Prophylactic Antibiotic Protocol Research Articles

What is the optimum antibiotic prophylaxis in patients undergoing implantation of a left ventricular assist device?

A best evidence topic was written according to a structured protocol. The question addressed was what the optimum antibiotic prophylaxis in patients undergoing implantation of a left ventricular assist device (LVAD) is. A total of 373 papers were found, of which 11 represented the best evidence. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Eight retrospective and two prospective studies, including one randomized controlled trial (RCT), were identified. Although highly variable, the prophylactic antibiotic protocols employed in these studies generally favour the use of vancomycin, a cephalosporin, beta-lactam and quinolone, with the option of additional fluconazole and mupirocin. However, the lack of standardized definitions for infection, and variations in the choice, timing and duration of prophylactic antibiotics complicates the interpretation of reported infection rates. Driveline and pocket infections comprised the majority of infectious complications, and were principally attributed to Gram-positive organisms, such as Staphylococcus, as well as Pseudomonas species. We conclude that a beta-lactam be used for primary prophylaxis, with vancomycin where the risk of MRSA is high. Topical mupirocin and an anti-fungal are also recommended. Prophylaxis should commence prior to device insertion, and be continued into the peri- and post-operative period. Large-scale RCTs are necessary to assess the impact of different antibiotic regimens on infection within LVAD recipients.

Changing Prophylactic Antibiotic Protocol for Reducing Clostridium Difficile—Associated Diarrhoeal Infections

To determine whether a change in prophylactic antibiotic protocol for orthopaedic surgeries may reduce the frequency of Clostridium difficile-associated diarrhoeal infections. Records of 1331 patients who underwent trauma or elective surgeries involving implantation of metalwork were reviewed. 231 trauma and 394 elective patients who received intravenous cefuroxime-based antibiotic prophylaxis between August 2006 and January 2007 were compared with 216 trauma and 490 elective patients who received a single dose of gentamicin and flucloxacillin or teicoplanin for antibiotic prophylaxis between August 2007 and January 2008. Diarrhoeal faecal specimens of 148 (33%) trauma patients and 106 (12%) elective patients were examined. The outcome variables were the rates of C difficile infection and early deep wound infection. There were 32 cases of C difficile-associated diarrhoeal infection and 28 cases of early deep wound infection. The frequency of C difficile-associated diarrhoeal infection decreased after use of the new antibiotic protocol (from 4 to 1%, p = 0.004), particularly in the trauma patients (from 8 to 3%, p = 0.02); in the elective patients the difference was not significant (from 1 to 0.5%, p = 0.27). The change of antibiotic protocol did not significantly affect the incidence of deep wound infections in the trauma (p = 0.46) or elective (p = 0.90) patients. The rate of C difficile infection was 8-fold higher in the trauma than elective patients, both before and after the change of protocol. Changing antibiotic protocol is one way of reducing the incidence of C difficile-associated diarrhoeal infections in orthopaedic patients, without increasing the rate of deep wound infections.

Impact of bloodstream infections on outcome and the influence of prophylactic oral antibiotic regimens in allogeneic hematopoietic SCT recipients

This study aimed to determine the impact of blood stream infections (BSIs) on outcome of allogeneic hematopoietic SCT (HSCT), and to examine the influence of old (non-levofloxacin-containing) and new (levofloxacin-based) prophylactic antibiotic protocols on the pattern of BSIs. We retrospectively enrolled 246 allogeneic HSCT recipients between January 1999 and June 2006, dividing patients into BSI (within 6 months post-HSCT, n=61) and non-BSI groups (n=185). We found that Gram-negative bacteria (GNB) predominated BSI pathogens (54%). Multivariate analyses showed that patients with a BSI, compared with those without, had a significantly greater 6-month mortality (hazard ratio, 1.75; 95% confidence interval, 1.09-2.82; P=0.021) and a significantly increased length of hospital (LOH) stay (70.8 vs 55.2 days, P=0.014). Moreover, recipients of old and new protocols did not have a significantly different 6-month mortality and time-to-occurrence of BSIs. However, there were significantly more resistant GNB to third-generation cephalosporins and carbapenem in recipients of levofloxacin-based prophylaxis. Our data suggest that BSIs occur substantially and impact negatively on the outcome and LOH stay after allogeneic HSCT despite antibiotic prophylaxis. Levofloxacin-based prophylaxis, albeit providing similar efficacy to non-levofloxacin-containing regimens, may be associated with increased antimicrobial resistance.

Perioperative Antibiotic Process Improvement Reaps Rewards

Recent health care improvement initiatives have linked financial payments to compliance with predetermined performance measures. This article reports the effect of a unique prophylactic antibiotic use program on compliance rates and costs. The Departments of Surgery, Infection Control, and Anesthesiology collaborated on a prophylactic preoperative antibiotic protocol, whereby Anesthesiology assumed responsibility for timely antibiotic prophylaxis (TAP) before surgical incision. Data from January 1, 2008, to December 31, 2008, were compared (z test) with the 12-month period before this change. χ(2) Analysis identified factors associated with TAP. Return on investment (ROI) was calculated. TAP compliance rates increased from 75.1% to 89.3% (P < .001) following program implementation. Factors associated with TAP failure included >60 minutes from anesthesia induction to surgical incision (P < .001), surgical procedure (P < .001), specific antibiotic administered (P < .001), and individual anesthesia provider (P < .001). The ROI was 2.2. TAP compliance rates increased after Anesthesiology assumed responsibility, with anesthesia providers being a significant factor.

Postoperative infections and antibiotic prophylaxis for hysterectomy in Sweden: a study by the Swedish National Register for Gynecologic Surgery

The purpose of the study was to evaluate the current use of antibiotic prophylaxis, the rate of postoperative infections, and risk factors for postoperative infections in patients undergoing elective hysterectomy for non-malignant pathology. The study was performed during the time period July 2000 to 1 January 1 2003, using data from the Swedish National Register for Gynecologic Surgery, covering 26 of 49 clinics and approximately 50% of the Swedish population. During this time period, 3267 women undergoing elective hysterectomy for non-malignant pathology (mainly dysfunctional bleeding and fibromas) and with complete data on the use of antibiotic prophylaxis and postoperative follow up were included. A postoperative infection was considered to have developed if patients or the physician reported an infection related to the surgical site, together with reported use of antibiotic treatment. Among the 3267 patients, 341 (10.4%) were considered to have developed a postoperative infection. In cases where antibiotic prophylaxis had not been given, total abdominal hysterectomies and vaginal hysterectomies were associated with the highest frequency for postoperative infections P < 0.05 and P < 0.01, respectively. Notably, also women undergoing subtotal hysterectomy reported significantly lower rates of postoperative infections if prophylactic antibiotics had been given, P < 0.05. Risk factors for postoperative infection were non-use of antibiotic prophylaxis, hospital, age less than 40 years, and BMI > 30 kg/m(2). The study results have indicated the need of prospective clinical trials on antibiotic prophylaxis for patients undergoing supravaginal abdominal hysterectomy. Also, a need to further evaluate the current prophylactic antibiotic protocols used for obese patients and younger women undergoing any kind of hysterectomy is warranted.

Continuous peritoneal dialysis-associated peritonitis: a review and current concepts.

The percentage of end-stage renal disease (ESRD) patients in the United States maintained on continuous peritoneal dialysis (CPD) therapy is decreasing. Complications from CPD therapy, including peritonitis, may be the reason for the decline. Improvements in CPD technology and a better understanding of the risk factors that predispose patients to the development of peritonitis have been responsible for a decline in the rate of peritonitis. Yet peritonitis remains a significant cause of patient morbidity and mortality and the overall outcome of peritonitis is not acceptable. Factors that have limited our ability to lessen the impact of peritonitis include a lack of data on dosing antibiotics in patients on continuous cycling peritoneal dialysis (CCPD) therapy, a lack of knowledge concerning the biology of bacterial biofilm, and the development of resistance to the current prophylactic antibiotic protocols. Further studies are needed concerning the optimal management of the peritoneal catheter and whether it is feasible to resume CPD therapy after catheter removal.

The successful use of antibiotic prophylaxis in selected high-risk surgical patients under non-trial, everyday conditions

The use of prophylactic antibiotic protocols in the control of wound infection in high-risk surgical patients under everyday ward conditions was evaluated over a period of between one and three years. Patients undergoing hip or large bowel surgery, caesarian section or hysterectomy, had the highest wound infection rates and were chosen as the target groups for intervention. The overall reduction in wound infection rates in all the groups after intervention was from 12·7 to 7·4 per cent. Reduction in wound infection rates varied in each group: in hip surgery from 25·7 to 1·2 per cent, in caesarian section from 10·5 to 5·1 per cent and in abdominal hysterectomy from 9·0 to 3·2 per cent. Not all patients within each group were similarly affected. When subdivided into different risk groups, patients in the highest risk group generally showed little, if any, reduction in wound infection rate. The length of postoperative stay was shortened considerably after the introduction of the protocol for hip surgery and abdominal hysterectomy. Although the proportion of patients who received prophylactic antibiotics increased after the introduction of the protocols there was a concomitant decrease in the total amount of antibiotics used.