Preoperative Vancomycin Research Articles

The Impact of Surgical Site Infection on Patient Outcomes After Open Posterior Instrumented Thoracolumbar Surgery for Degenerative Disorders.

Few reports in the literature have described the long-term outcome of postoperative infection from the patient perspective. The aim of the present study was to determine if complicated surgical site infection (SSI) affects functional recovery and surgical outcomes up to 2 years after posterior instrumented thoracolumbar surgery for the treatment of degenerative disorders. This retrospective cohort study involved patients who had been enrolled in a previous randomized controlled trial that examined antibiotic use for open posterior multilevel thoracolumbar or lumbar instrumented fusion procedures. In the present study, patients who had SSI (n = 79) were compared with those who did not (n = 456). Patient-reported outcome measures (PROMs) included the Oswestry Disability Index (ODI), leg and back pain scores on a numeric rating scale, Short Form-12 (SF-12) summary scores, and satisfaction with treatment at 1.5, 3, 6, 12, and 24 months. Surgical outcomes included adverse events, readmissions, and additional surgery. The median time to infection was 15 days. Of the 535 patients, 31 (5.8%) had complicated infections and 48 (9.0%) had superficial infections. Patients with an infection had a higher body mass index (BMI) (p = 0.001), had more commonly received preoperative vancomycin (p = 0.050), were more likely to have had a revision as the index procedure (p = 0.004), had worse preoperative mental functioning (mental component summary score, 40.7 ± 1.6 versus 44.1 ± 0.6), had more operatively treated levels (p = 0.024), and had a higher rate of additional surgery (p = 0.001). At 6 months after surgery, patients who developed an infection scored worse on the ODI by 5.3 points (95% confidence interval [CI], 0.4 to 10.1 points) and had worse physical functioning by -4.0 points (95% CI, -6.8 to -1.2 points). Comparison between the groups at 1 and 2 years showed no difference in functional outcomes, satisfaction with treatment, or the likelihood of achieving the minimum clinically important difference (MCID) for the ODI. SSI more than doubled the post-discharge emergency room visit and additional surgery rates. Patients with SSI initially (6 months) had poorer overall physical function representing the delay to recovery; however, the negative impact resolved by the first postoperative year. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prevention of Cardiac Implantable Electronic Device-Related Infection in Patients With Cancer: The Role of a Comprehensive Prophylactic Bundle Approach That Includes the Antimicrobial Mesh.

BackgroundOncological patients have several additional risk factors for developing a cardiac implantable electronic device (CIED)–related infection. Therefore, we evaluated the clinical impact of our comprehensive bundle approach that includes the novel minocycline and rifampin antimicrobial mesh (TYRX) for the prevention of CIED infections in patients living with cancer.MethodsWe retrospectively reviewed all consecutive patients who had a CIED placement at our institution during 2012–2017 who received preoperative vancomycin, intraoperative pocket irrigation with bacitracin and polymyxin B, plus TYRX antimicrobial mesh, followed by postoperative oral minocycline.ResultsA total of 154 patients had a CIED, with 97 permanent pacemakers (PPMs), 23 implantable cardioverter defibrillators (ICDs), and 34 cardiac resynchronization therapy (CRT) devices. An underlying solid cancer was present in 62% of patients, while 38% had a hematologic malignancy. Apart from a higher proportion of surgical interventions in the PPM group than in the ICD and CRT groups (P = .007), no other oncologic variables were statistically significantly different between groups. Despite an extensive median follow-up period (interquartile range) of 21.9 (6.7–33.8) months, 16 patients (10%) had a mechanical complication, while only 2 patients (1.3%) developed a CIED infection, requiring the device to be explanted.ConclusionsOur comprehensive prophylactic bundle approach using TYRX antimicrobial mesh in an oncologic population at high risk for infections was revealed upon extensive follow-up to be both safe and effective in maintaining the rate of CIED infection at 1.3%, well within published averages in the broader population of CIED recipients.

Intraoperative Microvascular Thrombosis Secondary to Henoch-Schönlein Purpura of Hidden Onset

Henoch-Schonlein purpura (HSP) is a systemic small-vessel vasculitis. Here, we report a case of recurrent microvascular thrombosis during microsurgery that initially presented as insidiously developing HSP. A 17-year-old male adolescent underwent latissimus dorsi myocutaneous free tissue transfer for an exposed tibia bone following a motorcycle accident. During microsurgery, gross clots rapidly formed in the artery and vein after anastomoses; Doppler sounds and the flap pallor indicated intravascular thrombosis. Multiple re-anastomoses and salvage interventions failed eventually; the flap was removed for an unknown reason. The patient developed nausea and vomiting, diarrhea, digestive tract hemorrhaging, and abdominal angina refractory to an opioid injection following the flap removal. A palpable petechial rash developed over the entirety of his extremities, bilaterally. Urinalysis revealed severe glomerular injury with microscopic hematuria and nephrotic-range proteinuria. After the 2-month-long consultation, the patient was eventually diagnosed with HSP-induced by preoperative vancomycin therapy. Renal biopsies indicated immunofluorescent deposition of IgA on the glomeruli, confirming grade III–V Henoch-Schonlein nephritis. Clinical and wound problems were corrected following daily bolus injections of 30 mg intravenous methylprednisolone for 7 days. The patient returned to our outpatient clinic 19 months postoperatively with an acceptable esthetic appearance and unrestricted ambulation and physical activity. HSP is rare; however, it is extremely challenging to overcome recurrent and refractory thrombosis during microsurgery in patients with insidiously developing vascular disease. Vancomycin, a commonly used antibiotic, can trigger HSP and is a possible culprit in patients who develop recurrent and unexplained thrombosis during microsurgery.

What Is the Primary Driver of Preoperative Vancomycin Use? It's Not Methicillin-resistant Staphylococcus aureus-or Allergy.

Factors driving vancomycin surgical prophylaxis are poorly understood. In a national Veterans Affairs cohort with manually validated data, surgical specialty (cardiac, orthopedics) and perception of high facility methicillin-resistant Staphylococcus aureus (MRSA) prevalence-not MRSA colonization-were the primary drivers of prescribing. A β-lactam allergy was the second most common reason. These data may inform perioperative stewardship.

Dual-Agent Antibiotic Prophylaxis Using a Single Preoperative Vancomycin Dose Effectively Reduces Prosthetic Joint Infection Rates With Minimal Renal Toxicity Risk

BackgroundWe performed this study to compare prosthetic joint infection (PJI) and renal toxicity rates following hip and knee total joint arthroplasty (TJA) when a first-generation cephalosporin was administered either alone or in combination with a single preoperative vancomycin dose, whether vancomycin administration timing potentially influenced dual-antibiotic PJI prophylaxis approach effectiveness, and whether single-dose vancomycin use increased risk of renal impairment. MethodsThis was a retrospective study of 1997 consecutive primary TJAs (1871 patients) treated with cefazolin alone (1044 TJAs) or cefazolin with single-dose vancomycin (953 TJAs). The vancomycin group included 476 TJAs (450 patients) with infusion started at least 45 minutes before the skin incision and 477 TJAs (464 patients) with infusion started less than 45 minutes before the skin incision. ResultsThe addition of a single dose of vancomycin did not significantly reduce PJI rates when compared with cefazolin alone (1.6% vs 2.1%, P = .32). However, the PJI rate was significantly lower following primary TJA when vancomycin administration was initiated at least 45 minutes before incision (0.2%) when compared with other TJA procedures performed using cefazolin and vancomycin (2.9%, P < .01) or cefazolin alone (2.1%, P < .01). We observed no difference in renal toxicity between treatment groups. ConclusionIn our institution, the addition of vancomycin to cefazolin at least 45 minutes before incision reduced PJI infection rates in primary hip and knee TJA with a low risk of renal impairment.

688The Effect of Preoperative Vancomycin on Bacteria Isolation from Operative Cultures

688The Effect of Preoperative Vancomycin on Bacteria Isolation from Operative Cultures

Perioperative Pharmacology: A Focus on Vancomycin

Given the increase in various drug-resistant organisms and in patients who are allergic to penicillin, perioperative nurses are likely to encounter patients who are receiving IV vancomycin, a tricyclic glycopeptide antibiotic. In general, vancomycin is not considered a first-line agent because of its possible adverse effects (eg, hypotension, phlebitis, nephrotoxicity, ototoxicity); therefore, it is reserved for treating serious or severe infections caused by organisms that are unresponsive to other antimicrobial agents. Vancomycin is administered intravenously over a minimum of 60 minutes to avoid infusion-related reactions. Some considerations for nurses administering vancomycin include ensuring a patent IV line, planning for administration of the preoperative dose as much as two hours before the initial incision is made, and including information about the dose and timing of preoperative vancomycin administration in the surgical time out.

Derivation and Validation of a Clinical Prediction Rule for Nosocomial Pneumonia after Coronary Artery Bypass Graft Surgery

Nosocomial pneumonia is an important cause of morbidity and mortality among surgical patients in the United States. The emergence of effective but potentially costly or risky preventive interventions makes perioperative risk stratification desirable. We sought to develop a prediction rule for pneumonia after coronary artery bypass grafting (CABG), a common surgical procedure. Data on individuals undergoing CABG at 32 hospitals in 6 states were extracted from Tenet Healthcare's Quality and Resource Management System. A logistic regression-based prediction rule was developed in half of the study sample and validated in the remaining patients. Of 17,143 individuals undergoing CABG from January 1999 through February 2004, 361 (2%) developed pneumonia without a known aspiration etiology. Thirteen independent predictors of pneumonia were identified in the derivation subset of the sample: body mass index <18.5 (defined as the weight in kilograms divided by the square of the height in meters), smoking history, admission from a nonresidential setting, cancer history, chronic obstructive pulmonary disease, Canadian Cardiovascular Society score 3, prior internal mammary artery CABG, emergency status, serum creatinine level >1.2 mg/dL, percutaneous transluminal coronary angioplasty, blood transfusion, preoperative vancomycin administration, and receipt of mechanical ventilation for >1 day. The model-based rule was well calibrated (Hosmer-Lemeshow X(2)=5.51; P=.70) and demonstrated good discrimination (area under the receiver-operating characteristic curve [ROC AUC], 0.78) in the derivation group. Discriminatory ability was also reasonable in the validation cohort (ROC AUC, 0.75; P=.18, for difference in ROC AUC between groups). Using a large cohort of patients treated at community and teaching hospitals, we derived and validated a prediction rule for pneumonia after CABG. This index may prove to be useful in prioritizing receipt of preventive interventions.

Vancomycin Disposition and Penetration into Ventricular Fluid of the Central Nervous System following Intravenous Therapy in Patients with Cerebrospinal Devices

Objective/Aims: To determine the cerebrospinal fluid concentrations and percent CNS penetration of intravenous vancomycin in patients with cerebrospinal devices at a pediatric institution. Methods: We performed a prospective evaluation of intravenous (IV) vancomycin in patients who received a single prophylactic dose of vancomycin (15–20 mg/, maximum dose 1 g) prior to insertion of a CNS shunt (group I) or a therapeutic regimen (a dose of 10–20 mg/kg every 6–12 h) for a documented/suspected shunt infection (group II). Ventricular cerebrospinal fluid (VCSF) samples were taken during the procedure in group I and multiple serum and VCSF samples were collected in group II. Pharmacokinetic parameters were calculated using a one-compartment model, and percent CNS penetration was estimated using area-under-the-curve methodology. Results: Group I: 21 VCSF samples were analyzed from 19 patients (mean age 7.2 ± 6.4 years). Over 40% of samples failed to have detectable vancomycin concentrations (range 0–2 µg/ml). Group II: 6 patients (mean age 11 ± 8.7 years) had VCSF concentrations ranging from nondetectable to 6.59 µg/ml (mean 2.48 ± 0.52 µg/ml). Percent penetration ranged from 0.77 to 18%. Conclusions: Single-dose, pre-operative vancomycin results in low VCSF vancomycin concentrations and repeated dosing in patients with documented/presumed device infections yields variable CNS penetration.

941: Peripheral and Corporal Blood Levels of Preoperative Vancomycin and Gentamycin in Patients Undergoing Penile Prosthesis Implantation

You have accessJournal of UrologyModerated Poster 28, Monday, May 21, 2007, 1:00 - 3:00 pm1 Apr 2007941: Peripheral and Corporal Blood Levels of Preoperative Vancomycin and Gentamycin in Patients Undergoing Penile Prosthesis Implantation Heman Carrion, Jorge R. Caso, Gerard D. Henry, J. Christopher Webster, and Rafael E. Carrion Heman CarrionHeman Carrion More articles by this author , Jorge R. CasoJorge R. Caso More articles by this author , Gerard D. HenryGerard D. Henry More articles by this author , J. Christopher WebsterJ. Christopher Webster More articles by this author , and Rafael E. CarrionRafael E. Carrion More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)31169-8AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "941: Peripheral and Corporal Blood Levels of Preoperative Vancomycin and Gentamycin in Patients Undergoing Penile Prosthesis Implantation." The Journal of Urology, 177(4S), pp. 311–312 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 177Issue 4SApril 2007Page: 311-312 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Heman Carrion More articles by this author Jorge R. Caso More articles by this author Gerard D. Henry More articles by this author J. Christopher Webster More articles by this author Rafael E. Carrion More articles by this author Expand All Advertisement PDF DownloadLoading ...

Infectious Diseases: Tolerance of Vancomycin for Surgical Prophylaxis in Patients Undergoing Cardiac Surgery and Incidence of Vancomycin-Resistant Enterococcus Colonization

In 2001, vancomycin replaced cefuroxime for antibiotic prophylaxis in patients undergoing cardiac surgery at our institution due to high rates of surgical site infections caused by methicillin-resistant Staphylococcus spp. However, few data supported the use of vancomycin for surgical prophylaxis. To determine the tolerance of vancomycin for antibiotic prophylaxis and incidence of vancomycin-resistant Enterococcus (VRE) in cardiac surgery patients. In 2 separate studies, we assessed the adverse effects in patients given perioperative vancomycin (study 1) and the incidence of VRE in patients given perioperative vancomycin (study 2). Study 1 was a prospective cohort study of patients undergoing coronary artery bypass graft (CABG) or valve replacement surgery given vancomycin (1 dose preoperatively/2 doses postoperatively) for antibiotic prophylaxis between October 2003 and December 2004. Patients were assessed for tolerance to the antibiotic regimen. In study 2, cardiac surgery patients receiving perioperative vancomycin were screened for VRE before therapy and at day 7 of hospitalization. VRE was detected using standard microbiologic procedures. In study 1, 1161 patients (CABG = 75%; valve = 19%; both = 6%) were evaluated. All patients but one (99.9%) were prescribed preoperative vancomycin. Therapy was changed for 34 (2.9%) patients, of which 20 changes were due to physician preference for another antibiotic. The only toxicity that required a change in the vancomycin regimen was red man's syndrome, which was experienced by 9 (0.8%) patients. Four patients did not receive a second postoperative dose due to prior renal insufficiency. Patients were most commonly switched to cefuroxime (n = 26), linezolid (n = 2), cefepime (n = 2), gatifloxacin, cefazolin, levofloxacin, or ceftriaxone (n = 1, each). In study 2, 100 patients were screened for the emergence of VRE colonization. No patient was VRE positive at baseline and 4 (4%) were positive at day 7. Surgical antibiotic prophylaxis with vancomycin was reasonably well tolerated in CABG and valve replacement surgery, with a 4% incidence of VRE colonization.

CHAPTER 1: THE MANAGEMENT OF ERECTILE DYSFUNCTION: AN AUA UPDATE

approach to develop a guideline for the ED treatment modalities that had become available in the United States after publication of the 1996 Report. Guideline statements from the 1996 Report on previously available therapeutic modalities were either revised or brought forward unchanged depending on the existing evidence. All guideline statements were graded according to the degree of flexibility in clinical application: standard, recommendation, or option, with standard being the least flexible and option being the most flexible (Table 1). Grading is based on two characteristics: knowledge of the health outcomes of the alternative intervention and preference for the intervention. The Panel believed that the patient, with physician guidance, must make his own decision in selecting treatment. Outcome estimates derived from review and meta-analysis of evidence provide physicians and patients with scientifically based information to assist them in making appropriate treatment decisions. Thus, a second Panel objective was to determine whether or not there was sufficient evidence for outcomes (both benefits and risks) to be estimated.

Role of preoperative antibiotic prophylaxis in preventing postoperative peritonitis in newly placed peritoneal dialysis catheters

The role of vancomycin and other antibiotics in the treatment of acute peritonitis in peritoneal dialysis (PD) patients is well established. However, the role of preoperative vancomycin or cephalosporins in preventing early infection in newly placed PD catheters remains controversial. We performed a prospective randomized study to examine the role of vancomycin or cefazolin prophylaxis in decreasing the incidence of postoperative peritonitis. Over a 6-year period, 221 patients undergoing 254 permanent peritoneal catheter placement procedures were randomized into three groups. Group I patients (86 procedures) were administered a single intravenous (IV) dose of vancomycin, 1,000 mg, 12 hours before peritoneal catheter placement procedures, whereas group II patients (85 procedures) were administered a single IV dose of cefazolin, 1,000 mg, 3 hours before the procedure. Group III patients (83 procedures) were not administered antibiotics preoperatively for at least 1 week before the procedure. Patients were monitored for peritonitis in the following 14 days. Peritonitis developed in 1 patient (1%) in group I (vancomycin group) and 6 patients (7%) in group II (cefazolin group) compared with 10 patients (12%) in group III (control group); P = 0.02. We conclude that the use of preoperative single-dose IV vancomycin prophylaxis for permanent PD catheter placement reduces the risk for postoperative peritonitis. Single-dose vancomycin is superior to single-dose cefazolin in reducing the risk for postoperative peritonitis. Absence of prophylaxis is associated with a high risk for developing postoperative peritonitis.

Preoperative vancomycin prophylaxis decreases incidence of postoperative hemodialysis vascular access infections

The role of vancomycin in the treatment of infected arteriovenous chronic dialysis access is well established. However, the role of preoperative vancomycin administration in preventing infection in newly placed, revised, or surgically thrombectomized grafts has not been determiend. We performed a prospective randomized study to examine whether vancomycin prophylaxis can decrease the incidence of postoperative graft infections. Over a 5-year period, 206 patients undergoing 408 permanent vascular access procedures were randomized into two groups. Group 1 (206 procedures) received a single intravenous dose of 750 mg of vancomycin approximately 6 to 12 hours before vascular access placement procedures, while group 2 (202 procedures) did not. Patients were evaluated for access infection within the following 30 days and before use of the access for chronic dialysis. Access infection developed in two patients (1%) in group 1 and in 12 patients (6%) in group 2 (P = 0.006. All 14 infections occurred in upper extremity polytetrafluoroethylene grafts. We conclude that the use of preoperative single-dose intravenous vancomycin prophylaxis for hemodialysis vascular graft procedures reduces the risk of postoperative access infection.