Prophylactic Antibiotic Treatment Research Articles

Efficacy of intramuscular penicillin in the eradication of group B streptococcal colonization at delivery

Objective. Due to rapid deliveries and human error, not all group B streptococcal positive mothers will receive adequate prophylactic antibiotic treatment in labor. We sought to determine if long acting intramuscular penicillin given after a positive culture result would be efficacious in eradicating group B streptococcal colonization at the time of delivery.Methods. Patients positive for group B streptococci at 35–37 weeks were randomized to receive 2.4 million units of intramuscular benzathine penicillin G suspension (Bicillin® L-A) versus no treatment. Study patients were recultured at the time of admission to labor and delivery prior to receiving prophylactic antibiotics according to CDC guidelines.Results. A total of 53 patients were enrolled. A small but significant decrease in the rate of group B streptococcal colonization was observed in the treatment group (14/27, 52%) versus the control group (20/23, 87%), p = 0.03.Conclusion. The large number of persistent carriers suggests that 2.4 million uni...

Post-traumatic endophthalmitis after penetrating injury in Vietnam: risk factors, microbiological aspect and visual outcome

Post-traumatic endophthalmitis associated with penetrating injury represents a distinct kind of intraocular infection and is still a severe problem for diagnosis and treatment in developing countries. We report the incidence, microbiological presentation and visual outcome of post-traumatic endophthalmitis in South Vietnam. In a retrospective study medical reports of 515 patients with penetrating injury treated at Eye Hospital in Ho Chi Minh city, Vietnam, from 1/1999 to 5/2000 were reviewed and analysed. The treatment was standardised: 1. after vitreous-biopsy intravitreous injection of 0.1 mg/0.1 ml Gentamycine and 1 mg/0.1 ml Vancomycine; 2. subconjunctival injection of 25 mg/0.5 ml Vancomycine and 20 mg/0.5 ml Gentamycine; 3. topical and systemic antibiotic treatment due to microbiological presentation; 4. systemic steroids treatment. Clinical parameters were evaluated for association with an increased risk of endophthalmitis. Out of 515 patients with penetrating injury 61 patients (11.8 %) with endophthalmitis were treated and evaluated. Mean time interval from trauma to diagnosis of endophthalmitis was 16.8 +/- 5.6 days. Follow-up period was 15.6 +/- 23.4 days. Visual acuity at the diagnosis of endophthalmitis in 96 % of all patients was only finger counting or light perception. Enucleation was needed in 14 % of patients, 29 % of patients developed phthisis bulbi. A visual acuity better than finger counting was reached in only 10 % of all patients with endophthalmitis. Cultures of the vitreous aspirate were positive in only 50 % of cases available and showed Gram-positive (51 %), Gram-negative bacteria (33 %) and fungi (16 %). Risk factors found to be significant were: 1. a purely corneal wound; 2. wound length less than 5 mm; 3. surgical primary repair more than 24 hour after trauma; 4. inadequate antibiotic treatment and 5. a rural injury setting. Post-traumatic endophthalmitis is still a major problem in Vietnam. Delay in primary wound closure or inadequate antibiotic treatment worsen the prognosis profoundly. Comprehensive prophylactic antibiotic treatment at the time of injury repair is in dispensable. In risk eyes particular attention should be paid to prophylaxis and signs of infection. Further prospective studies are necessary to develop optimal and adequate diagnostic and treatment options in Vietnam.

Percutaneous endoscopic gastrostomy to set up a long-term enteral feeding route in children: an encouraging result.

Percutaneous endoscopic gastrostomy (PEG) is now accepted as the preferred technique to establish long-term enteral feeding. A total of 30 pediatric patients (21 males and 9 females, aged from 5 months to 14 years) underwent PEG in the National Taiwan University Hospital from December 1994 to February 2001. The underlying diseases of the patients receiving PEG were neurological dysfunction ( n=26), gastrointestinal disease ( n=2) and metabolic disorders ( n=2). All patients received intravenous sedation and PEG was performed successfully. Prophylactic antibiotic treatment was given for 1 day. Tube feeding began 48 h after the placement. The Z-score of weight before and 6 months after PEG was -1.54+/-1.74 and -0.98+/-1.46, respectively, which is significant (paired t-test, p<0.0001). Accelerated weight gain was found after PEG. Complications of PEG in our patients included local wound infection ( n=15), gastrocolic fistula ( n=1), pneumoperitoneum ( n=1), dislodgement of tube ( n=6) and tube occlusion ( n=2). Of these patients 12 received button replacement after PEG and the gastrostomy tube was discontinued in 2 patients when they resumed adequate oral intake. Removal of PEG was performed in 2 patients due to complications of gastrocolic fistula and severe dislodgement. Our results encourage the use of PEG as a long-term route for nutritional supply.

Antibiotic prophylaxis in severe acute pancreatitis: Randomized multicenter prospective study with meropenem

Nowadays, most deaths in acute pancreatitis are caused by infection, thus the role of prophylaxis of infectious complications in, severe acute pancreatitis (SAP) still remains a debatable issue. Aim: The aim of the study was to assess the efficacy of prophylactic antibiotic treatment comparing rates of local and infectious complications, mean hospital stay, necessity of surgical treatment and mortality in two groups of patients with SAP Methods: Fourty one patients with SAP were enrolled into the randomized muhicenter prospective study according to the clinical criteria defined at the Atlanta symposium or CRP level exceeding 190 rag/1. The patients were randomized either into the prophylactic (P) or into the therapeutic (T) groap In the P-group, meropenem 500 nag was administrated every 8 hours for 10 days. In the T-group, the patients received the same antibiotic treatment only in the case of confirmed infectious complications (infected necrosis, abscess, urinary infection, pneumonia, catheter related bacteriemia etc.). Results are summarized in the table. Conclusions: Prophy~ hctic antibiotic treatment reduces the rate of infectious complications in patients with SAP. Although it does not decrease overall mortality, antibiotic prophylaxis can be recommended in patients with SAP.

Current Indications for Transurethral Resection of the Prostate and Associated Complications

Transurethral resection of the prostate (TURP) is the most common surgical procedure for relieving symptoms of benign prostatic hyperplasia. Here, we report our experience of current indications for TURP and their associated outcomes at Kaohsiung Medical University Hospital (KMUH). A total of 111 patients who underwent TURP at KMUH between May 2000 and December 2001 were included in this retrospective review. For each patient, the surgical indication was categorized into acute urinary retention, chronic complications (including renal impairment, recurrent urinary infection, bladder stone/diverticulum, post-void residue, and recurrent hematuria), and symptomatic prostatism. Thirty-five patients (31%) had acute urinary retention, 28 (27%) had chronic complications, and 48 (42%) had symptomatic prostatism. Most patients chose TURP only when medical treatment had failed to relieve symptoms, no matter what category they belonged to. Patients with acute urinary retention and chronic complications had larger prostates (p = 0.002) and more tissue resected (p = 0.05) than those with symptomatic prostatism. Patients with acute urinary retention seemed to be at greater risk of postoperative complications such as recurrent urinary retention and urinary tract infection. We suggest that urodynamic study may be necessary to rule out concomitant bladder dysfunction before surgery and that adequate prophylactic antibiotic treatment be used to decrease the risk of urinary tract infection during or after TURP, especially when pyuria is noted preoperatively in patients with acute urinary retention.

Management of infection in acute pancreatitis.

The clinical course of acute pancreatitis varies from a mild, transitory illness to a severe, rapidly fatal disease. In about 80% to 90% of cases pancreatitis presents as a mild, self-limiting disease with low morbidity and mortality. Unlike mild pancreatitis, necrotizing pancreatitis develops in about 15% of patients, with infection of pancreatic and peripancreatic necrosis representing the single most important risk factor for a fatal outcome. Infection of pancreatic necrosis in the natural course develops in the second and third week after onset of the disease and is reported in 40% to 70% of patients with necrotizing pancreatitis. Just recently, prevention of infection by prophylactic antibiotic treatment and assessment of the infection status of pancreatic necrosis by fine-needle aspiration have been established in the management of severe pancreatitis. Because medical treatment alone will result in a mortality rate of almost 100% in patients with signs of local and systemic septic complications, patients with infected necrosis must undergo surgical intervention, which consists of an organ-preserving necrosectomy combined with a postoperative closed lavage concept that maximizes further evacuation of infected debris and exudate. However, intensive care treatment, including prophylactic antibiotics, reduces the infection rate and delays the need for surgery in most patients until the third or fourth week after the onset of symptoms. At that time, debridement of necrosis is technically easier to perform, due to better demarcation between viable and necrotic tissue compared with necrosectomy earlier in the disease. In contrast, surgery is rarely needed in the presence of sterile pancreatic necrosis. In those patients the conservative approach is supported by the present data.

Chlamydia trachomatis in subfertile women undergoing uterine instrumentation: an alternative to direct microbial testing or prophylactic antibiotic treatment.

Chlamydia trachomatis is the major cause of tubal occlusion, and is also associated with IVF failure and spontaneous abortion. These infections are asymptomatic in most individuals and can persist in the genital tract for long periods of time in a form resistant to immune destruction. A significant percentage of couples seeking treatment for infertility might, therefore, harbour C. trachomatis in their genital tract. An unresolved question is what to do about this possible chlamydial persistence. Cervical, endometrial and semen samples can be tested for C. trachomatis and only positive individuals treated. Alternatively, all couples undergoing infertility treatment can receive prophylactic antibiotics. We advocate a third option, to screen and treat only individuals who are positive for systemic and/or local anti-chlamydial antibody production. Detection of species-specific C. trachomatis antibodies in peripheral blood will determine which individuals have been exposed to this organism and who, therefore, may be at risk for harbouring persistent forms. Identification of IgA antibodies in genital tract secretions may be an even better indicator of the presence of C. trachomatis in the genital tract. Circulating antibodies to the chlamydial 60kDa heat shock protein (hsp60) is a specific indicator of tubal occlusion and, furthermore, correlates with the continued presence of this micro-organism in the genital tract of non-human primates. Screening for both cervical IgA antibodies to C. trachomatis and serum IgG anti-chlamydial hsp60 appears to provide the best indication as to which women may be harbouring C. trachomatis.

Antibiotic prophylaxis for cesarean section.

The single most important risk factor for postpartum maternal infection is cesarean delivery. The objective of this review was to assess the effects of prophylactic antibiotic treatment on infectious complications in women undergoing cesarean delivery. We searched the Cochrane Pregnancy and Childbirth Group trials register (January 2002) and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001). Randomized trials comparing antibiotic prophylaxis or no treatment for both elective and non-elective cesarean section. Two reviewers assessed trial quality and extracted data. Eighty-one trials were included. Use of prophylactic antibiotics in women undergoing cesarean section substantially reduced the incidence of episodes of fever, endometritis, wound infection, urinary tract infection and serious infection after cesarean section. The reduction in the risk of endometritis with antibiotics was similar across different patient groups: the relative risk (RR) for endometritis for elective cesarean section (number of women = 2037) was 0.38 (95% confidence interval (CI) 0.22 to 0.64); the RR for non-elective cesarean section (n = 2132) was 0.39 (95% CI 0.34 to 0.46); and the RR for all patients (n = 11,937) was 0.39 (95% CI 0.31 to 0.43). Wound infections were also reduced: for elective cesarean section (n = 2015) RR 0.73 (95% CI 0.53 to 0.99); for non-elective cesarean section (n = 2780) RR 0.36 95% CI 0.26 to 0.51]; and for all patients (n = 11,142) RR 0.41 (95% CI 0.29 to 0.43). The reduction of endometritis by two thirds to three quarters and a decrease in wound infections justifies a policy of recommending prophylactic antibiotics to women undergoing elective or non-elective cesarean section.

Methicillin-resistant Staphylococcus aureus infection in a cardiac surgical unit.

Increased antibiotic resistance of common bacteria is attributed in part to the widespread use of various antibiotic agents. Prophylactic and therapeutic antibiotic treatments are routinely used in cardiac surgical units, and it is no surprise that methicillin-resistant Staphylococcus aureus infection is becoming a major cause of surgical infections in cardiac patients. We reviewed our experience with patients who underwent cardiac surgery and experienced infection caused by methicillin-resistant Staphylococcus aureus. Between 1992 and 2000 at the Montreal Heart Institute, 39 patients had methicillin-resistant Staphylococcus aureus surgical infections, and 13,199 patients underwent cardiac surgery. The yearly incidence of methicillin-resistant Staphylococcus aureus infection, the relative risk of acute mediastinitis and of superficial wound infections or other types of methicillin-resistant Staphylococcus aureus infection episodes, and the effect of preventive measures were analyzed. The annual incidence of methicillin-resistant Staphylococcus aureus acute mediastinitis decreased from 0.37% (5/1321) of cardiac patients in 1992 and 0.44% (6/1355) in 1993 to 0% between 1994 and 1997, 0.13% (2/1528) in 1999, and 0% (0/1700) in 2000. The total incidence of methicillin-resistant Staphylococcus aureus infection, including mediastinitis, superficial and deep sternal and leg wound infection, and all systemic infection episodes ranged from 0.68% of patients in 1992 and 0.96% of patients in 1993 to 0.46% of patients in 1999 and 0.53% of patients in 2000. The relative risk of severe mediastinal methicillin-resistant Staphylococcus aureus infection to all other methicillin-resistant Staphylococcus aureus infection episodes decreased from 1.65 in 1992 to 0.41 in 1999 and 0 in 2000. Beginning in 1993, all patients given a diagnosis methicillin-resistant Staphylococcus aureus infection and all nasal carriers of methicillin-resistant Staphylococcus aureus were strictly isolated on the surgical unit, and vancomycin was used as the prophylactic antibiotic agent for cardiac surgery in these patients. Moreover, since 1998, all patients admitted in the hospital were screened, and nasal carriers were isolated and treated with topical antibiotic ointment. Mediastinal and other infections caused by methicillin-resistant Staphylococcus aureus have a significant morbidity in cardiac surgical patients. After an outbreak of methicillin-resistant Staphylococcus aureus mediastinal infections, several preventive measures to control methicillin-resistant Staphylococcus aureus contamination of surgical patients were implemented (nasal screening, preventive isolation, application of mupirocin, prophylaxis with vancomycin and alcohol gels) and were effective in decreasing the incidence of methicillin-resistant Staphylococcus aureus infection and mediastinitis after cardiac surgery.

Total cervix occlusion--an efficient measure in prolapsed amniotic membranes in extreme prematurity?

We analysed retrospectively whether the total cervix occlusion implicates efficient the prolongation of pregnancy in patients with bulging fetal membranes during extreme prematurity. Between 1993 and 1999 nineteen pregnant women (17 singleton and 2 twin pregnancies) with cervical incompetence and bulging membranes at 20 to 27 weeks' gestation (mean 24 weeks) underwent total cervix occlusion (TCO) at the Department of Obstetrics at the Technische Universität of Munich after taking cervical cultures, prophylactic antibiotic treatment, tocolysis and induction of fetal lung maturity (after 33 weeks of gestational age). Eleven of nineteen pregnancies were carried beyond 32 weeks' gestation. 6 of 21 fetuses, included 2 twin pregnancies died. Considering the perinatal mortality the mean prolongation of pregnancy was 9.4 weeks after total cervix occlusion. 9 of 19 pregnant women were delivered beyond 37 weeks of gestational age. Taking the small number and the lack of a randomized trial into consideration, these results implicate the total cervix occlusion as an efficient method in cases of bulging membranes during extreme prematurity. Nevertheless a thorough postoperative control and screening of infectious complications are required.

Pancreatic infection in severe pancreatitis: the role of fungus and multiresistant organisms.

Recent controlled clinical studies suggest a positive effect of early antibiotic treatment on late morbidity and mortality in severe acute pancreatitis. However, widespread use of antibiotics may lead to an increased number of fungal infections and multiresistant bacteria, thereby worsening the outcome of the disease. Single-center prospective study. University hospital, gastrointestinal surgical service. One hundred three patients with necrotizing pancreatitis seen consecutively in our service. In addition to standard treatment, patients with proven necrotizing pancreatitis received a prophylactic intravenous antibiotic treatment. Pancreatic infection was regarded as an indication for surgery. Pancreatic infection, microbiological findings, drug resistance, fungal infections. Thirty-three patients (32%) had infected necrosis. Gram-negative organisms were isolated from 19 patients (58%), Gram-positive organisms were isolated from 18 patients (55%), fungal organisms were isolated from 8 patients (24%), and multiresistant organisms were isolated from 3 patients (9%). In 7 patients (21%), the organisms cultured from the pancreatic tissue were resistant to the antibiotics given in for prophylaxis. Infection with multiresistant organisms or organisms resistant to the antibiotic used for prophylaxis, but not with fungal infection or Gram-positive or Gram-negative infection, was correlated with a negative outcome. Fungal infection under adequate treatment is not associated with a negative outcome. The occurrence of multiresistant organisms seems to be a rare finding (3 of 103 patients). Antibiotic prophylaxis is effective in preventing infection in necrotizing pancreatitis, but optimal choice and duration of administration of the antibiotic agent(s) need to be carefully determined to avoid the sequelae of multiresistant organisms.

Morbidity and Discomfort of Ten-Core Biopsy of the Prostate Evaluated by Questionnaire

Transition zone biopsies have been found to increase the detection rates of cancer of the prostate in patients with negative digital rectal examination. There are however no data available whether the higher biopsy rate is associated with greater morbidity. The present study was therefore designed to evaluate the complication rate of extended sextant biopsy. In this prospective study, 162 consecutive patients who presented for prostatic evaluation were included. After starting prophylactic antibiotic treatment 48 h prior to the procedure, transrectal ultrasound-guided core biopsies were obtained from each lobe: three each from the peripheral zone (apex, mid-zone and base) and two from the transition zone of each prostatic lobe. In all patients a questionnaire was obtained 10–12 days after the procedure. Major complications occurred in 3 patients. In 2 of the 3 cases major macroscopic hematuria was treated by an indwelling catheter for 1 or 2 days and 1 patient developed fever >38.5°C for 1 day. Minor macroscopic hematuria was present in 68.5% of the patients. In 17.9% of these cases, the hematuria lasted for more than 3 days. Hematospermia was observed in 19.8% and minor rectal bleeding occurred in 4.9%. Ten-core biopsies did not lead to an increase in adverse effects or complications when compared to the results of sextant biopsies reported in the literature.

The value of a screen and treat policy for Chlamydia trachomatis in women attending for termination of pregnancy

We aimed to assess the efficacy of a screen and treat policy for sexually transmitted infections in women requesting termination of pregnancy, with particular reference to Chlamydia trachomatis. A retrospective...

Invasive urodynamic studies are well tolerated by the patients and associated with a low risk of urinary tract infection.

An essential part of investigation of the lower urinary tract is pressure/flow studies (pQS). In fact, pQS is the only way of diagnosing bladder outlet obstruction. There is controversy regarding whether or not prophylactic antibiotic treatment is necessary. This prospective study was carried out in order to determine the frequency of infections and/or distress after pQS performed without the use of antibiotic prophylaxis. One hundred and twenty-three patients were included in the present study, all males. They were requested to answer a questionnaire I week after pQS. Questions were asked concerning symptoms of voiding disorders, dysuria, hematuria, incidence of fever and the patient's acceptance of the investigation after the pQS procedure. Urine was obtained for culture immediately before the investigation and 3 and 7 days after the pQS. Forty-six per cent of the patients experienced some degree of transient dysuria after pQS. and 18.5% experienced voiding problems of varying nature. Five per cent of the patients had hematuria and 2.5% reported fever. Fifty per cent of the patients experienced some degree of discomfort during the pQS investigation, and 4.1% had positive culture and symptoms of UTI requiring antibiotic treatment. PQS is well accepted by the patients and the regular use of propylactic antibiotics is not indicated. We recommend, though, that patients at risk for serious complications from infections (e.g. those with prosthetic heart valves) should receive prophylactic antibiotics.

Single administration of thrombopoietin to lethally irradiated mice prevents infectious and thrombotic events leading to mortality.

A sufficiently high dose of thrombopoietin to overcome initial c-mpl-mediated clearance stimulates hematopoietic reconstitution following myelosuppressive treatment. We studied the efficacy of thrombopoietin on survival after supralethal total body irradiation (9 Gy) of C57BL6/J mice and the occurrence of infectious and thrombotic complications in comparison with a bone marrow graft or prophylactic antibiotic treatment. Administration of 0.3 microg thrombopoietin, 2 hours after irradiation, protected 62% of the mice as opposed to no survival in placebo controls. A graft with a supraoptimal number of syngeneic bone marrow cells (10(6) cells) fully prevented mortality, whereas antibiotic treatment was ineffective. Blood cell recovery was observed in the thrombopoietin-treated mice but not in the placebo or antibiotic-treated group. Bone marrow and spleen cellularity as well as colony-forming unit granulocyte-macrophage and burst-forming unit erythroid were considerably increased in thrombopoietin-treated mice relative to controls. Histologic examination at day 11 revealed numerous petechiae and vascular obstructions within the brain microvasculature of placebo-treated mice, which was correlated with hypercoagulation and hypofibrinolysis. Thrombopoietin treatment prevented coagulation/fibrinolysis disorder and vascular thrombosis. High fibrinogen levels were related to bacterial infections in 67% of placebo-treated mice and predicted mortality, whereas the majority of the thrombopoietin-treated mice did not show high fibrinogen levels and endotoxin was not detectable in plasma. We conclude that thrombopoietin administration prevents mortality in mice subjected to 9-Gy total body irradiation both by interfering in the cascade leading to thrombotic complications and by amelioration of neutrophil and platelet recovery and thus protects against infections and hemorrhages.

The effectiveness of tobramycin and Ocuflox® in a prophylaxis model of Staphylococcus keratitis

Purpose. To determine the effectiveness of prophylactic antibiotic treatment prior to intra-corneal infection with Staphylococcus aureus. Methods. One topical drop of Tobrex ® (0.3% tobramycin), tobramycin (0.3%) in the Tobrex ® vehicle with 0.05% dodecyl maltoside (DDM)/4.0% hydroxypropylmethycellulose (HPMC), Ocuflox ® (0.3% ofloxacin) or DDM/HPMC vehicle were applied to rabbit eyes at one or five hours prior to injection of bacteria. Approximately 500 colony-forming units (CFU) of S. aureus strain 8325-4 were injected into the corneal stroma. Rabbits were sacrificed five hours after infection and corneal homogenates were cultured to determine the number of colony forming units (CFU) per cornea. Results. Rabbits treated at five hours prior to infection with tobramycin-DDM/HPMC reduced the bacterial load by approximately 2.4 log CFU/cornea as compared to the untreated control (3.47 ± 0.98 vs. 5.71 ± 0.14 log CFU/cornea, respectively; P = 0.0010); however, Ocuflox ®, Tobrex ®, or DDM/HPMC vehicle did not significantly reduce the log CFU (P = 0.4837). Rabbits treated at 1 hour prior to infection with Ocuflox ® or tobramycin-DDM/HPMC had significantly reduced CFU/cornea (1.31 ± 0.86 and 0.48 ± 0.31 log CFU/cornea, respectively) as compared to the untreated group (5.71 ± 0.14 log CFU/cornea; P = 0.0001). Neither Tobrex ® nor the DDM/HPMC vehicle significantly reduced the CFU/cornea compared to the untreated group (P = 0.2312). Conclusions. This pre-treatment model of Staphylococcus keratitis quantitatively measured the prophylactic effectiveness of topical antibiotic formulations. An important finding was that a tobramycin-DDM/HPMC formulation was highly effective as a prophylactic medication.

Effect of antibiotic therapy in preterm premature rupture of the membranes on neonatal mortality and morbidity.

The objective of this study was to evaluate the effect of prophylactic antibiotic treatment on prenatal and neonatal outcome after preterm premature rupture of the membranes (P-PROM). The study population consisted of 172 pregnant women admitted to the Rabin Medical Center in Israel with P-PROM at 23-34 gestational weeks. The patients were divided into two groups by mode of expectant management-prophylactic ampicillin and erythromycin (study group, n = 121) or observation only (control group, n = 51) and compared for neonatal outcome. There were no significant differences between the groups in age, gravidity, parity, or gestational age at admission. Significantly more women in the study group had an interval of more than 24 hours from onset of P-PROM to delivery (98 women, 81%) than the control group (32 women, 63%) (p = 0.001). The neonatal mortality rate was significantly lower in the study group (6.6%) than the control group (1 7.6%) (p = 0.03). The lower neonatal mortality rate associated with prophylactic antibiotic treatment in P-PROM has important clinical implications for the effectiveness of this type of management.

Endoscopic CO 2 Laser Therapy of Zenker's Diverticulum - Experience from 61 Patients

Endoscopic laser resection of hypopharyngeal diverticula has been used in the ENT Department, Odense, Denmark, since 1989. The outcome of treatment is reported in this presentation. Of the 61 patients, 32 (52%) were males. Age at operation was 72 years (median), range 37-94 years. The diagnosis in all patients was confirmed by barium radiography of the hypopharynx and the oesophagus. A Benjamin-Hollinger diverticuloscope was used for viewing the tissue bridge separating the diverticulum and the oesophagus. The tissue bridge was cut from the apex to the base using a CO 2 laser. Perioperative complications were seen in 6 patients: Bleeding (1), subcutaneous emphysema without (3) or with (1) inflammation, inflammation without emphysema (1). The duration of postoperative nasogastric feeding was 2 days (median) (range 1-11 days). Fifty-four patients received prophylactic antibiotic treatment for a median of 3 days (range 0.5-13 days). The duration of postoperative hospitalization was 3 days (median), range 2-14 days. The patients were routinely examined 2-3 months postoperatively. There were recurrences in 6 patients (10%), all successfully re-operated. A follow-up questionnaire was sent to patients who had finished their postoperative examination in March 1999. All 37 patients still alive responded. Median follow-up time was 37 months (range 3-96 months). Two patients reported recurrence at the time of follow-up and have been successfully re-operated. Eight patients reported minor and intermittent symptoms that did not indicate further evaluation. We conclude that laser resection of hypopharyngeal diverticula is an efficient therapy, which is applicable to and well tolerated in the great majority of patients. The rate of recurrence is low and re-operation can be performed without difficulty.

Chemoprophylaxis for Lyme borreliosis?

Chemoprophylaxis is a term which describes treatment with an antimicrobial chemotherapeutic before, during or shortly after an actual or suspected exposure to an infectious agent in order to prevent clinical disease, which may be severe or even fatal. Lyme borreliosis is considered the most frequent ixodid-tick-transmitted human bacterial infection in the northern hemisphere. For several years there has been a debate on the prophylactic application of antimicrobial chemotherapeutics after an attached Ixodes tick was removed. Would this measure prevent a subsequent borrelia infection and would it be practical? People are exposed to tick-bites mostly during leisure spent in recreational areas which are often tick infested. The proportion of I. ricinus ticks infected with B. burgdorferi s. l. varies from area to area and in a given area also from year to year (infection rate up to a maximum of 55%). The transmission rate strongly depends on the duration of feeding, but it could be shown that the critical time of feeding is much shorter for European I. ricinus than for the North American I. scapularis or I. pacificus ticks. Nevertheless, even the low risk of complications despite the very good chance of treating erythema migrans successfully seems to justify prophylactic treatment for some investigators whilst others do not see an argument for this. Double blinded studies in the USA showed a relatively low frequency of illness after vector tick-bite and absence of disseminated disease manifestations. The efficacy of prophylactic antibiotic treatment after tick-bites is not established. Suggestions to examine removed ticks for borrelia in order to obtain indication for prophylactic antibiotic treatment will fail in practice because of high costs and uncertainty in verifying the transmission. Do we need blinded studies in central Europe on a representative number of cases, although it is known that Lyme borreliosis can be treated effectively even in its second and third stage and has never caused a fatal outcome? We conclude that only a reliable diagnosis of symptoms is the basis for a rational antibiotic treatment, and that instead of chemoprophylaxis for Lyme borreliosis after a vector tick-bite the wait and watch policy is recommended.

Renal transplantation in patients with urinary diversion: a case-control study.

Renal transplantation in Sweden in patients with ileal conduits or continent reservoirs was investigated in order to compare the outcome with regard to graft and patient survival as compared to controls. Patient data from the four transplantation centres in Sweden were collected on: treatment prior to transplantation, time needed for the operative procedure, and postoperative care and outcome in terms of renal function as well as graft and patient survival at 1 and 5 years. The pattern of urinary tract infection was also investigated. Each case with urinary diversion was matched with two non-diabetic controls. Ten male and 12 female cases were found who had received 27 grafts between 1982 and 1996. Five patients had a Kock reservoir and 17 had a Bricker conduit. The time needed for the transplant procedure was significantly longer in the case group. After matching the case group with 54 controls, we found that the renal function was similar in both groups. Graft and patient survival was similar in both groups, over 90% after 1 year. Graft survival was about 70% after 5 years. Postoperative surgical complications in the case group were only seen in a few cases. The pattern of bacteria causing urinary tract infection was slightly different among the patients with ileal conduits or continent reservoirs. Patients with ileal conduits or continent reservoirs have similar graft and patient survival rates as the general kidney transplant population. The presence of constant bacteriuria did not adversely affect survival. Prophylactic antibiotic treatment seems not to be warranted. There appears to be no indication for native nephrectomy, except in selected cases. The study did not show any advantage with regard to continent reservoirs vs ileal conduits.