Postoperative Antibiotic Regimens Research Articles

Clinical characteristics and bacterial culture in complicated appendicitis at Hue University of Medicine and Pharmacy Hospital

Objectives: To evaluate the clinical, laboratory features, bacterial culture outcomes, and antibiotic susceptibilities of these bacteria in intraoperative samples from patients with perforated appendicitis and to establish whether they influence postoperative outcomes. Materials and methods: A descriptive study was conducted on 68 laparoscopic surgery patients from June 2022 to March 2023 at the Digestive Surgery Department, Hue University of Medicine and Pharmacy Hospital. Results: The male/female ratio is 1.2. The mean age was 37.5 ± 25.7. The mean time of the symptom onset was 37.2 ± 29.1 hours; CRP increased in 86.8% of cases. The average postoperative hospital stay was 6.3 ± 2.2 days; Postoperative complications were observed in 20.6%. Peritoneal fluid samples yielded a positive culture in 58 (85.3%); Gram-negative bacteria were isolated in 89.7%; gram-positive bacteria were isolated in 10.3%; polymicrobial growth was observed in 29.4% of the patients. E. coli in 67.6%, P.aeruginosa in 10.3%, Enterobacter spp. in 8.8%, Klebsiella spp. in 4.4%, Citrobacter spp. in 3%; positive ESBL was present in 17 (37%) of the 46 E. coli strains, ESBL was positivity detected in one of Morganerlla morganii strains. In E. coli, ampicillin resistance was 88.6%, amoxicillin-clavulanic acid resistance was 61.5%, and Trimethoprim-sulfamethoxazole resistance was 65%. Conclusion: It is necessary to choose treatment regimens based on local bacteriology and resistance status to optimize empiric empirical postoperative antibiotic regimens. Key words: perforated appendicitis, ESBL, complications, bacteria culture.

Usage of antimicrobials in patients having intricate clean-contaminated head and neck surgeries.

Objective: The goal of this study is to characterize, the infectious complications and to identify the risk variables most frequently linked, after head and neck surgeries.Methodology: 47 patients who underwent major clean-contaminated head and neck surgery between 2019 and 2022 at the cervicomaxillofacial Surgery Department (Saint-Pierre Hospital) were the subject of a prospective cohort analysis. Two groups of patients were created: group I received a postoperative antibiotic regimen for just 24 hours; group II re-ceived a longer postoperative antibiotic course lasting more than 24 hours. Amoxicillin and clavulanate were given intra-venously 30 to 60 minutes before making the incision as antibacterial precautions. Following surgery, the antibiotic course was maintained. Univariate analysis was used to assess the predictive importance of the antibiotic regimen on postoperative outcomes, including clinical symptoms of infection and biological indicators like the white blood cell count and C-reactive protein levels was evaluated using univariate analysis.Results: 18 patients experienced SSIs. Antibiotics were used to treat each of these grade 2 illnesses. Only a history of hypothyroidism appears to be a predictor of SSI after univariate analysis (P = 0.038). When we compared the patients who received antibiotics for 24 h or more, there was no discernible difference in terms of onset and hospital stay. Addi-tionally, neither group had a different rate of germs that were multidrug resistant.Conclusion: Our findings imply that using postoperative antibiotics for more than 24 hours has no positive effects on SSI.
 Key words: Cervico-maxillofacial Surgery, clean contaminated surgery, antimicrobials, Surgical Site Infection.

2732. Peri-Operative Antibiotic Management for Lung Transplant Recipients with Cystic Fibrosis

Abstract Background Lung transplant (LTx) recipients universally receive peri- and post-transplant antibiotics. Approaches to antibiotics for candidates with cystic fibrosis (CF) are institution specific. Little has been published about these practices. Routine LTx perioperative prophylaxis at our institution is 96 hours of vancomycin and cefepime with antibiotics then adjusted for positive intraoperative donor and recipient cultures. In recipients with CF, perioperative prophylaxis is determined pre-LTx to cover colonizing organisms isolated in culture from the 2 years before LTx, adjusted for intraoperative cultures, and administered for 14-21 days post-LTx. Our study aims to add to the current literature by describing our center’s experience with antibiotic management and outcomes in lung transplant recipients with CF to help guide best practices for prophylaxis strategies for this patient population. Methods We performed a retrospective chart review of patients with CF who underwent LTx from 3/1/2015-11/18/21 at our center and were colonized pre-LTx with MRSA, Pseudomonas aeruginosa, or Burkholderia cepacia complex. Peri- and post-operative antibiotic regimens, donor and recipient culture results, changes in antibiotic therapy post-LTx, and duration of antibiotic therapy were documented. Outcomes included rehospitalization, isolation in culture of the prophylaxis-targeted organisms post-LTx, and mortality, within 6 months of LTx. Results Nineteen incidents of LTx were included in this study. Pre-LTx colonizing organisms and antibiotics administered are outlined in table 1. Prophylaxis-targeted organisms were infrequently isolated in culture after LTx (table 2), with 7/19 (36.8%) developing post-transplant infection with prior colonizing organisms. Four (21.1%) recipients developed post-LTx Clostridioides difficile infection. One (5.3%) recipient died within 6 months post-LTx. Conclusion LTx recipients with CF who received targeted perioperative prophylaxis for pre-LTx colonizing organisms infrequently developed post-LTx culture positivity with the same bacteria including none during the antimicrobial prophylaxis period. Future prospective studies are needed to determine optimal antibiotic duration of peri-LTx antibiotics in this patient population. Disclosures All Authors: No reported disclosures

Comparing the Efficacy of Postoperative Antibiotic Regimens in the Treatment of Maxillofacial Fractures: A Prospective Study.

The present study was designed to investigate the difference in the effectiveness of a 3 day postoperative course and a single perioperative dose of antibiotics on the incidence of postoperative infection in the management of maxillofacial trauma patients. About 183 maxillofacial trauma patients requiring open reduction and internal fixation (ORIF) under general anesthesia were divided based on the type of fracture sustained, i.e., mandibular fractures, Le Fort fractures, and zygomaticomaxillary complex fractures. Patients from each fracture type were randomized into two groups, A and B. All patients were administered amoxicillin/clavulanate 1.2 grams intravenously 8 hours from the time of admission till the patient was taken up for surgery. Once the patients were taken up for surgery, a perioperative dose was administered. No antibiotics beyond this point were given to patients in Group A. Patients in Group B were administered the same antibiotic for 3 postoperative days additionally. Outcomes in terms of purulent discharge from the surgical site, an abscess or any other sign of infection, and wound dehiscence requiring reopening of the surgical site were considered. Patients were reviewed at 1 week, 2 weeks, 1 month, 2 months, and 3 months. No statistically significant difference was found between the two groups across all three fracture types in terms of postoperative outcomes. However, increased numbers of complications were noted in the patients treated with an intra-oral approach in each fracture type irrespective of group. All complications were managed with local measures. A single perioperative dose of antibiotics is effective in minimizing postoperative complications following ORIF of maxillofacial fractures and there is no significant benefit in prolonging the course of antibiotics postoperatively with the need for further studies to be conducted considering comminuted, complex fractures and old fractures. In maxillofacial trauma, fractures frequently communicate with contaminated indigenous flora on the skin surface, oral cavities, or sinus cavities. Surgery is frequently performed using an approach across a contaminated area, even in closed fractures. Postoperative infections can be significantly decreased by using antibiotics in surgical procedures to treat facial fractures.

Central Adjudication Committee and Clinical Site Investigator Agreement on Outcomes in the PARITY Trial: A Secondary Analysis of the PARITY Trial Data.

The detection of a surgical site infection (SSI) in patients with metal implants requires a high degree of clinical acumen. The inherent subjectivity of SSI diagnosis poses a challenge in the design of surgical trials because this subjectivity raises concern for outcome assessment bias. Central Adjudication Committees (CACs) are often utilized to minimize the variability in outcome assessment. Little research has been done to determine the reliability of outcome assessment in trials utilizing a CAC. In the present study, we determined the agreement between the study CAC and the clinical site investigators for the primary and secondary outcome assessments. The Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial was a multicenter, blinded, parallel 2-arm, randomized controlled trial that aimed to determine the effect of a 5-day versus 1-day postoperative prophylactic antibiotic regimen on the rate of SSI in patients undergoing surgical excision of tumors in the femur or tibia. The blinded PARITY CAC adjudicated all primary and secondary outcomes identified during the 1-year study follow-up. In the present secondary analysis, the Cohen kappa statistic was utilized to determine the level of agreement. The primary outcome of SSI diagnosis demonstrated a substantial level of agreement between the CAC and the site investigators (0.699; 95% confidence interval [CI], 0.595 to 0.803]). Categorization of the SSI (i.e., superficial, deep, or organ space) showed moderate agreement (0.470; 95% CI, 0.382 to 0.558). Secondary outcomes such as the types of reoperations and the indication for reoperation typically showed substantial to almost perfect agreement, whereas antibiotic-related complications showed fair agreement (0.241; 95% CI, 0.000 to 0.474). Although there was a substantial level of agreement between the PARITY CAC and site investigators on the diagnosis of an SSI, as well as typically at least substantial agreement on the causes and types of reoperations, there was less agreement regarding the type of SSI and the occurrence of an antibiotic-related complication. Therefore, the CAC appears to have provided value when adjudicating the depth of infection and when determining the causality of medical complications associated with antibiotics. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Outcomes after débridement, antibiotics, and implant retention for prosthetic joint infection in shoulder arthroplasty

Patients who undergo total shoulder arthroplasty usually have excellent long-term outcomes. However, a subset of patients is diagnosed with a prosthetic joint infection (PJI) requiring revision procedures and prolonged recovery. The purpose of this study was to evaluate rates of recurrent shoulder PJI in patients undergoing débridement, antibiotics, and implant retention (DAIR), single-stage revision, and 2-stage revision. We also sought to compare outcomes and complications across procedures. Retrospective chart review was conducted for patients diagnosed with PJI after primary shoulder arthroplasty between January 2010 and August 2021. Patients were included if they underwent treatment with DAIR, single-stage revision, or 2-stage revision. Demographic information, surgical details, complications, laboratory data, postoperative antibiotic regimen, and infectious pathogen were collected. Postoperative patient-reported outcomes were collected: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation, Shoulder Activity Scale, and PROMIS Upper Extremity. Chi-square, t test, and 1-way analysis of variance were used as appropriate to evaluate each factor. Sixty-five patients were included in the study, 26% treated with DAIR, 9% treated with single-stage revision, and 65% treated with 2-stage revision. There were no significant differences in patient comorbidities. Patients undergoing DAIR were diagnosed significantly earlier than those undergoing single- and 2-stage revision procedures (12.6±22.9 months vs. 49.6±48.4 vs. 25.0±26.6, P=.010). Recurrent PJI was noted in 23.1% of patients: 29.4% of DAIR patients, no single-stage patients, and 23.8% of 2-stage patients (P=.330). Patients undergoing 2-stage revision with treatment failure had a significantly higher Elixhauser Comorbidity Index (0.2±3.7 vs. 3.7±3.9, P=.027). There was no significant difference in patient-reported outcomes across groups. Patients undergoing treatment of shoulder PJI with DAIR did not have an increased rate of reinfection compared with single-stage and 2-stage revision procedures. Patients treated with DAIR were diagnosed with PJI significantly earlier than those undergoing single-stage and 2-stage revision procedures. There was no difference in complication rates between groups. This information adds to the body of work detailing outcomes after DAIR for shoulder PJI and provides encouraging data for use in this patient population. Future studies with a larger sample size may be conducted to further investigate specific pathogens, infection timelines, and antibiotic regimens that reduce the risk of treatment failure.

What's New in Musculoskeletal Infection.

What's New in Musculoskeletal Infection.

A novel sacral neuromodulation protocol is associated with reduction in removal for device infection.

Sacral neuromodulation (SNM) has been established as an effective third-line therapy for non-obstructive urinary retention and urinary urgency-frequency syndrome. Device infection, ranging from 2-10%, is a severe complication usually necessitating device explanation. This study sought to demonstrate an infection protocol founded upon established device implantation risk factors and novel approaches to reduce the incidence of device infection, while maintaining good antibiotic stewardship following best practice statements. A single-surgeon protocol was enacted from 2013 to 2022. Preoperatively, nasal swabs were cultured from each patient. If positive for methicillin-resistant Staphylococcus aureus or methicillin-sensitive Staphylococcus aureus, preoperative treatment with intranasal mupirocin was employed. Preoperative cefazolin was administered in patients with negative cultures or MSSA-positive. All protocol patients were given chlorhexidine wipes before surgery and prepped with a chlorhexidine scrub followed by alcohol/iodine paint. Post-procedural antibiotics were not given. Pre-protocol patients from 2011 to 2013 served as controls. Pre-protocol (n=87) patients had a significantly higher rate of device infection compared to protocol patients (n=444) in both the percentage of patients experiencing device infection (4.6% vs 0.9%, p=0.01) and percentage of procedures associated with device infection (2.9% vs 0.5%, p<0.05). A successful culture of the nares was achieved in 91.4% of protocol patients, with 11.6% MRSA-positive. Risk ratio for infection of pre-protocol/protocol patients was 0.19 (0.05-0.77) with odds ratio 5.1 (1.3-20.0). Utilization of a novel SNM infection protocol tailored to a patient's preoperative MRSA colonization is associated with a reduction in the overall incidence of explant for device infection while avoiding prolonged postoperative antibiotic regimens. The study was initiated prior to January 18, 2017 and does not meet the definition of an applicable clinical trial (ACT) as defined in section 402 (J) of the US PHS Act.

Antibiotic Use in Patients Undergoing Complex Clean-Contaminated Head and Neck Surgery: A Prospective Study.

Oncological surgery of the upper aerodigestive tract is a complex procedure and often includes neck dissection and flap reconstruction. It can be complicated by severe surgical site infection (SSI) leading to flap necrosis, delayed wound healing, and increasing mortality and morbidity. The purpose of this study is to perform a systematic descriptive analysis and to evaluate the effect of our adapted antibiotic regimen strategy on postoperative outcomes. A prospective cohort analysis of 47 patients undergoing major clean-contaminated head and neck surgery was conducted at the Cervicomaxillofacial Surgery Department (Saint-Pierre Hospital), between 2019 and 2022. The patients were divided into two groups: group I, which received a short-term postoperative antibiotic regimen for 24 h, and group II, which received a more extended postoperative antibiotic course for more than 24 h. Antibioprophylaxy amoxicillin and clavulanate were administered intravenously 30-60 min before making the incision. The antibiotic regimen was continued after surgery. The prognostic significance of the antibiotic regimen on postoperative outcomes, including clinical signs of infection and biological markers such as white blood cells count, and C-reactive protein levels was evaluated using univariate analysis. Eighteen patients developed SSIs. All of these infections were grade 2 and were treated with antibiotics. After univariate analysis, only a history of hypothyroidism seems to be a predictor of SSI (P = 0.038). No significant difference was found in terms of onset and hospital stay when we compared the patients who received antibiotics for 24 h or more. Moreover, the rate of multidrug-resistant bacteria was not different in both groups. Our results suggest that postoperative antibiotics for more than 24 h do not confer benefit in terms of SSI. Oncological patients undergoing complex clean-contaminated head and neck surgery are often suffering from infectious complications and, despite the absence of guidelines, practicians should consider these findings in their decision-making.

Single-Stage Revision Reverse Shoulder Arthroplasty: Preoperative Planning, Surgical Technique, and Mixed Reality Execution.

Revision shoulder arthroplasty is increasing with the number of primary shoulder replacements rising globally. Complex primary and revisions of shoulder arthroplasties pose specific challenges for the surgeon, which must be addressed preoperatively and intraoperatively. This article aimed to present strategies for the management of revision of shoulder arthroplasties through a single-stage approach. Preoperatively, patient factors, such as age, comorbidities, and bone quality, should be considered. The use of planning software can aid in accurately evaluating implants in situ and predict bony anatomy that will remain after explantation during the revision surgery. The planning from such software can then be executed with the help of mixed reality technology to allow accurate implant placement. Single-stage revision is performed in two steps (debridement as first step, implantation and reconstruction as the second step), guided by the following principles: adequate debridement while preserving key soft tissue attachments (i.e., rotator cuff, pectoralis major, latissimus dorsi, deltoid), restoration of glenoid joint line using bone grafting, restoration of humeral length, reconstruction and/or reattachment of soft tissues, and strict compliance with the postoperative antibiotic regimen. Preliminary results of single-stage revision shoulder arthroplasty show improvement in patient outcomes (mean 1 year), successful treatment of infection for those diagnosed with periprosthetic joint infection, and improved cost-benefit parameters for the healthcare system.

Retrospective Review of Surgical Site Infections after Endoscopic Endonasal Sellar and Parasellar Surgery: Multicenter Quality Data from the North American Skull Base Society.

Introduction Transnasal access to the anterior skull base provides a minimally invasive approach for sellar and parasellar masses compared with its open counterparts. The unique microbiome of the sinonasal mucosa provides distinct challenges not encountered with other cranial approaches. The use of antibiotics in these cases has not been standardized, and data remain scarce regarding infectious outcomes. Methods We conducted a multicenter retrospective analysis of shared quality data points for the endoscopic endonasal approach (EEA) for pituitary adenomas, along with other sellar and parasellar region masses that were included by participating institutions. Patient and operative characteristics, perioperative and postoperative antibiotic regimens and their durations, intraoperative and postoperative cerebrospinal fluid leak, and onset of postoperative meningitis and sinusitis were compared. Results Fifteen institutions participated and provided 6 consecutive months' worth of case data. Five hundred ninety-three cases were included in the study, of which 564 were pituitary adenomectomies. The incidences of postoperative meningitis and sinusitis were low (0.67 and 2.87% for all pathologies, respectively; 0.35% meningitis for pituitary adenomas) and did not correlate with any specific antibiotic regimen. Immunocompromised status posed an increased odds of meningitis in pituitary adenomectomies (28.6, 95% confidence interval [1.72-474.4]). Conclusions The results show no clear benefit to postoperative antimicrobial use in EEA, with further larger studies needed.

Cutibacterium Positive Cultures in Total Hip Arthroplasty: Contaminant or Pathogen?

Cutibacterium spp. is an emerging pathogen in total hip arthroplasty (THA) that is not well evaluated in the literature. This study reported on the presentation and management of THA complicated by positive intraoperative Cutibacterium cultures. This is a retrospective review of 27 revision THAs with positive monomicrobial intraoperative Cutibacterium cultures from 2014 to 2020 at one academic center. These patients were divided into two cohorts based on meeting Musculoskeletal Infection Society (MSIS) criteria for prosthetic joint infections (PJI). Patient demographics, preoperative labs, and hip aspirate results were collected. Procedure performed, postoperative antibiotic regimens, and repeat infections were recorded. Data were compared with univariate analysis. Nine of the 27 patients preoperatively met MSIS criteria for PJI. Patients with positive MSIS criteria had significantly higher median synovial cell count (P= .048) and neutrophil percentage in a preoperative aspirate (P= .050). Eight patients with positive MSIS criteria received six weeks of postoperative antibiotics compared to two patients with negative criteria. Two patients with positive MSIS criteria had a postoperative infection that required further surgical intervention. Four patients with negative criteria who required further surgical intervention did not receive postoperative antibiotics after initial revision. While often categorized as a contaminant, Cutibacterium is an increasingly recognized pathogen in THA. Cutibacterium can often present with normal serology, which may result in misdiagnosis as aseptic THA failure. Without the administration of postoperative antibiotics after positive cultures, there is a risk for persistent infection requiring further surgical intervention.

Surgical Factors Influencing Wound Complication After Cochlear Implantation: A Systematic Review and Meta-Analysis.

To identify perioperative surgical factors associated with wound complications following cochlear implantation (CI). PubMed, Web of Science, and Cochrane databases. Eligible studies included peer-reviewed research in English evaluating wound complications (wound infection, skin flap breakdown/dehiscence, seroma/hematoma) following CI. Studies with paired samples were included in the meta-analysis. Surgical factors (techniques and perioperative management) in CI and reported wound complications were examined. Level of evidence was assessed using the Oxford Centre for Evidence-based Medicine guidelines and bias was assessed using the NIH Quality Assessment Tool. Twenty-six studies representing 10,214 cochlear implantations were included. The overall wound complications rate was 3.1% (range 0.03-13.9%). Eleven studies contained paired data and were used for meta-analysis regarding three different surgical factors: incision length, implant placement method, and antibiotic usage. Longer incision lengths (≥7 cm) demonstrated a higher risk of wound complications (risk ratio 2.27, p = 0.02, CI 1.16-4.43). Different implant placement techniques (suture fixation versus periosteal pocket) (p = 0.08, CI 0.92-3.69) and postoperative antibiotic regimens (postoperative use versus none) (p = 0.68, CI = 0.28-7.18) were not associated with differences in wound complication rates following CI. Overall rate of wound complications following CI is low. Shorter incision length is associated with lower risk of wound complications. Differences in perioperative techniques and practices regarding implant placement and antibiotic use were not associated with differences in wound complication rates. Considering the low number and quality of studies, there is a need for research in CI outcomes using paired sample prospective designs and standardized reporting.

Do postoperative antibiotics influence one-year peri-implant crestal bone remodelling and morbidity? A double-blinded randomized clinical trial.

ObjectivesThe primary objective of this study was to assess whether giving postoperative antibiotics to healthy patients after straightforward platform‐switched implant placement would influence peri‐implant crestal bone levels and postoperative morbidity after 1 year.MethodsThirty‐eight healthy individuals were recruited in this pilot, randomized, double‐blinded, placebo‐controlled clinical trial. The intervention group (n = 18) received two grams of amoxicillin one hour before implant placement followed by a 7 days postoperative regimen (500 mg tid). The control group (n = 20) took the same preoperative dose of amoxicillin and an identical placebo postoperatively. Mesial and distal peri‐implant crestal bone levels were measured at baseline, four months and one year later with standardized periapical radiographs. Postoperative pain severity was assessed through self‐administered questionnaires for 7 days. Surgery‐associated morbidities were evaluated after one, three, 16 weeks and 1 year. Descriptive and bivariate analyses were used.ResultsThirty‐seven participants completed the trial. At the one‐year follow‐up, the mean combined peri‐implant crestal bone changes for the intervention (n = 18) and control (n = 19) groups were ‐ 0.44 ± 0.41 mm and ‐ 0.27 ± 0.56 mm, respectively. The difference between the groups (intervention–control) for mean combined crestal bone level changes was not statistically significant. There were no significant differences in surgery‐associated morbidities between the intervention and control groups. The one‐year implant survival rate was 100% in both groups.ConclusionsStudy results suggest that a routine postoperative antibiotic regimen for healthy patients undergoing straightforward platform‐switched implant placement might not be necessary to prevent postoperative peri‐implant bone loss and complications.

Postoperative prophylactic antibiotics for retropubic mid-urethral slings.

The primary objective is to measure the difference in urinary tract infection (UTI) rates within 6 weeks of placement of a retropubic mid-urethral sling (RMUS) in the setting of various postoperative prophylactic antibiotic regimens. UTI rates were measured by antibiotic prescriptions to treat UTI and/or culture. Secondary aims included determining risk factors for postoperative UTI. A retrospective chart review from 2014 to 2016 was performed at Baylor Scott and White Medical Center-Temple for CPT code 57288. Univariate comparisons were performed using chi-square and Student's t-test. Logistic regression analysis was performed for UTI risk factors with univariate p values ≤ 0.1. One hundred twelve subjects were included. Seventeen (15%) were treated for postoperative UTI. Postoperative prophylactic antibiotics included trimethoprim (39.3%), nitrofurantoin (31.3%), trimethoprim-sulfamethoxazole (5.4%), ciprofloxacin (2.7%), and cephalexin (1.8%). Ninety subjects were prescribed postoperative prophylactic antibiotics (80.4%). The postoperative UTI rate was not significantly different between those who were prescribed postoperative prophylactic antibiotics (16%) and those who were not (14%). None of the treatments showed a significant difference on postoperative UTI rate compared to no treatment. Significant risk factors for UTI included catheterization past postoperative day 1 (OR 6.4, 95% CI 1.7 - 23.8; p = 0.006). There was no significant difference in postoperative UTI rate in the group without postoperative prophylactic antibiotics compared to those who did receive it. Catheterization past postoperative day 1 was significantly associated with postoperative UTI. However, definitive conclusions are limited by a lack of power.

IMPPACT (Intravenous Monotherapy for Postoperative Perforated Appendicitis in Children Trial): Randomized Clinical Trial of Monotherapy Versus Multi-drug Antibiotic Therapy.

Perforated appendicitis is the most common cause of intraabdominal abscess (IAA) in children. The optimal postoperative antibiotic regimen to reduce IAA has evolved in the last decade from triple-drug to 2-drug therapy (CM). Recent retrospective studies show decreased infectious complications with monotherapy PT. To date prospective comparative data are lacking. Therefore, a prospective randomized trial comparing PT versus CM was conducted. A multi-institutional prospective randomized trial was performed in children with perforated appendicitis comparing postoperative antibiotic regimens PT or CM. The primary outcome was 30-day postoperative IAA formation. Perforation was strictly defined as a hole in the appendix or fecalith in the abdomen, documented with intraoperative photographs. One hundred sixty-two patients were enrolled during the study period. No differences in age, weight, or duration of presenting symptoms were identified. In addition, length of stay, duration of intravenous antibiotic treatment, discharge oral antibiotic treatment, and antibiotic-related complications did not differ between groups. Compared to the CM group, the PT group had significantly lower IAA rate [6.1% vs 23.8%, odd ratio (OR) 4.80, P = 0.002], lower postoperative computed tomography imaging rate (13.9% vs 29.3%, OR 2.57, P = 0.030), and fewer emergency room visits (8.8% vs 26.4%, OR 3.73, P = 0.022). Multivariate logistic regression analysis found the use of CM versus PT (OR 9.21, P = 0.021) to be the most significant predictor for developing IAA. In children with perforated appendicitis, postoperative monotherapy with PT is superior to standard 2-drug therapy with CM and does not increase antibiotic-related complications or antibiotic exposure duration.

Systemic Antibiotic Prophylaxis to Reduce Early Implant Failure: A Systematic Review and Meta-Analysis.

Systemic antibiotics are routinely prescribed in implant procedures, but the lack of consensus causes large differences between clinicians regarding antibiotic prophylaxis regimens. The objectives of this systematic review are to assess the need to prescribe antibiotics to prevent early implant failure and find the most appropriate antibiotic prophylaxis regimen. The electronic search was conducted in PubMed/MEDLINE, Scielo and Cochrane Central Trials Database for randomized clinical trials of at least 3 months of follow-up. Eleven studies were included in the qualitative analysis. Antibiotics were found to statistically significantly reduce early implant failures (RR = 0.30, 95% CI: 0.19–0.47, p < 0.00001; heterogeneity I2 = 0%, p = 0.54). No differences were seen between preoperative or both pre- and postoperative antibiotic regimens (RR = 0.57, 95% CI: 0.21–1.55, p = 0.27; heterogeneity I2 = 0%, p = 0.37). A single preoperative antibiotic prophylaxis dose was found to be enough to significantly reduce early implant failures compared to no antibiotic (RR = 0.34, 95% CI: 0.21–0.53, p < 0.00001; heterogeneity I2 = 0%, p = 0.61). In conclusion, in healthy patients a single antibiotic prophylaxis dose is indicated to prevent early implant failure.

Unexpected low-grade infections in revision hip arthroplasty for aseptic loosening : a single-institution experience of 274 hips.

The purpose of this study was to evaluate unexpected positive cultures in total hip arthroplasty (THA) revisions for presumed aseptic loosening, to assess the prevalence of low-grade infection using two definition criteria, and to analyze its impact on implant survival after revision. A total of 274 THA revisions performed for presumed aseptic loosening from 2012 to 2016 were reviewed. In addition to obtaining intraoperative tissue cultures from all patients, synovial and sonication fluid samples of the removed implant were obtained in 215 cases (79%) and 101 cases (37%), respectively. Histopathological analysis was performed in 250 cases (91%). Patients were classified as having low-grade infections according to institutional criteria and Musculoskeletal Infection Society (MSIS) International Consensus Meeting (ICM) 2013 criteria. Low-grade infections according to institutional criteria were treated with targeted antibiotics for six weeks postoperatively. Implant failure was defined as the need for re-revision resulting from periprosthetic joint infection (PJI) and aseptic reasons. The mean follow-up was 68 months (26 to 95). Unexpected positive intraoperative samples were found in 77 revisions (28%). Low-grade infection was diagnosed in 36 cases (13%) using institutional criteria and in nine cases (3%) using MSIS ICM 2013 criteria. In all, 41 patients (15%) had single specimen growth of a low-virulent pathogen and were deemed contaminated. Coagulase-negative Staphylococcus and anaerobes were the most commonly isolated bacteria. Implant failure for PJI was higher in revisions with presumed contaminants (5/41, 12%) compared to those with low-grade infections (2/36, 6%) and those with negative samples (5/197, 3%) (p = 0.021). The rate of all-cause re-revision was similar in patients diagnosed with low-grade infections (5/36, 14%) and those with presumed contaminants (6/41, 15%) and negative samples (21/197, 11%) (p = 0.699). Our findings suggest that the presumption of culture contamination in aseptic revision hip arthroplasty may increase the detection of PJI. In this cohort, the presence of low-grade infection did not increase the risk of re-revision. Further studies are needed to assess the relevance of single specimen growth and the benefits of specific postoperative antibiotic regimens. Cite this article: Bone Joint J2021;103-B(6):1070-1077.

LOCAL VANCOMYCIN IN PREVENTION OF SURGICAL SITE INFECTION IN SPINAL SURGERIES

Background: SSIs can lead to greater post-operative morbidity, mortality and healthcare costs. Despite current prophylactic measures, SSIs is still being reported in patients undergoing spine surgery. Local application of vancomycin in spine surgery is a low-cost strategy to help reduce SSIs as it is active against pathogens which might contaminate the wound during spinal surgery.Aim of the Work: A systematic review discussing the effect of Local vancomycin in prevention of surgical site in spinal surgeries.Patients and Methods: Literature search and filtration on intra- wound application of vancomycin in spinal surgeries yielded 9 studies with a total of 46,907 patients.Results: Review of the enrolled studies confirmed that intra-wound vancomycin use appears to be safe and effective for reducing postoperative SSIs in spinal surgeries with a low rate of adverse events. However, these studies use different definitions for surgical site infections and different pre-, peri- and postoperative antibiotic regimens. That is why intra wound application of vancomycin in spinal surgeries is recommended to reduce postoperative SSIs and further studies using standardized protocols are needed to confirm findings of the current study.Conclusion: The different follow-up periods, particularly for patients with short-term follow up, may underestimate the incidence of SSIs and adverse events especially in the vancomycin group.

Antibiotic prophylaxis for sagittal split ramus osteotomy using resorbable plate and screw fixation: a randomised trial to compare extended dual-agent and inpatient single-agent regimens

Resorbable materials are used to fix bony fragments after sagittal split ramus osteotomy (SSRO), but to our knowledge, there is no clear regimen for antibiotic prophylaxis when such materials are used. The purpose of this study therefore was to compare inpatient single-agent and extended dual-agent antibiotic prophylaxis for the prevention of surgical site infections (SSI) in patients after SSRO. This prospective study included 100 patients who underwent SSRO for deformities of the jaw. Cephalometric analysis was performed preoperatively, and at one month and one year postoperatively. Patients were divided into two groups of 50 each. Group A was given cefazolin sodium 1g preoperatively and every eight hours for 48 hours postoperatively. Group B was given cefazolin sodium 1g preoperatively and every eight hours for 48 hours postoperatively, after which they were provided with oral amoxicillin for three days. Both groups were assessed for SSIs for one year postoperatively using the Clavien-Dindo classification. SSIs were documented in seven patients in Group A and six in Group B, with no significant difference between the groups. The two regimens had no significant association with SSI. In conclusion, our results suggest that the inpatient, single-agent, postoperative antibiotic regimen is sufficient to prevent SSI in patients who have SSRO with resorbable plate and screw fixation.