumonia in patients with retained haemothorax: Results of a prospective, observational AAST study

IntroductionRetained haemothorax (RH) is a problematic sequela of thoracic trauma, reported in up to 20% of patients following chest injury. RH is associated with a higher severity of thoracic trauma and may portend the onset of other serious post-traumatic complications, including pneumonia. The development of pneumonia has previously been reported to be as high as 19.5% in the setting of traumatic RH. The purpose of this study was to identify risk factors for the development of pneumonia as a complication in RH. MethodsWe utilized the American Association for the Surgery of Trauma Post-Traumatic Retained Haemothorax database. Patients with post-traumatic RH were prospectively enrolled from 2009 to 2011. Inclusion criteria were placement of a thoracostomy tube within 24h of admission for the evacuation of pneumothorax or haemothorax and subsequent chest computed tomography scan chest showing RH. Patients treated with thoracotomy before placement of tube thoracostomy were excluded. For univariate analysis, the Chi-square test with Yates correction was used for comparison of categorical risk factors and the Student's t-test or the Mann–Whitney test for comparison of continuous risk factors. To identify independent risk factors for the development of pneumonia, variables from the univariate analysis significant at p<0.2 were entered into a forward logistic regression model. Adjusted odds ratio and 95% confidence intervals (CI) were derived. Results328 patients with post-traumatic RH from 20 United States centres were enrolled. After stepwise regression analysis, ISS>25 (adjusted OR: 7.1; 95% CI: 3.1, 16.4; p<0.001), blunt mechanism of injury (adjusted OR: 3.5; 95% CI: 1.7, 7.2; p=0.001), and failure to administer peri-procedural antibiotics on the initial thoracostomy tube placement (adjusted OR: 2.6; 95% CI: 1.30, 5.4; p=0.01) were found to be independent predictors of the pneumonia in patients with post-traumatic RH. ConclusionsTo our knowledge, our current study is the largest attempt to identify the independent predictors for pneumonia in this population. Our data show that elevated ISS, blunt thoracic trauma, and failure to administer peri-procedural antibiotics on tube thoracostomy placement are the statistically significant independent risk factors.

Efficacy of periprocedural vs extended use of antibiotics in patients with external ventricular drains – A randomized trial

BackgroundExternal ventricular drains (EVD) are considered gold standard for intracranial pressure monitoring. Antibiotics are routinely administered to patients with EVD for extended duration, however, no conclusive evidence supports this practice. AimTo compare the efficacy of periprocedural versus extended use of antibiotics, in patients requiring external ventricular drains. Patients and methodsThis is a three year prospective study starting from 1st Jan 2002. All patients who required EVDs as part of their treatment protocol were randomized into two groups, group A who received periprocedural antibiotics and group B who received, antibiotics for extended duration, while EVD was in situ. Patients with open head injuries, pre-existing CNS infection, who required EVD for second time, breach in surgical technique and who had antibiotics for other reasons were excluded from this study. A standard protocol was used to insert and monitor EVDs. No EVD was left in situ for a period more than 144 h. Cerebrospinal fluid cultures were sent on day 0, 1, 3 and 5. On removal, EVD tip was sent for culture. Group A received two doses of intravenously administered ceftazidime. Group B received ceftazidime extended till removal of EVD. ResultsBoth groups were well matched in number of patients, age, sex, duration of ventriculostomy Closed head injury was the most common indication (42.86%) for ventriculostomy. One patient in group A (6.67%) and two patients in group B (7.40%) had ventriculostomy related infection with overall infection rate of 7.14%. ConclusionOur observation, despite being underpowered, definitely points towards limiting the antibiotic prophylaxis to only periprocedural period for clean neurosurgical procedures like ventriculostomy.

Critique of ‘Management of post-traumatic retained hemothorax: A prospective, observational, multicenter AAST study’

Background: The natural history and optimal management of retained hemothorax (RH) after chest tube placement is unknown. The intent of our study was to determine practice patterns used and identify independent predictors of the need for thoracotomy. Methods: An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of chest tube within 24 h of trauma admission and RH on subsequent computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors of successful intervention for each of the management choices chosen and complications. Results: RH was identified in 328 patients from 20 centers. Video-assisted thoracoscopy (VATS) was the most commonly used initial procedure in 33.5%, but 26.5% required two and 5.4% required three procedures to clear RH or subsequent empyema. Thoracotomy was ultimately required in 20.4%. The strongest independent predictor of successful observation was estimated volume of RH≤300 cc (odds ratio [OR], 3.7 [2.0–7.0]; p&lt;0.001). Independent predictors of successful VATS as definitive treatment were absence of an associated diaphragm injury (OR, 4.7 [1.6–13.7]; p=0.005), use of periprocedural antibiotics for thoracostomy placement (OR, 3.3 [1.2–9.0]; p=0.023), and volume of RH≤900 cc (OR, 3.9 [1.4–13.2]; p=0.03). No relationship between timing of VATS and success rate was identified. Independent predictors of the need for thoracotomy included diaphragm injury (OR, 4.9 [2.4–9.9]; p&lt;0.001), RH&gt;900 cc (OR, 3.2 [1.4–7.5]; p=0.007), and failure to give periprocedural antibiotics for initial chest tube placement (OR 2.3 [1.2–4.6]; p=0.015). The overall empyema and pneumonia rates for RH patients were 26.8% and 19.5%, respectively. Conclusion: RH in trauma is associated with high rates of empyema and pneumonia. VATS can be performed with high success rates, although optimal timing is unknown. Approximately, 25% of patients require at least two procedures to effectively clear RH or subsequent pleural space infections and 20.4% require thoracotomy.

1077 EMPIRIC ANTIBIOTICS FOR AN ELEVATED PSA A RANDOMIZED, PROSPECTIVE MULTI-INSTITUTIONAL TRIAL

You have accessJournal of UrologyInfections/Inflammation of the Genitourinary Tract: Prostate & Genitalia1 Apr 20121077 EMPIRIC ANTIBIOTICS FOR AN ELEVATED PSA A RANDOMIZED, PROSPECTIVE MULTI-INSTITUTIONAL TRIAL Scott Eggener, Michael Large, Glenn Gerber, Joseph Pettus, John Smith, Ofer Yossepowitch, Norm Smith, Shilajit Kundu, and Jay Raman Scott EggenerScott Eggener Chicago, IL More articles by this author , Michael LargeMichael Large Chicago, IL More articles by this author , Glenn GerberGlenn Gerber Chicago, IL More articles by this author , Joseph PettusJoseph Pettus Winston-Salem, NC More articles by this author , John SmithJohn Smith Winston-Salem, NC More articles by this author , Ofer YossepowitchOfer Yossepowitch Tel Aviv, Israel More articles by this author , Norm SmithNorm Smith Chicago, IL More articles by this author , Shilajit KunduShilajit Kundu Chicago, IL More articles by this author , and Jay RamanJay Raman Hershey, PA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1184AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The impact of an empiric course of antibiotics for a newly elevated PSA in an asymptomatic male is poorly understood. METHODS Men of any age with a PSA > 2.5 ng/ml and normal digital rectal examination undergoing their first prostate biopsy were recruited from six medical centers. Patients with previous biopsy, prostate cancer, urinary tract infection (UTI) or prostatitis within the prior year, antibiotic use within one month, 5-α reductase inhibitor use, allergy to fluoroquinolones or clinical suspicion of UTI were excluded. Men were randomized to two weeks of ciprofloxacin 500 mg twice daily or no antibiotic. A PSA was obtained 21-45 days following randomization and immediately prior to prostate biopsy. All patients received institution-specific prophylactic peri-procedural antibiotics. Primary endpoint was change in PSA between baseline and on the day of biopsy. The trial was closed early following an interim analysis and decision rule for futility and early stopping. RESULTS Complete data was available on 77 men with a mean age of 60.6 (IQR: 53.8 – 66.7). In the control group (no antibiotic; n=39), mean baseline and pre-biopsy PSA were 6.5 and 6.9 ng/ml, respectively (p=0.8). In men receiving antibiotic (n=38), mean baseline and pre-biopsy (post-antibiotic) PSA were 7.6 and 8.5 ng/ml, respectively (p=0.7). Prostate cancer was detected in 36 (47%) men. Detection rates did not significantly differ between individuals with an increasing PSA or decreasing PSA between the two measurements. CONCLUSIONS Empiric use of antibiotics for an elevated PSA in an asymptomatic patient is not of clinical benefit. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e437 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Scott Eggener Chicago, IL More articles by this author Michael Large Chicago, IL More articles by this author Glenn Gerber Chicago, IL More articles by this author Joseph Pettus Winston-Salem, NC More articles by this author John Smith Winston-Salem, NC More articles by this author Ofer Yossepowitch Tel Aviv, Israel More articles by this author Norm Smith Chicago, IL More articles by this author Shilajit Kundu Chicago, IL More articles by this author Jay Raman Hershey, PA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Management of post-traumatic retained hemothorax

The natural history and optimal management of retained hemothorax (RH) after chest tube placement is unknown. The intent of our study was to determine practice patterns used and identify independent predictors of the need for thoracotomy. An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of chest tube within 24 hours of trauma admission and RH on subsequent computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors of successful intervention for each of the management choices chosen and complications. RH was identified in 328 patients from 20 centers. Video-assisted thoracoscopy (VATS) was the most commonly used initial procedure in 33.5%, but 26.5% required two and 5.4% required three procedures to clear RH or subsequent empyema. Thoracotomy was ultimately required in 20.4%. The strongest independent predictor of successful observation was estimated volume of RH ≤300 cc (odds ratio [OR], 3.7 [2.0-7.0]; p < 0.001). Independent predictors of successful VATS as definitive treatment were absence of an associated diaphragm injury (OR, 4.7 [1.6-13.7]; p = 0.005), use of periprocedural antibiotics for thoracostomy placement (OR, 3.3 [1.2-9.0]; p = 0.023), and volume of RH ≤900 cc (OR, 3.9 [1.4-13.2]; p = 0.03). No relationship between timing of VATS and success rate was identified. Independent predictors of the need for thoracotomy included diaphragm injury (OR, 4.9 [2.4-9.9]; p < 0.001), RH >900 cc (OR, 3.2 [1.4-7.5]; p = 0.007), and failure to give periprocedural antibiotics for initial chest tube placement (OR 2.3 [1.2-4.6]; p = 0.015). The overall empyema and pneumonia rates for RH patients were 26.8% and 19.5%, respectively. RH in trauma is associated with high rates of empyema and pneumonia. VATS can be performed with high success rates, although optimal timing is unknown. Approximately, 25% of patients require at least two procedures to effectively clear RH or subsequent pleural space infections and 20.4% require thoracotomy.

1436 INFECTIOUS COMPLICATIONS FOLLOWING TRANSRECTAL PROSTATE BIOPSY AT A SINGLE INSTITUTION

You have accessJournal of UrologyInfections/Inflammation of the Genitourinary Tract: Prostate & Genitalia1 Apr 20111436 INFECTIOUS COMPLICATIONS FOLLOWING TRANSRECTAL PROSTATE BIOPSY AT A SINGLE INSTITUTION Nathan Moore, Alexander Lepak, and Timothy Moon Nathan MooreNathan Moore Madison, WI More articles by this author , Alexander LepakAlexander Lepak Madison, WI More articles by this author , and Timothy MoonTimothy Moon Madison, WI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1348AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Infection is a known complication of transrectal ultrasound-guided prostate biopsy (TRUS Bx). While a prophylactic antimicrobial strategy is utilized, we have noticed an increased rate of hospital admissions for infectious complications following TRUS Bx at our institution. The identification of pre-procedural risk factors associated with post-procedural infectious complications could be an initial step towards prevention. METHODS Institutional review board approval was obtained for a retrospective chart review of patients who underwent TRUS Bx at UW Hospitals and Clinics. Data on total number of biopsies was available for the dates between January 2005 and March 2010. Departmental morbidity and mortality reports and the hospital blood culture microbiology database were reviewed to identify patients who were admitted to the hospital for an infectious complication. A control group of men who underwent biopsy without complication was randomly selected and matched to the case group in a 4:1 ratio. Charts were reviewed for risk factors that could be possible indicators of colonization with a resistant organism. RESULTS 1358 TRUS Bx were performed between January 2005 and March 2010. Overall infectious complications, bacteremia, and fluoroquinolone-resistant (FQR) bacteremia significantly increased over the 5 years. On univariate analysis, history of renal calculi was associated with bacteremia and FQR bacteremia. The absence of prostate cancer on biopsy and an increased number of doses of peri-procedural antibiotics were also associated with FQR bacteremia. On multivariate analysis, history of renal calculi was associated with an infectious complication following TRUS Bx (OR 7.2, 95% CI 1.7–31.2, p value 0.009). CONCLUSIONS There has been a concerning increase in the incidence of infectious complications, primarily FQR bacteremia, following TRUS Bx at our institution. A history of renal calculi was associated with a 7-fold increased risk of infection following TRUS Bx in our patient population. These findings are likely due to the overuse of FQs. Patients with a history of renal calculi may represent a subpopulation of patients with previous heavy FQ exposure. Year Biopsies Overall Infections (%) Bacteremia (%) FQ resistant Bacteremia (%) 2005 248 1(0.40) 0 0 2006 228 2(0.88) 0 0 2007 279 6(2.2) 4(1.4) 4(1.4) 2008 257 10(3.9) 6(2.3) 6(2.3) 2009 280 4(1.4) 1(0.36) 0 2010 66 3(4.6) 2(3.0) 2(3.0) Total 1358 26(1.9) 13(0.96) 12(0.88) p value 0.0003 0.0008 0.0006 © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e575 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nathan Moore Madison, WI More articles by this author Alexander Lepak Madison, WI More articles by this author Timothy Moon Madison, WI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...