Preoperative Antibiotics Research Articles

The Impact of a Multidisciplinary Approach Protocol and Integrated Guidelines for Antibiotic Prophylaxis in Plastic Surgery Procedures.

BACKGROUNDSurgical antibiotic prophylaxis has been widely used for prevention of surgical site infections (SSI’s). World Health Organization (WHO) global guidelines strongly recommend the administration of pre-operative prophylactic antibiotic, depending on the type of surgery, to reduce SSI’s. However, within Gulf Cooperation Council (GCC) countries, antibiotic resistance has been rising due to unregulated prescribing practice. We aimed to assess adherence to local/international guidelines in the plastic surgery unit of Salmaniya Medical Complex.METHODSThis study was a retrospective review of adults’ undergoing plastic surgery between the dates of 1st of January 2019 to 30th of April 2019. Recommendations and guidelines were provided by South Australian Guidelines for Surgical Antimicrobial Prophylaxis, NHS Greater-Glasgow Foundation Trust. Salmaniya Medical Complex Guidelines were also taken into consideration. This was followed by an implementation of standardized guidelines and a re-assessment period for another four months.RESULTSThere were 106 patients who met the inclusion/exclusion criteria throughout the primary cohort. With respect to choice and dose of antibiotics, only 21 (19.8%) of the procedures were adherent to global/local guidelines. Similarly, only 11.5% of those cases have met the recommended timing for pre-operative antibiotic administration. After the implementation period, adherence to guidelines regarding choice and time of antibiotic administration has increased to 36.8% and 32.6% respectively. SSI decreased from 1.8% to 0.08%.CONCLUSIONPractice in SMC in plastic surgery pre-operative antibiotic prophylaxis shows poor compliance to both local and international guidelines in terms of choice, dose, and time of administration. We were able to significantly improve adherence to international/local practice in both areas by implementing an integrated protocol in liaison with the medical staff involved in the plastic surgery unit and operating theatres.

Management of sacrococcygeal pilonidal sinus disease in children: A survey study in Turkey.

Sacrococcygeal pilonidal sinus disease is common in children. The disease reduces the quality of life of patients with symptoms such as pain and chronic discharge. Variable surgical techniques have been described for the treatment of pilonidal sinus disease. This study aims to evaluate clinical approach of Turkish pediatric surgeons to children with pilonidal sinus disease. Survey questions were prepared through a literature review for controversial issues. The participants were asked pre-selected and checkbox questions. The survey was sent to 450 pediatric surgeons, members of the Association of Turkey Pediatric Surgery via a link to Google Forms. Nineteen percent (88) of the members responded. Seventy five (85.2%) of the pediatric surgeons stated that they did not perform additional preoperative imaging. Surgical excision methods were preferred more than minimally invasive procedures (102 to 46). Sixty (68.2%) of the participants preferred preoperative prophylactic single dose intravenous antibiotics and postoperative oral antibiotics. Regarding the participants' practices, poor local hygiene, overweight, wide or deep sinus pit were stated as the most common causes of recurrence. Vast majority of the pediatric surgeons recommended laser epilation (%85.2) and slimming (59.1%) to patients. Various studies have been published from Turkey for pilonidal sinus disease. As seen in the current study, Turkish pediatric surgeons do not have a common opinion in pilonidal sinus disease and prefer surgical excision methods more frequently. Prospective randomized studies with bigger number of patients are required to establish common guidelines in disease management.

Vaginal preparation with povidone-iodine or chlorhexidine before hysterectomy: a propensity score matched analysis

Antiseptic vaginal preparation is recommended before gynecologic surgery; however, there is a lack of data regarding the effectiveness of different agents. To compare rates of postoperative infectious complications and hospital utilization with preoperative vaginal preparation using povidone-iodine or chlorhexidine before hysterectomy. This was a retrospective analysis of patients who underwent hysterectomy for gynecologic indications at 70 hospitals in a statewide surgical collaborative between January 2017 and December 2019. The primary outcome was postoperative infectious complications (including urinary tract infection, surgical site infections involving superficial, deep, or organ space tissues, or cellulitis) within 30 days of surgery. To adjust for confounding, propensity score matching, 1:1 without replacement and with a caliper of.005 was performed to create cohorts that had vaginal preparation with either povidone-iodine or chlorhexidine and did not differ in observable characteristics. We compared the rates of infectious morbidity and hospital utilization (emergency department visits, readmission, reoperation) in the matched cohorts. In the statewide collaborative, there were 18,184 patients who received povidone-iodine and 3018 who received chlorhexidine. After propensity score matching of 2935 pairs, the povidone-iodine and chlorhexidine groups did not differ in demographics, comorbidities, choice of preoperative antibiotics, benign vs malignant surgical indication, and surgical approach. Povidone-iodine was associated with a lower rate of infectious morbidity (3.0% vs 4.3%; P=.01), urinary tract infection (1.1% vs 1.7%; P=.03) and emergency department visits (7.9% vs 9.7%; P=.01) than with chlorhexidine. There were nonsignificant trends of lower rates of surgical site infection (2.0% vs 2.7%; P=.07) and reoperation (1.6% vs 2.1%; P=.18). This propensity score matched analysis provides evidence that povidone-iodine is preferable to chlorhexidine for vaginal preparation before hysterectomy because of lower rates of infectious morbidity and fewer emergency department visits. However, the absolute differences in infectious morbidity rates were approximately 1%, and in the event of an iodine allergy, chlorhexidine appears to be a reasonable alternative.

Global Current Practice Patterns for the Management of Open Globe Injuries

To determine global current practice patterns for the management of open globe injuries and identify areas of variation. Cross-sectional survey. An online survey assessed global management paradigms for open globe injuries from August 2020 to January 2021. Responses were collected from experts at eye trauma centers and emergency departments worldwide who manage ≥1 open globe injury per month. The survey assessed the use/selection of antibiotics and steroids, procedural and imaging decisions, and admission practices for open globe injuries. Responses were received from representatives of 36 of 42 institutions (85.7%), of which 33 (78.6%) had sufficient trauma volume to be included. Included responses were distributed across North America (n=12, 36.4%), Asia (n=12, 36.4%), South America (n=4, 12.1%), Africa (n=3, 9.1%), Europe (n=1, 3.0%), and Australia (n=1, 3.0%). Preoperative systemic antibiotics for open globe injuries were administered by 75.8% (n=25/33) of institutions, while 30.3% (n=10/33) administered preoperative topical antibiotics. Intraoperative ophthalmic antibiotics for open globe injuries were used by 54.5% (n=18/33) of experts. Most institutions also administered postoperative systemic antibiotics (n=23 [69.7%]) and topical steroids (n=29 [87.9%]), although specific medication choices diverged. At 19 responding centers (61.3% of the 31 that had trainees), residents participated in surgical repairs. Many institutions discharged patients after repair, but 54.5% (n=18/33) of locations routinely admitted them for observation. Preferred management practices for open globe injuries vary widely. To ensure the highest standard of care for all patients, evidence-based international guidelines for the treatment of these injuries are needed.

Impact of an educational intervention on WHO surgical safety checklist and pre-operative antibiotic use at a referral hospital in southwestern Uganda.

The World Health Organization (WHO) recommends adherence to its surgical safety checklist (SSC) to optimize patient safety and reduce cesarean surgical site infection (SSI). Educational interventions combined with audit and feedback mechanisms on the checklist use by clinicians have the potential to improve adherence and clinical outcomes. Despite the increase in cesarean delivery rates, there is a paucity of data on how such interventions can improve adherence in resource-limited settings. We performed a quality improvement project to measure the impact of an educational intervention with daily audit and feedback procedures on rates of WHO SSC adherence, including pre-operative antibiotic administration and SSI at Mbarara Regional Referral Hospital maternity ward in Uganda. The study involved chart abstraction of WHO SSC and pre-operative antibiotic use during cesarean deliveries and signs of subsequent SSI in three phases. First, we conducted a retrospective review of all charts from May to June 2018 (pre-intervention phase). Second, we instituted an educational intervention on the WHO SSC and pre-operative antibiotics use, followed by a daily audit of charts and feedback to clinicians from July to August 2018 (the intervention phase). Third, we reviewed charts from September to October 2018 (the post-intervention phase). The WHO SSC adherence, pre-operative antibiotic administration and SSI rates were measured as the proportion of the total cesarean deliveries per study phase and then compared across the three phases. We reviewed 678 patients' charts (200 in the pre-intervention phase, 230 in the intervention phase and 248 in the post-intervention phase). The mean patient age was 25 years. The use of the WHO SSC was 7% in the pre-intervention phase compared to 92% in the intervention phase (P < 0.001), and 77% in the post-intervention phase (P < 0.001). Pre-intervention antibiotic receipt was 18% compared to 90% in the intervention phase (P < 0.001) and 84% in the post-intervention phase (P < 0.001). The documented SSI rate in the pre-intervention phase was 15% compared to 7% in the intervention phase (P = 0.02) and 11% in the post-intervention phase (P = 0.20). An educational intervention, daily audit and feedback to clinicians increased the use of the WHO SSC and prophylactic antibiotics for cesarean delivery-although the rates waned with time. Research to understand factors influencing the checklist use and antibiotic prophylaxis including prescriber knowledge, motivation and clinical process is required. Implementation interventions to sustain usage and impact on clinical outcomes need to be explored.

Effectiveness of Cefotaxime in the prevention of surgical site infections in children undergoing elective inguinal surgery at the University Teaching Hospital, Lusaka, Zambia

Introduction and objectives: Inguinal operations are the most performed surgeries in children. There is a divergent view on use of pre-operative antibiotic prophylaxis to prevent Surgical site infections (SSI) after these surgeries. The aim of this study was to detect if the use of cefotaxime had a significant impact on prevention of SSI in children under 8 years undergoing elective inguinal surgery at the University Teaching Hospitals (UTHs), Lusaka.&#x0D; Method: This was a cohort study. A total of 170 patients below 8 years of age undergoing elective inguinal herniotomy, orchidopexy or patent processus vaginalis (PPV) ligation at UTHs were enrolled. Group A with 85 patients received preoperative cefotaxime while group B with 85 patients did not receive any antibiotics. A data collection sheet was used to record pre-operative demographic details. Intraoperative variables and post-operative outcomes. No patient received post-operative antibiotics. Follow up to look for SSI was done at 2 weeks and 30 days.&#x0D; Results: Out of 170 patients, 11(6.47%) had SSI. Six of the 85 that received surgical antibiotic prophylaxis (SAP) had SSI while 5 of the 85 that did not receive SAP had SSI (P=0.551). Deep SSI were seen in 2 patients that did not receive SAP (p=0.155) and grew Staphylococcus aureus in their cultures. Only 1 adverse allergic reaction to preoperative antibiotics was noted.&#x0D; Conclusion: Despite a low risk of adverse reactions, there is no benefit of using pre-operative antibiotics to prevent SSI in children undergoing elective inguinal surgery.

Effectiveness of Cefotaxime in the prevention of surgical site infections in children undergoing elective inguinal surgery at the University Teaching Hospital, Lusaka, Zambia

Introduction and objectives: Inguinal operations are the most performed surgeries in children. There is a divergent view on use of pre-operative antibioticprophylaxis to prevent Surgical site infections (SSI) after these surgeries. The aim of this study was to detect if the use of cefotaxime had a significantimpact on prevention of SSI in children under 8 years undergoing elective inguinal surgery at the University Teaching Hospitals (UTHs), Lusaka.&#x0D; Method: This was a cohort study. A total of 170 patients below 8 years of age undergoing elective inguinal herniotomy, orchidopexy or patent processus vaginalis (PPV) ligation at UTHs were enrolled. Group A with 85 patients received preoperative cefotaxime while group B with 85 patients did not receive any antibiotics. A data collection sheet was used to record pre-operative demographic details. Intraoperative variables and post-operative outcomes. No patient received post-operative antibiotics. Follow up to look for SSI was done at 2 weeks and 30 days.&#x0D; Results: Out of 170 patients, 11(6.47%) had SSI. Six of the 85 that received surgical antibiotic prophylaxis (SAP) had SSI while 5 of the 85 that did not receive SAP had SSI (P=0.551). Deep SSI were seen in 2 patients that did not receive SAP(p=0.155) and grew Staphylococcus aureus in their cultures. Only 1 adverse allergic reaction to preoperative antibiotics was noted.&#x0D; Conclusion: Despite a low risk of adverse reactions, there is no benefit of using pre-operative antibiotics to prevent SSI in children undergoing elective inguinal surgery.

Efficacy of Antibiotics in Supracondylar Fractures.

Controversy exists surrounding antibiotic use in the setting of pediatric supracondylar humerus fractures treated with closed reduction and percutaneous Kirschner wire (K-wire) fixation. While the reported incidence of infection in the literature is low, surgeons frequently administer preoperative antibiotics. The purpose of this study was to retrospectively review preoperative antibiotic use and incidence of infection in children with supracondylar humerus fractures treated with closed reduction and K-wire fixation. It was hypothesized that antibiotic administration will not affect the incidence of infection following this procedure. We performed a retrospective review of 1053 patients with supracondylar humerus fractures treated with closed reduction and K-wire fixation at 3 institutions between 2006 and 2016. Patient demographics, antibiotic administration and follow-up data were reviewed in 905 patients. Of 905 patients, 755 patients received preoperative antibiotics and 150 patients did not. The incidence of infection was 2.5% (n=22) in the group that received preoperative antibiotics and 2.0% in the group that did not receive antibiotics with an overall incidence of infection of 2.4%. The difference between groups did not reach significance (P>0.5). The majority of infections were treated with oral antibiotics with or without early pin removal. Four patients, all in the preoperative antibiotic group, required surgical debridement and intravenous antibiotics. Retrospective review of the incidence of infection in closed reduction and percutaneous pinning of supracondylar humerus fractures found no difference between patients who received preoperative antibiotics and those who did not receive preoperative antibiotics. Level III-therapeutic.

Wide local excision of the vulva for premalignant or benign lesions: do antibiotics decrease the risk of postoperative wound complication?

Objectives: To investigate determinants of wound complication following wide local excision (WLE) of the vulva for suspected premalignant or benign disease at a tertiary care center over the years 2016 to 2020. To determine factors associated with perioperative antibiotic use for WLE of the vulva and whether preoperative intravenous (IV) antibiotics or postoperative topical antimicrobial agents are associated with a decreased risk of wound complication. Methods: Consecutive patients were identified who underwent wide local excision of the vulva for suspected premalignant or benign lesions between June 1, 2016 and February 28, 2020. IRB approval was obtained and surgical records were reviewed; patients undergoing ‘wide local excision, vulva,’ ‘simple partial vulvectomy,’ or ‘destruction of vulvar lesion with excision’ were considered for inclusion. Demographic, peri- and postoperative, and pathologic data were recorded. Dimensions of specimen and elliptical surface areas were recorded. Patient follow up was documented at least through the postoperative appointment. Patients were separated by receipt of preoperative IV antibiotics or postoperative antimicrobial agents and by postoperative wound complications. Fisher's exact tests and Chi squared tests were used to compare categorical variables between groups and logistic regression models were used for continuous variables. P-values Results: Three-hundred thirty-five patients met inclusion criteria over the study period. One-hundred forty-one patients developed a wound complication (42%); this included 134 wound separations (40%), 22 infections (6.6%), and 4 hematomas (1.2%). Thirty-two patients (9.6%) received preoperative IV antibiotics and 42 (12.5%) received postoperative topical antimicrobial agents. Neither IV nor topical antimicrobial agents were associated with a decreased risk of wound complication (RR 0.96, 95% CI 0.62-1.49; RR 0.99, 95% CI 0.66-1.48). Demographics and preoperative characteristics were similar between those who received and did not receive antibiotics. Antibiotic administration was not associated with the maximum length or total surface area of excisions, number of vulvar excisions per surgery, or indication for WLE. Preoperative antibiotic use was similar between the gynecologic oncology and general gynecology divisions (RR 1.23, 95% CI 0.59-2.59). Patients who received IV antibiotics were more likely to be undergoing concurrent hysterectomy or other laparoscopic procedure (RR 12.8, 95% CI 7.87-20.75). Conclusions: WLE of the vulva is a common procedure among gynecologic oncologists and general gynecologists and carries a high rate of wound complication. Recent ERAS guidelines report low-level evidence to consider preoperative antibiotics for WLE and do not comment on topical antimicrobials.[1] In our study neither preoperative antibiotics nor postoperative topical antimicrobials were associated with improved outcomes. Prospective data on this topic is lacking and should be an area of future research. Antibiotic use for WLE-in the absence of concurrent clean-contaminated procedures-appears to be guided by surgeon preference.

Implementation of a broader pre-operative antibiotic coverage and chlorhexidine irrigation associated with a lower postoperative surgical site infection

<h3>Objectives:</h3> Post-operative surgical site infections (SSI) cause major health and economic burden on the patients and the healthcare systems. Multiple risk factors such as obesity and medical comorbidities are known to increase the risk of SSI in gynecologic oncology patients. Commonly used preoperative antibiotic regimens focus on targeting the skin flora as described by the enhanced recovery protocols adopted by many hospitals. We sought to investigate the effect of the addition of metronidazole to the preoperative antibiotic regimen and the intraoperative pelvic irrigation with 0.05 % chlorhexidine gluconate (CHG) on the rate of SSI after a minimally invasive surgery in gynecologic oncology. <h3>Methods:</h3> After IRB approval, we collected data from June 2018 to January 2020 for patients who underwent minimally invasive gynecologic oncology surgery at Marshall University School of Medicine. Implementation of the infection control model (pre-operative Metronidazole + intraoperative CGH pelvic irrigation) started in July 2019. Demographic and medical data, as well as intraoperative and postoperative data, were collected. The rate of SSI was analyzed before and after adoption of the model. <h3>Results:</h3> A total of 508 patients underwent a minimally invasive gynecologic oncology procedure: 262 before the implementation of the infection control model and 318 afterward. The median age of the patients was 59 years old and the rate of comorbidities was equal between the groups. The rate of SSI before the implementation of the model (Group 1) was 2.29% (6/262) and the rate of SSI afterward (Group 2- post infection control model) was 0.94% (3/318). The most common bacteria isolated from the first group were gram-negative bacilli (Klebsiella and E. Coli) and anaerobes, while Group 2 had a single patient with Klebsiella infection, one Bacteroides species infection, and one MRSA infection. All of these infected patients required pelvic abscess drainage and hospital readmission for intravenous antibiotics, with an average of 2-day hospital stay. <h3>Conclusions:</h3> The addition of metronidazole to the preoperative antibiotics regimen and the intraoperative pelvic irrigation with 0.05 % CHG appears to decrease the rate of SSI after a minimally invasive gynecologic oncology surgery. This model merits further studying in order to validate these results.

The Effect of Preoperative Oral Antibiotics in the Prevention of Surgical Site Infection after Laparoscopic Colorectal Cancer Surgery: A Propensity Score Matching Study.

Objectives: Recent findings suggest that the combination of mechanical bowel preparation (MBP) and preoperative oral antibiotics (OA) decreases the risk of surgical site infection (SSI) in colorectal surgery; however, this remains controversial. The present study examined the efficacy of OA plus MBP in laparoscopic colorectal cancer (CRC) surgery using propensity score matching (PSM). Methods: A total of 1080 patients with CRC underwent MBP followed by laparoscopic surgery between 2007 and 2019. OA was administered to all patients with CRC who underwent colectomy from 2018. PSM was performed to compare the effects of OA plus MBP (OA) versus MBP only (non-OA) on the rate of superficial SSI. Results: Overall, 128 patients received OA. Significant differences were observed in age, the American Society of Anesthesiologists performance status (ASA-PS), liver disease, and preoperative serum albumin (Alb) between the OA and non-OA groups. The enrolled patients were matched using PSM into two groups based on the following factors: sex, age, body mass index, ASA-PS, diabetes mellitus, liver disease, Alb, and tumor location, which resulted in the disappearance of significant differences. A univariate analysis showed that blood loss of 100 g or more, non-OA, and preoperative chemotherapy or radiation correlated with SSI (p = 0.021, 0.010, 0.038). A multivariate analysis of these three variables identified blood loss of 100 g or more and non-OA as independent risk factors for SSI (hazard ratio (HR): 3.238, p = 0.031; HR: 2.547, p = 0.033). Conclusions: The present study revealed that OA plus MBP markedly reduced SSI rate. OA with MBP needs to be adopted in laparoscopic CRC surgery.

Nipple-Sparing Mastectomy: Are We Providing Proper Prophylactic Antibiotic Coverage?

Infection after nipple-sparing mastectomy (NSM) and implant-based reconstruction (IBR) can be a devastating complication. The retained nipple may act as a portal or nidus for different ductal organisms, and as such, the bacteriology of surgical-site infections (SSIs) in this setting may not be adequately covered by current antibiotic recommendations. This study sought to evaluate SSI and reconstruction outcomes in relation to antibiotic choice and identify the different microbial species implicated. A prospective database was reviewed for patients who underwent NSM with IBR from 2010 to 2019. Patient characteristics, operative details, antibiotic regimens, and subsequent treatment details were evaluated. The study analyzed SSI incidence, timing, and type of causative organisms. The study analyzed 571 NSMs with IBR performed for 347 patients (55% with direct implants and 45% with tissue expanders). The preoperative antibiotics consisted of cephalosporin alone for 65% of the patients, a more broad single-antibiotic use for 12% of the patients, and dual-coverage antibiotics for 20% of the patients. During a median follow-up of 1.7years, SSI developed in 12% of the reconstructions, with 6% requiring prosthesis removal. The most common SSI organism cultured was Staphylococcal species. Neither pre- nor postoperative antibiotic choice was associated with incidence of infection, type of bacteria, or need for prosthetic explanation. For patients undergoing NSM with IBR, a more aggressive antibiotic choice is not associated with an improved SSI rate. Patient and treatment factors continue to carry the highest risk for SSI.

COMPARATIVE EFFECTIVENESS OF MECHANICAL BOWEL PREPARATION WITH AND WITHOUT ORAL ANTIBIOTICS FOR ELECTIVE COLORECTAL SURGERY

Background: Surgical site infections (SSI) are a major cause of morbidity after surgery and are associated with increased hospital length of stay, readmissions, costs, and mortality. Surgical site infections are disproportionally high in colorectal surgery and are estimated to affect between 15% and 30% of patients. Surgical site infections (SSIs) increase the cost of care and are associated with increased morbidity and mortality and it is the third most common nosocomial infection. Objective: To clarify oral antibiotics (OAs) use together with mechanical bowel preparation (MBP) patients outcome following elective colorectal surgery. Patients and methods: The current study was conducted at Al-Hussein University Hospital and Kafr Elsheikh General Hospital. We selected forty patients who underwent elective colorectal surgery. All the studied patients were divided into two equal groups: Group I received mechanical bowel preparation with oral antibiotics, and Group II received mechanical bowel preparation with oral antibiotics. Results: We found that there was no significant difference between two groups of patients as regards mean age and sex distribution. Anterior resection was the most frequent surgical procedure done for the two studied groups of patients. The least frequent procedures done for group I patients were radical sigmoidectomy. Total colectomy and sigmoidectomy, the least frequent procedures done for group II patients, were total colectomy and extended right hemicolectomy. However, the difference between the two groups of patient as regards type of surgery and time of closure did not reach the significant value. All studied patients had ileostomy as a type of stoma. As regards complications after surgery, the most frequent complications among patients of group I were pneumonia and ileus. On the other hand, the most frequent complications among patients of Group II were ileus, leakage and intra-abdominal collection. The mean values of hospital stay in days significantly decreased among patients of group 1. Conclusion: Current study suggested a potentially significant role for prophylactic preoperative oral antibiotic in addition to mechanical bowel preparation, in the prevention of postoperative complications during elective colorectal surgery.

Is a single dose of prophylactic antibiotics sufficient in patients with acute noncomplicated appendicitis

Background Antibiotics prescription before surgery is considered to be effective in reducing the infectious complications of appendectomy. As a result, most surgeons prescribe antibiotics before surgery for patients diagnosed with appendicitis. Objective The aim of study was to evaluate the effect of a single antibiotic dose compared with the concurrent regimen on the outcome of appendectomy, especially infective complications. Patients and methods A total of 60 cases diagnosed with appendicitis were included, and they were divided into two groups: group A (single dose of cefotaxime 1 g and metronidazole 500 mg before surgery) and group B (the same regimen was received, and it was repeated twice daily for 4 days). All cases were subjected to history taking, physical examination, and routine investigations. At follow-up, all cases were clinically assessed. Results There were no significant statistical differences between groups in age, sex, and BMI variables. No significant statistical differences were observed during the surgery and hospitalization period between two groups. Wound infection occurred in 10 and 6.67% of cases in both groups, respectively (P > 0.05). However, the cost was significantly higher in group B. Conclusion A single dose preoperative antibiotics appears to be as efficacious as concurrent regimen in preventing wound infections after appendectomy. Continuing antibiotic prophylaxis in the postoperative period was not necessary, and it added additional unnecessary financial costs.

Antibiotic eluting envelopes: evidence, technology, and defining high-risk populations.

Cardiovascular implantable electronic devices (CIED) are effective and important components of modern cardiovascular care. Despite the dramatic improvements in the functionality and reliability of these devices, over time patients are at risk for developing several morbidities, the most feared of which are local and systemic infections. Despite significant financial investment and aggressive therapy with hospitalization, intravenous antibiotics, and transvenous lead extraction, the outcomes include a 1-year mortality rate as high as 25%. This risk of infection has increased over time, likely due to the increased complexity of the surgical interventions required to insert and replace these devices. The only way to reduce this morbidity and mortality is to prevent these infections, and other than preoperative antibiotics, there were little data supporting effective therapy until the WRAP-IT trial provided randomized data showing that pocket infections can be reduced by 60% at 12 months and major CIED infections reduced by 40% at 1 year with the use of the absorbable antibiotic eluting envelope in patient CIED procedures at high risk of infection. Not all CIED procedures are at high risk of infection and justify the use of the envelope, but cost-effectiveness data support the use of the antibiotic envelope particularly in patients with defibrillator replacements, revisions, and upgrades, such as to a resynchronization device and in patients with prior CIED infection, history of immunocompromise, two or more prior procedures, or a history of renal dysfunction.

Surgical site infections in gynecology: the latest evidence for prevention and management.

Surgical site infection (SSI) remains one of the most common postoperative surgical complications. Prevention and appropriate treatment remain paramount. Evidence-based recommendations include recognition and reduction of preoperative risks including hyperglycemia and smoking, treatment of preexisting infections, skin preparation with chlorhexidine gluconate, proper use of preoperative antibiotics, and implementation of prevention bundles. Consideration should be given to the use of dual antibiotic preoperative treatment with cephazolin and metronidazole for all hysterectomies. Despite advancements, SSI in gynecologic surgery remains a major cause of perioperative morbidity and healthcare cost. Modifiable risk factors should be evaluated and patients optimized to the best extent possible prior to surgery. Preoperative risks include obesity, hyperglycemia, smoking, and untreated preexisting infections. Intraoperative risk-reducing strategies include appropriate perioperative antibiotics, correct topical preparation, maintaining normothermia, and minimizing blood loss. Additionally, early recognition and prompt treatment of SSI remain crucial.

Surgical Strategies to Promote Cutaneous Healing.

Usually, cutaneous wound healing does not get impeded and processes uneventfully, reaching wound closure easily. The goal of this repair process is to restore the integrity of the body surface by creating a resilient and stable scar. Surgical practice and strategies have an impact on the course of wound healing and the later appearance of the scar. By considering elementary surgical principles, such as the appropriate suture material, suture technique, and timing, optimal conditions for wound healing can be created. Wounds can be differentiated into clean wounds, clean–contaminated wounds, contaminated, and infected/dirty wounds, based on the degree of colonization or infection. Furthermore, a distinction is made between acute and chronic wounds. The latter are wounds that persist for longer than 4–6 weeks. Care should be taken to avoid surgical site infections in the management of wounds by maintaining sterile working conditions, using antimicrobial working techniques, and implementing the principles of preoperative antibiotics. Successful wound closure is influenced by wound debridement. Wound debridement removes necrotic tissue, senescent and non-migratory cells, bacteria, and foreign bodies that impede wound healing. Additionally, the reconstructive ladder is a viable and partially overlapping treatment algorithm in plastic surgery to achieve successful wound closure.

Single-dose antibiotic regimens in total shoulder arthroplasty are safe in an outpatient surgery setting

BackgroundRecent literature supports that outpatient total shoulder arthroplasty (TSA) is a safe alternative to the traditional inpatient setting in appropriately selected patients; however, one concern with outpatient TSA is the inability to administer 24 hours of intravenous (IV) prophylactic antibiotics. The purpose of this study was to determine the infection and revision rates after outpatient TSA using single-dose preoperative IV antibiotics in an ambulatory setting and compare those to TSA performed inpatient with 24 hours of IV antibiotics. MethodsAn institutional database query was used to identify patients undergoing either primary anatomic TSA or reverse TSA. Patients were grouped into inpatient receiving 24 hours of IV antibiotics or outpatient receiving a single dose of IV antibiotics. Outcomes measured included overall infection (superficial and deep) and revision rates (infectious or noninfectious indications). Timing of infection was categorized as early (diagnosis <3 months postoperatively) or late (>3 months postoperatively). Patient demographics and comorbidities were analyzed. ResultsOf the total 1022 patients identified, 896 were inpatient and received 24 hours of IV antibiotics, and 126 patients were outpatient and received a single dose of IV antibiotics prior to TSA at an ambulatory surgery center. Average follow-up was 23 ± 21 and 18 ± 16 months for the 24-hour antibiotic cohort and single-dose cohort, respectively. The 896 patients receiving 24-hour antibiotics were on average 10.3 years older than the 129 patients who received a single dose (<0.001). Patients in the 24-hour cohort also were more likely to have rTSA (<0.0001), diabetes mellitus (=0.001) and hypertension (P ≤ .0001) than those receiving a single dose. Patients receiving a single dose had significantly more nonarthroplasty shoulder surgeries on the operative side than those receiving 24-h antibiotics (P = .04). There were no significant differences in overall postoperative infection rates (P = .71) or revision rates (P = .47). ConclusionPostoperative infection rates were low in both groups. There were no statistically significant differences in postoperative infection or revision rates. Patients in the single-dose cohort were significantly younger and had fewer comorbidities than patients in the 24-hour cohort; however, the single-dose cohort was more likely to have had previous nonarthroplasty shoulder surgery, which was most likely related to stricter patient selection criteria. The results of this study suggest that a single dose of IV antibiotic prophylaxis can be safely used in patients having outpatient TSA in an ambulatory center.Level of Evidence. Level III; Retrospective Cohort

JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias.

JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias.

P581 Pre-operative prolonged antibiotic treatment in ileocecal Crohn’s disease: single center non-randomized prospective study

Abstract Background Patients with complicated Crohn’s disease are the most difficult cohort to make right decision in treatment and timing surgery. These patients are at risk for the long duration of operations, length of hospital stay, repeated urgent interventions because of complications and the need for a temporary stoma. In literature there is lack of information concerning the usage of prolonged antibiotics in such cases and results are conflicting in some studies. Single center non-randomized prospective study was held. Methods 120 patients were evaluated from 2012 to 2017. All patients had a complicated Crohn’s disease with abdominal mass, fistulas and stricture of the terminal ileum and all of them were operated on. In the first group there were 48 patients who received preoperative treatment with ciprofloxacin and metronidazole for at least 2.5 (1–4) months. In the second group patients also received the same treatment for the median time of 13 (1–33) days. Our hypothesis has been that prolonged treatment allows to reduce postoperative complications and the risk of stoma formation. To prove this statement, we did Chi-squared and Fisher’s exact test, univariant and multivariant analyses. The following criteria were included: prolonged treatment, gender, age, perianal lesion, laparoscopic operation, blood loss and duration of surgery. Results In the first group the complication rate was 4 (8.3%) and in 27 (56.2%) patients there was the need for stoma formation. In the second group – 18 (25%) and 58 (80.5%), respectively. First, we used Fisher’s test to see some correlations between the treatment and complications and the need of stoma formation. Prolonged treatment reduces the rate of complications in 4-fold (OR 0.25; x2= 5.34; p=0.02) and the need of stoma in 3-fold (OR 0.3; x2=8.24; p=0.004). In uni- and multivariant analyses prolonged treatment significantly reduces the complication rate and the risk for stoma creation (OR 2.73 CI 0.037–0.86; p= 0.02 and OR 0.310 CI 0.02–0.72 p=0.004, respectively). Gender, age, perianal lesion, laparoscopic operation, blood loss and duration of surgery were not statistically significant in multivariant analysis. Conclusion preoperative prolonged antibiotic treatment in complicated Crohn’s disease significantly reduced complications rate and the risk of stoma creation.