Prolonged Antibiotic Use Research Articles

Evaluating antibiotic therapy for ventilator-associated pneumonia caused by gram-negative bacilli

IntroductionVentilator-associated pneumonias (VAPs) are a complication of mechanical ventilation in the intensive care unit (ICU) that increase length of stay, morbidity, and mortality. While identifying and treating infections early is paramount to improving patient outcomes, more and more data demonstrate limited courses of antibiotics improve outcomes. Prolonged (10–14 day) courses of antibiotics have remained the standard of care for pneumonia due to gram-negative bacilli (GNR). We aimed to review our GNR VAPs to assess risk factors for recurrent GNR infections. MethodsWe reviewed trauma patients who developed VAP from 02/2019 through 05/2022. Demographics, injury characteristics, and outcomes were reviewed with a focus on pneumonia details including the cultured pathogen(s), antibiotic(s) used, treatment duration, and presence of recurrent infections. We then compared single episode VAPs to multiple episode VAPs among patients infected by GNRs. ResultsEleven of the fifty trauma patients admitted to the ICU suffered a VAP caused by a GNR. Of these eleven patients, six experienced a recurrent infection, four of which were caused by Pseudomonas aeruginosa and two of which were caused by Enterobacter aerogenes. Among the patients who received ten days of antibiotic treatment, half suffered a recurrence. Although, there was no difference in the microbiology or antibiotic duration between the recurrences and single episodes. ConclusionDespite prolonged use of antibiotics, we found that the risk of recurrent or persistent infections was high among patients with VAP due to GNB. Further study is needed to determine optimal treatment to minimize the risk of these recurrences. Key messageVentilator-associated pneumonia due to gram-negative bacilli is a rare but high morbidity complication in intensive care units. Despite prolonged duration of therapy, these infections still appear to account for many recurrent infections and further study into optimal therapy is warranted.

Silver nanoparticle technology in orthopaedic infections.

The irrational and prolonged use of antibiotics in orthopaedic infections poses a major threat to the development of antimicrobial resistance. To combat antimicrobial resistance, researchers have implemented various novel and innovative modalities to curb infections. Nanotechnology involves doping ions/metals onto the scaffolds to reach the target site to eradicate the infective foci. In this connotation, we reviewed silver nanoparticle technology in terms of mechanism of action, clinical applications, toxicity, and regulatory guidelines to treat orthopaedic infections.

Effectiveness of Phenol Application in Pediatric Pilonidal Sinus

Purpose: Phenol application is an increasingly popular method in the treatment of pediatric pilonidal sinus because of its ease of use. However, there has been insufficient research on standards for phenol application in children. This study aimed to determine standards for evaluating phenol applications to identify parameters that can be used in treatment planning.
 Methods: Pediatric patients with pilonidal sinus who underwent surgical excision and/or phenol injection between January 2011 and January 2021 were evaluated retrospectively. Data related to the patients’ age, sex, treatment method (phenol, surgery), number of phenol applications, preoperative complications and antibiotic use, postoperative complications, and treatment duration were analyzed.
 Results: The study included 57 patients, 34 boys (59.6%) and 23 girls (40.3%), with a mean age of 15.15±1.62 years (range: 11-18). Number of phenol applications and postoperative complications were significantly higher in patients with prolonged preoperative antibiotic use (>2 weeks) and preoperative complications (p

Лактулозосодержащие кормовые добавки как фактор прижизненного формирования качественной и безопасной продукции

Purpose. Evaluation of various types of modern lactulose-containing additives and the effectiveness of their use in feeding farm animals as one of the options for decision the problem of in vivo formation of high-quality and safe livestock products for the healthy nutrition of the modern population. Discussion. The revolution in feed production made by the Soviet scientist Minenkov A.R. in the middle of the 20th century, namely the use of antibiotics as a feed additive to stimulate productivity, became a failure by the beginning of the 21st century. By this time, the negative consequences of prolonged use of antibiotics were revealed, which led to the active rejection of them in animal husbandry practice as productivity stimulants. They were replaced by pro- and prebiotic feed additives that have a healing effect on animal organism, thereby beneficially influencing their productive characteristics. Prebiotics in feed production are more convenient to use than probiotics, as they have a greater degree of unpretentiousness to storage conditions, but at the same time they are easier to obtain than live microorganisms. Lactulose is the most well-known and proven prebiotic in animal husbandry. Feed additives based on it in the body of animals have an identical mechanism of action based on enzymatic cleavage in the large intestine of this disaccharide by bifidobacteria and lactobacilli, which triggers a number of interrelated processes that have a beneficial physiological effect. The considered results of the use of some lactulose-containing feed additives on broiler chickens, Saanen goats, pigs and rabbits made it possible to conclude that for the above animal species there is a similar positive effect from the presence of new lactulose-based feed additives in the diet: intensification of growth and development of animals, as well as strengthening of resistance to adverse external factors, which directly affects the life-time formation of better and safer livestock products. Conclusion. Reviewed studies on the use of modern lactulose-based feed additives and the results obtained confirm their ability to have a beneficial effect on the growth, development and resistance to negative factors from outside the body of farm animals, such as broiler chickens, goats, pigs and rabbits. This, in turn, contributes to the lifetime formation of improved quantitative and qualitative characteristics of the resulting livestock raw materials.

A survey of Asian Eye Institutions on perioperative antibiotic prophylaxis in cataract surgery

PurposeTo determine current institutional practice patterns for the use of perioperative antibiotics and other measures to prevent infection after cataract surgery in Asia.MethodsAn online survey-based study of leading eye institutions in China, Hong Kong, India, Indonesia, Japan, Malaysia, Pakistan, Philippines, Singapore, South Korea, Taiwan, Thailand and Vietnam was conducted. The survey was administered to 26 representative key opinion leaders from prominent tertiary eye institutions that are also national academic teaching institutions in Asia. Survey responses were collated and anonymized during analysis.ResultsAll surveyed institutions used povidone iodine for the preoperative antiseptic preparation of the eye, with notable variations in the concentration of povidone iodine used for conjunctival sac instillation. Preoperative topical antibiotics were prescribed by 61.5% and 69.2% of institutions in low-risk and high-risk cases, respectively. Regarding the use of intra-operative antibiotics, 60.0% and 66.7% of institutions administered intracameral antibiotics in low-risk and high-risk patients, respectively. Postoperative topical antibiotics use patterns were generally very similar in low-risk and high-risk patients. Over half of the institutions (52.2% and 68.0% in low-risk and high-risk patients, respectively) also indicated prolonged postoperative use of topical antibiotics (> 2 weeks). Not all surveyed institutions had established policies/protocols for perioperative antibiotic use in cataract surgery, endophthalmitis surveillance, and/or a monitoring program for emerging antimicrobial resistance.ConclusionThere are variations in antimicrobial prophylaxis approaches to preoperative, intra-operative and postoperative regimens in cataract surgery in Asia. More evidence-based research is needed to support the development of detailed guidelines for perioperative antibiotic prophylaxis to reduce postoperative infections.

Compliance with Antimicrobial Prophylaxis Guidelines in Endourological Procedures: Frequency and Related Outcomes

Introduction: Surgical antimicrobial prophylaxis (SAP), when used appropriately based on evidence-based guidelines, reduces the rate of infectious complications following endourological procedures without compromising patient outcomes.
 Aims: to audit the appropriateness of the current SAP used in endourological surgeries based on international guidelines and report their associated outcomes (urinary tract infection (UTI) and bloodstream infection (BSI)).
 Methodology: The adherence to international guidelines recommendations; AUA 2019 and EAU 2020, regarding indication, duration, choice, and dose of the antibiotics used in endourological procedures were assessed in two medical centers in Amman/Jordan. Also, patients were asked to conduct laboratory urine test to determine the rate of infectious complications within one-month post-procedure.
 Results: Three hundred sixty-one patients were recruited for the study. The adherence rate to guidelines regarding indication, choice, and dose of pre-operative antibiotics was 90.3%, 2.8%, and 77.8% respectively. The duration was concordant with guidelines in only 3.4% of participants. A total of 41.8% of patients completed follow-up. Among those, 4.6% developed bacterial UTIs, and 0.7% developed BSI.
 Conclusion: Adherence to SAP guidelines in endourological procedures is far from optimal, especially by an inappropriate selection of broad-spectrum antibiotics as the agent of choice and prolonged use of antibiotics after the procedure in the absence of any documented infectious complication.

Antibacterial Activity Of Lime Peel (Citrus Aurantifolia (Christm.) Swingle) Ethanolic Extract Against Skin Infection Bacteria (Propionibacterium Acnes And Staphylococcus Epidermidis)

The skin is the outermost part of the body that serves as a protective body. In addition to protecting the skin of the face, it also acts as a beautifier. The main problem with facial skin is inflammation of the skin, which can cause acne. Bacteria like Propionibacterium acnes, Staphylococcus aureus, Staphylococcus epidermidis, and Pseudomonas aeruginosa can cause acne on the face. Prolonged use of antibiotics as therapy against acne will cause a new problem, namely resistance to antibiotics. Lime peel has many uses, especially as an antibacterial, which makes it a good candidate for use as an antibacterial agent in acne treatment. The goal of this study was to find out if the etTMhanolic extract of lime peel could kill bacteria like Propionibacterium acnes and Staphylococcus epidermidis. The research method used the Kirby-Bauer method and the Streaking methods to analyze the minimum inhibitory concentration and minimum bactericidal concentration. The results showed MIC at a concentration of 1 mg/mL for each bacterium, while MBC at a concentration of 40 mg/mL in Propionibacterium acnes and 50 mg/mL in Staphylococcus epidermidis. The conclusion is that the extract of lime peel in ethanol can kill bacteria.

Study of Diabetic Foot Problems Among Patients Attending the Diabetic Foot Clinic at Royal Hampshire County Hospital, United Kingdom: A Single-Centre Experience.

Background Patients with diabetes mellitus (DM) are on the rise all over the world. Simultaneously, the complications of DM are also increasing. Diabetes-related foot problems have been another concern among health professionals, especially foot ulcers, osteomyelitis, and amputations. Objectives We determined the prevalence of gender, age, types of DM including non-diabetics, various foot-related presentations, complications, and their outcomes. Methods A retrospective descriptive cross-sectional study was conducted among new patients attending a diabetic foot clinic over a period of six months, from January 1, 2019 to June 30, 2019. To confirm the outcome of the study, all of them were followed up for at least four months from the date of diagnosis. Results The study showed that most patients were males (65.5%). The most common age group for diabetic foot problems was 81-90 years, and about 80% of the foot problems were diagnosed in patients over 60 years. The study disclosed that 86.2% of the population had type 2 DM, 56.9% had ulcers, and 13.8% had osteomyelitis. The outcome of our study demonstrated that 65.5% of the patients were cured and discharged within four months of the diagnosis, but 10.3% of the population needed amputation. During the four-month follow-up period, 3.4% of our study population died due to non-foot-related causes. A total of 48.1% of our ulcer patients were discharged within eight weeks of diagnosis. However, 26% of ulcer patients and 75% of osteomyelitis patients needed more than four months to be discharged. Peripheral neuropathy and peripheral arterial disease (PAD) were present in 91% of ulcer patients. Among our osteomyelitis group, 100% had peripheral neuropathy, and 87.5% had PAD. About 20% of ulcer patients and none of the osteomyelitis patients were diagnosed with chronic kidney disease (CKD) stages beyond 3b. About 2/3rd of our ulcer and osteomyelitis population had an HbA1C level of more than 7.5%. Conclusion Male patients over 60 years of age with type 2 DM are more at risk of developing diabetes-related foot issues. Ulcer with or without osteomyelitis was the most common complication among our study population. Results showed that a significant amount of osteomyelitis patients underwent foot amputation. Poor glycaemic control of HbA1C of more than 7.5%, peripheral neuropathy, and PAD were the most common risk factors for developing foot-related complications. Prolonged use of antibiotics and a dedicated professional team may be needed to manage these complications successfully.

Early Postoperative Fever and Atelectasis in Patients Undergoing Upper Abdominal Surgery.

Atelectasis is a common complication after upper abdominal surgery and considered as a cause of early postoperative fever (EPF) within 48 hours after surgery. However, the pathophysiologic mechanism of how atelectasis causes fever remains unclear. Data for adult patients who underwent elective major upper abdominal surgery under general anesthesia at Seoul National University Hospital between January and December of 2021 were retrospectively analyzed. The primary outcome was the association between fever and atelectasis within 2 days after surgery. Of 1,624 patients, 810 patients (49.9%) developed EPF. The incidence of atelectasis was similar between the fever group and the no-fever group (51.6% vs 53.9%, p = 0.348). Multivariate analysis showed no significant association between atelectasis and EPF. Culture tests (21.7% vs 8.8%, p < 0.001) and prolonged use of antibiotics (25.9% vs 13.9%, p < 0.001) were more frequent in the fever group compared to the no-fever group. However, the frequency of bacterial growth on culture tests and postoperative pulmonary complications within 7 days were similar between the two groups. EPF after major upper abdominal surgery was not associated with radiologically detected atelectasis. EPF also was not associated with the increased risk of postoperative pulmonary complications, bacterial growth on culture studies, or prolonged length of hospital stay.

O-227 Viral, bacterial and fungal infections in patients with recurrent miscarriage

Abstract Miscarriages occur in 15% of clinically recognized pregnancies in the general population. Miscarriage has several physical and psychological consequences and might be a risk marker of severe obstetrical complications during the following pregnancies and various long-term pathological conditions, such as venous thromboembolism and cardiovascular diseases. Up to 80% of reproductive losses occur in the first trimester. Miscarriage may be caused by chromosomal abnormalities, antiphospholipid syndrome and other thrombophilia’s, immune and endocrine disorders as well as inflammation. However, in up to 50% of cases, the cause of the miscarriage remains unknown. The microbiome consists of microbes that are both helpful and potentially harmful. Most are symbiotic and some, in smaller numbers, are pathogenic. In a healthy body, pathogenic and symbiotic microbiota coexist without problems. But if there is a disturbance in that balance brought on by infectious illnesses, certain diets, or the prolonged use of antibiotics or other bacteria-destroying medications dysbiosis occurs, stopping these normal interactions. In this presentation the role of the microbiome as well as the virome in recurrent miscarriage will be discussed. Possible mechanism of action will be reviewed and, if available, treatment of a perturbed microbiome will be presented. Trial registration number XXXX

An overview of Clostridioides difficile and faecal microbiota transplant: implications for nursing practice.

Clostridioides difficile bacteria can cause excessive diarrhoea in patients, leading to further complications, such as severe dehydration and sepsis. Although C.difficile bacteria tend to reside harmlessly in many people's bowels, prolonged antibiotic use can alter the bacterial balance of the bowel resulting in a C.difficile infection. Guidance from the National Institute for Health and Care Excellence recommends treating a C.difficile infection with further antibiotic therapy; however, it also states that in cases of recurrent infection, a faecal microbiota transplant (FMT) should be considered. This article focuses on the treatment modality of FMT and is aimed at increasing awareness of the treatment. As well as discussing how the nurse can approach the topic with a patient considering FMT, the article also considers the nurse's role throughout the process.

Healthy Diet and Lifestyle Improve the Gut Microbiota and Help Combat Fungal Infection.

Western diets are rapidly spreading due to globalization, causing an increase in obesity and diseases of civilization. These Western diets are associated with changes in the gut microbiota related to intestinal inflammation. This review discusses the adverse effects of Western diets, which are high in fat and sugar and low in vegetable fiber, on the gut microbiota. This leads to gut dysbiosis and overgrowth of Candida albicans, which is a major cause of fungal infection worldwide. In addition to an unhealthy Western diet, other factors related to disease development and gut dysbiosis include smoking, excessive alcohol consumption, lack of physical activity, prolonged use of antibiotics, and chronic psychological stress. This review suggests that a diversified diet containing vegetable fiber, omega-3 polyunsaturated fatty acids, vitamins D and E, as well as micronutrients associated with probiotic or prebiotic supplements can improve the biodiversity of the microbiota, lead to short-chain fatty acid production, and reduce the abundance of fungal species in the gut. The review also discusses a variety of foods and plants that are effective against fungal overgrowth and gut dysbiosis in traditional medicine. Overall, healthy diets and lifestyle factors contribute to human well-being and increase the biodiversity of the gut microbiota, which positively modulates the brain and central nervous system.

D-Mannose for Recurrent Urinary Tract Infection Prevention in Postmenopausal Women Using Vaginal Estrogen: A Randomized Controlled Trial

(Abstracted from Urogynecology (Phila) 2023;29:367–377 Up to 25% of women experience recurring urinary tract infections, which are typically managed through long-term antibiotic prophylaxis intended for common urogenital pathogens. Unfortunately, prolonged use of antibiotics can lead to several adverse effects such as allergic reactions, sequelae from microbiome alterations, drug interactions/toxicities, and antibiotic resistance. One commonly prescribed prophylactic therapy, vaginal estrogen therapy (VET), is used as a first-line nonantibiotic therapy for rUTIs.

Antibiotic treatment duration for community-acquired pneumonia in children.

A 4-year-old child was seen in our clinic with a clinical presentation consistent with community-acquired pneumonia (CAP). He was prescribed oral amoxicillin and a colleague asked about the duration of treatment. What is the current available evidence for treatment duration for uncomplicated CAP in an outpatient setting? Previously the recommended duration of antibiotic treatment of uncomplicated CAP was 10 days. Recent evidence from several randomized controlled trials suggests that a 3- to 5-day duration is noninferior to a longer treatment course. In an effort to prescribe the shortest effective duration of antibiotics to minimize the risk of antimicrobial resistance associated with prolonged antibiotic use, family physicians should offer 3 to 5 days of appropriate antibiotics and monitor the recovery of children with CAP.

Antifungal Stewardship Programs in Children: Challenges and Opportunities.

Antifungal Stewardship Programs in Children: Challenges and Opportunities.

Prevalence, Severity and Associated Risk Indicators of Molar Incisor Hypomineralization amongst 8-13-year-old Children of Vadodara District Gujarat: A Cross-sectional Study.

Molar incisor hypomineralization (MIH) is an emerging clinical problem as the affected tooth is prone to dental caries with the lapse of time. To assess the prevalence, severity, and associated risk indicators of MIH amongst 8-13 years of children of Vadodara District, Gujarat, India. A cross-sectional study with a sample size of 3,000 government schoolchildren. A total of 1,500 children each from urban and rural areas were randomly selected and examined. Only permanent incisors and first molars were examined. MIH was diagnosed clinically based on the diagnostic criteria established by the European Academy of Paediatric Dentistry (EAPD), 2003. To check the relation between the two variables-Pearson's chi-squared test was applied. Fisher's exact test was applied when less than five expected values were found. A total of 286 children (9.6 %) had MIH, with 189 (rural) and 97 (urban) children. MIH was significantly higher in the rural population as compared to the urban. In the rural area, the cause was found to be a child suffering from an illness (>15 days) which was 35.98%, and in the urban area was due to prolonged use of antibiotics before 4 years of age, which was 28.87%. The overall prevalence rate of MIH among the screened children between the age-group 8 and 13 was found to be 9.6%. Males were more affected. The severity of MIH was more in molars compared to incisors and more in children of rural areas. Protocol for early diagnosis and follow-up to access the squeal of breakdown should be undertaken along with parents and health workers. Shah VU, Dave BH, Chari DN, et al. Prevalence, Severity and Associated Risk Indicators of Molar Incisor Hypomineralization amongst 8-13-year-old Children of Vadodara District Gujarat: A Cross-sectional Study. Int J Clin Pediatr Dent 2023;16(2):280-286.

Evidence-Based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-Site Infections in Plastic and Reconstructive Surgery.

After nearly a decade of new data, the Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons was updated for prophylactic systemic antibiotics to prevent surgical-site infections (SSI). Pharmacotherapeutic concepts using antimicrobial stewardship were applied for clinical interpretation and management to optimize patient outcomes and minimize resistance. PRISMA, Cochrane, and GRADE certainty of evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched for randomized controlled trials (RCTs). The authors included patients who had plastic and reconstructive surgery and were treated with prophylactic systemic antibiotics administered perioperatively (preoperatively, intraoperatively, or postoperatively). Comparisons were made between active interventions and nonactive interventions (placebo) at different prespecified durations to determine the development of an SSI. Meta-analyses were performed. The authors included 138 RCTs that met eligibility criteria. RCTs consisted of 18 breast, 10 cosmetic, 21 hand/peripheral nerve, 61 pediatric/craniofacial, and 41 reconstructive studies. The authors examined bacterial data extracted from studies for patients who did or did not take prophylactic systemic antibiotics for prevention of SSI. Clinical recommendations were provided using level I evidence. Surgeons have long been overprescribing systemic antibiotic prophylaxis in plastic and reconstructive surgery. Evidence supports antibiotic prophylaxis to prevent SSI for specific indications and durations. Prolonged antibiotic use has not been linked to reductions in SSIs, and misuse may increase the bacterial diversity of infections. Greater efforts should focus on transitioning from practice-based to pharmacotherapeutic evidence-based medicine. Therapeutic, II.

Interstate Practice Variation and Factors Associated with Antibiotic Use for Suspected Neonatal Sepsis in the United States.

This study aimed to estimate national time trends of overall and statewise antibiotic utilization (AU) rates for suspected neonatal sepsis (SNS) in the United States. In this cross-sectional study, we used retrospective linked birth cohort and vital records data from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research database for the years 2016 to 2020 and analyzed data containing antibiotic use for SNS. The primary outcome was proportional national and state-specific AU rates per 1,000 live births during the birth hospitalization. Secondary outcomes included overall trends and association between maternal education, race, sex, chorioamnionitis, mode of delivery, gestational age at birth, Apgar's scores, and insurance status with antibiotics exposure for SNS among newborns. Contingency tables, two-tailed t-test, and chi-square for independence tests were performed with statistical significance set at p < 0.05. For a birth cohort of >18 million, 2.2% of infants received antibiotics during birth hospitalization nationwide. There were wide variations in AU among U.S. states and territories, whereas overall treatment rates decreased by 16.1% (95% confidence interval [CI]: 15.2-17.0; p < 0.001). Compared with White newborns, Black newborns had higher AU rates (odds ratio [OR]: 1.33; 95% CI: 1.32-1.34), and Asians had the lowest rates (OR: 0.96; 95% CI: 0.95-0.97). There was a significant difference in mean AU rates by race (p < 0.001). Chorioamnionitis at birth significantly increased the odds for AU (OR: 14.5 ;95% CI: 14.4-14.6), although AU rates for chorioamnionitis showed a significant downward trend (OR: 0.52; 95% CI: 0.50-0.53) during the study period. Our findings suggest that there has been a gradual decline in AU for SNS in more than a third of states in last 5 years. While risk-based management approaches achieve widespread implementation, state- and nationwide quality improvement collaborates might have contributed to the relative decline in antibiotic use in newborns. Further studies are warranted to understand factors related to practice variation in the management of SNS in the United States KEY POINTS: · Early and prolonged use of antibiotics can lead to altered gut microbiome and adverse long-term neonatal outcomes.. · There is considerable clinical practice variation in antibiotic-prescribing practices for suspected neonatal sepsis.. · This cross-sectional study reports the differences in neonatal antibiotic usage patterns by region and maternal factors.. · Antibiotic use should be limited to newborns at high risk of infection and proven sepsis.. · Judicious use of antibiotics can be promoted by following evidence-based approaches to sepsis risk assessment..

50. Evidence-based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-site Infections in Plastic and Reconstructive Surgery

PURPOSE: After nearly a decade of new data, the Evidence-Based Consensus Conference Statement from the AAPS was updated for prophylactic systemic antibiotics to prevent surgical site infections (SSI). Pharmacotherapeutic concepts using antimicrobial stewardships were applied for clinical interpretation and management to optimize patient outcomes and minimize resistance. METHODS: PRISMA, Cochrane, and GRADE certainty of evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched for randomized controlled trials (RCTs). We included patients that had Plastic and Reconstructive Surgery and were treated with prophylactic systemic antibiotics administered perioperatively (preoperative, intraoperative, postoperative). Comparisons were made between active interventions and/or non-active interventions (placebo) at different prespecified durations to determine the development of an (SSI). Meta-analyses were performed. RESULTS: We included 138 RCTs that met eligibility criteria. RCTs consisted of 18 Breast, 10 Cosmetic, 21 Hand/Peripheral Nerve, 61 Pediatric/Craniofacial, and 41 Reconstructive studies. We further examined bacterial data extracted from studies for patients that did and did not take prophylactic systemic antibiotics for prevention of SSI. Clinical recommendations were provided using Level-I evidence. CONCLUSION: Surgeons have long been overprescribing systemic antibiotic prophylaxis in Plastic and Reconstructive Surgery. Evidence supports antibiotic prophylaxis to prevent SSI for specific indications and durations. Prolonged antibiotic use has not been linked to reductions in SSIs and misuse may increase the bacterial diversity of infections. Greater efforts should focus on transitioning from practice-based medicine to pharmacotherapeutic evidence-based medicine.

Nightmare in the ward: difficult Clostridioides infection.

Clostridioides difficile is a Gram-positive, anaerobic, spore-forming bacillus. It is isolated in 80% of the stools of children and infants and in 3% of healthy adults. It causes gastrointestinal tract infections and affects patients who make prolonged use of antibiotics. It causes C. difficile colitis with symptoms ranging from diarrhoea to pseudomembranous colitis to toxic megacolon. The main virulence factors of C. difficile are toxin A, toxin B, and binary toxin. It is one of the most common nosocomial infections but in recent years, however, many infections have also been found at the community level. They are associated not only with a high risk of mortality but also with a prolongation of hospital stay. One of the critical aspects of C. difficile infections is also represented by the high frequency of relapses. Consequently, the economic impact is significant. Specific situations constitute risk factors for infection, such as exposure to antibiotic therapy in the previous months, in particular fluoroquinolones, third-generation cephalosporins, clindamycin, repeated hospitalizations in healthcare facilities, including long-term care, as well as the patient's clinical conditions such as comorbidities, age >65, chemotherapy and immunosuppressive treatments, recent surgery of any type, and pump inhibitor therapy. Treatment protocols will be described in the paper.