Prophylactic Intravenous Antibiotics Research Articles

Antibiotic impregnated catheters and intrathecal antibiotics for CSF shunt infection prevention in children undergoing low-risk CSF shunt surgery

BackgroundCerebrospinal fluid (CSF) shunts allow children with hydrocephalus to survive and avoid brain injury (J Neurosurg 107:345-57, 2007; Childs Nerv Syst 12:192-9, 1996). The Hydrocephalus Clinical Research Network implemented non-randomized quality improvement protocols that were shown to decrease infection rates compared to pre-operative prophylactic intravenous antibiotics alone (standard care): initially with intrathecal (IT) antibiotics between 2007–2009 (J Neurosurg Pediatr 8:22-9, 2011), followed by antibiotic impregnated catheters (AIC) in 2012–2013 (J Neurosurg Pediatr 17:391-6, 2016). No large scale studies have compared infection prevention between the techniques in children. Our objectives were to compare the risk of infection following the use of IT antibiotics, AIC, and standard care during low-risk CSF shunt surgery (i.e., initial CSF shunt placement and revisions) in children.MethodsA retrospective observational cohort study at 6 tertiary care children’s hospitals was conducted using Pediatric Health Information System + (PHIS +) data augmented with manual chart review. The study population included children ≤ 18 years who underwent initial shunt placement between 01/2007 and 12/2012. Infection and subsequent CSF shunt surgery data were collected through 12/2015. Propensity score adjustment for regression analysis was developed based on site, procedure type, and year; surgeon was treated as a random effect.ResultsA total of 1723 children underwent initial shunt placement between 2007–2012, with 1371 subsequent shunt revisions and 138 shunt infections. Propensity adjusted regression demonstrated no statistically significant difference in odds of shunt infection between IT antibiotics (OR 1.22, 95% CI 0.82–1.81, p = 0.3) and AICs (OR 0.91, 95% CI 0.56–1.49, p = 0.7) compared to standard care.ConclusionIn a large, observational multicenter cohort, IT antibiotics and AICs do not confer a statistically significant risk reduction compared to standard care for pediatric patients undergoing low-risk (i.e., initial or revision) shunt surgeries.

Is topical antibiotic use necessary to prevent surgical site infection following oculoplastic surgery?

To assess whether oculoplastic surgeries can be performed without any topical and systemic antibiotics, in a "100% antibiotic free" fashion. We conducted a multicenter retrospective study between November 2017 and December 2022. Patients who underwent an oculoplastic procedure were screened. Patients who received preoperative or postoperative systemic antibiotics were excluded. Intraoperative IV antibiotics were allowed. Patients were divided into two groups: those who were treated with local antibiotics ointments (LATB group) and those who were treated without local antibiotics ointments (LATB free group) postoperatively. The primary outcome was the incidence of surgical site infections (SSI). The relationship between the use of local antibiotics and the occurrence of SSI was assessed using Fisher's exact test. The alpha risk was set to 5% and two-tailed tests were used. Among the 947 procedures included, 617 were included in the LATB group and 330 in the LATB free group. 853 and 80 procedures were classified Altemeier class 1 (clean) and class 2 (clean-contaminated) surgeries, respectively. Overall, 310 (32.73%) procedures were performed without any systemic nor topical antibiotics (100% antibiotic free fashion). SSI occured in four (4/617; 0.65%) and five (5/330; 1.52%) procedures in the LATB and LATB free group respectively, without any statistical difference between the groups (p = 0.290). A subgroup analysis was carried out by excluding the procedures performed under prophylactic intraoperative intravenous antibiotics and did not reveal any statistical difference between the two groups (p = 0.144). All SSI patients were treated with systemic antibiotics with favorable outcomes. Postoperative wound dehiscence was the only risk factor associated with postoperative SSI (p = 0.002). This study suggests that performing a "100% antibiotic free" oculoplastic surgery without systemic and topical antibiotics is reasonable in Altemeier class 1 and class 2 procedures.

Enhanced Recovery After Surgery Cardiac Society turnkey order set for surgical-site infection prevention: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023

ObjectivesSurgical-site infections (SSIs) after cardiac surgery increase morbidity and mortality, consume health care resources, impair recovery, and diminish patients’ quality of life. Numerous guidelines and expert consensus documents have been published to address the prevention and management of SSIs. Our objective is to integrate these documents into an order set that will facilitate the adoption and implementation of evidence-based best practices for preventing and managing SSIs after cardiac surgery. MethodsSubject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set for SSI reduction. Orders derived from consistent class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the turnkey order set in bold type. Selected orders that were inconsistent class I or IIA, class IIB or otherwise supported by published evidence, were also included in italicized type. ResultsPreventative care begins with the preoperative identification of both modifiable and nonmodifiable SSI risks by health care providers. Assessment tools can be used to assist in identifying patients at a high risk of SSI. Preoperative recommendations include screening for and treating Staphylococcus aureus nasal carriage. Intraoperatively, tailored prophylactic intravenous antibiotics and maintaining blood glucose levels below 180 mg/dL are essential elements. Postoperative care includes maintaining normothermia, glucose control and patient engagement. ConclusionsDespite the well-documented advantages of a multidisciplinary care pathway for SSI in cardiac surgery, there are inconsistencies in its adoption and implementation. This article provides an order set that incorporates recommendations from existing guidelines to prevent SSI in the cardiac surgical population.

Role of antibiotics in Milligan-Morgan hemorrhoidectomy for Grade III to IV Hemorrhoids: A randomized clinical trial

This study was mainly to compare the safety and long-term clinical efficacy of using intravenous antibiotics in Milligan Morgan hemorrhoidectomy for Grade III to IV Prolapsing Hemorrhoids. This was a parallel group, 3-arm, randomized clinical trial to evaluate the efficacy of intravenous prophylactic antibiotics. A total of 150 consecutive patients undergoing Milligan Morgan hemorrhoidectomy (MMH) in a tertiary hospital for grade III/IV hemorrhoids from January 2020 to August 2022 were enrolled. Patients were randomly assigned to three groups using a computer-generated table. Group A did not receive any prophylactic antibiotic, group B received 2g I/V Cefoxitin Sodium before the induction of anesthesia, and group C received 2g I/V Cefoxitin Sodium before the induction of anesthesia and 6h after operation. There was no significant difference in measured VAS values on the 1st day,3rd day and 7th day after surgery (p> 0.05). Compared with VAS values on the 1st day postoperatively, these values got decreased on the 3rd day and 7th day after surgery (p< 0.05). In addition, there was no significant difference among the first defecation time, wound edema, bleeding, urinary retention after surgery (p> 0.05). There was no significant difference in the outcome comparison between all 3 groups' basal and the 3rd day postoperatively no matter in WBC, NUET% or CRP (p> 0.05). However, compared with basal, the WBC, NUET%,CRP(p< 0.05) of group A and group B on the 3rd day postoperatively got rised, the rate of recurrence of hemorrhoids follow-up for 1 year was 1.4%. Our results suggest that there is no efficacy on intravenous prophylactic antibiotics in Milligan Morgan hemorrhoidectomy.

Comparison of Short-Term Infectious Rates Related to Implantable Venous Port Placement With and Without Prophylactic Antibiotic Administration

Abstract The purpose of this study is to determine the rate of short-term central line-associated bloodstream infections (CLABSI) related to port placement in patients who received prophylactic intravenous antibiotics compared with those who did not receive prophylactic antibiotics. A retrospective review of 545 consecutive patients who underwent implantable port placement at Mayo Clinic, Rochester, Minnesota, from May 2020 to June 2021 was conducted. A total of 270 patients underwent port placement with prophylactic antibiotics administration. A total of 275 patients underwent port placement without the administration of antibiotics. The rate of short-term or 30-day CLABSI in both groups was reviewed. Indications for port placement included vascular access for chemotherapy and need for long-term vascular access for intravenous hydration, intravenous immunoglobulin infusion, electroconvulsive therapy, and photophoresis. Short-term infections occurred in a total of 3 of 545 patients (0.55%). Rate of short-term infection in patients who had port placement without prophylactic antibiotics was 2 of 275 (0.72%). Rate of short-term infection in patients who underwent port placement with prophylactic antibiotics was 1 of 270 (0.37). All 3 patients presented with bacteremia and were treated with port explantation and intravenous antibiotics. Overall, 30-day CLABSI in 545 patients who underwent port placement was 0.55%. There was no significant difference in the rate of short-term infections in the group who received prophylactic antibiotics (0.37%) compared with patients who did not receive any preprocedural antibiotics (0.72%).

Preoperative Elective Bowel Preparation In Children With Polyethylene Glycol Versus Polyethylene Glycol and Mannitol - A Comparative Study

Background: Oral mechanical bowel preparation is a routine practice prior to colorectal surgery in many centers. Virtually all colorectal surgeons consider a mechanically cleansed and empty bowel as one of the prerequisites for a safe colonic resection and anastomosis. Various agents had been used in different centers in mechanical bowel preparation. Methods: A comparative prospective interventional analysis of preoperative elective bowel preparation in children with polyethylene glycol versus polyethylene glycol and mannitol was conducted on 60 children underwent elective GIT surgery between July 2014 and June 2016. The patients were allocated into 2 groups by simple random sampling, 30 in each group. Children of 6 months to 14 years were selected as study population. In group I, PEG was given per orally or through nasogastric tube at the rate of 1.5 gm powder/kg/dose, in group II, PEG &amp; Mannitol were given orally or via nasogastric tube. PEG was administered as same dose of group I and mannitol 20% at a dose of 10 ml/kg/dose. All patients received prophylactic intravenous antibiotics (ceftriaxone + metronidazole) preoperatively as well as in postoperative period. All children were investigated preoperatively and post operative follow up was recorded. Structured questionnaire was used to collect information regarding preoperative status and post operative follow up. Statistical assessments were done by SPSS version 21. An Ethical clearance had been sought. Results: Sixty children underwent mechanical bowel preparation prior to GIT surgery. 30 with PEG (group I) and 30 with PEG and Mannitol (group II). Our outcome variables were wound infection, anastomotic leakage, and Electrolyte balance. Demographic pattern also evaluated. The age range of both groups was 6-68 months, p value 0.987. In both group male and female were same in number, 16 male and 14 female each in both groups. Wound infection occurred 3 cases (10%) in PEG group and 2 cases in PEG and Mannitol group, p value 0.64. No anastomotic leakage in PEG and Mannitol group and only 1 leakage in PEG group. No Electrolyte imbalance was found in both groups. No mortality was recorded in this study. Conclusions: No significant difference was found between the two study groups in respect of wound infection, anastomotic leakage and electrolyte balance. Ingestion of two drugs did not have any better outcome. So, mannitol can be omitted in MBP in children. J Dhaka Med Coll. 2022; 31(1) : 29-36

Proper Timing for Administration of Prophylactic Intravenous Antibiotics for Elective Surgical Procedures

Background: Preoperative antibiotic prophylaxis is administering antibiotics before performing surgery to help decrease the risk of postoperative infections. The antibiotic selected should only cover the likely pathogens. It should be given at the correct time. The timing of antibiotic administration may vary, but the goal of administering preoperative systemic prophylactic antibiotics is to have the concentration in the tissues at its highest at the start and during surgery. The literature supports at least 30 minutes, but no greater than 60 minutes before the skin incision is made to the optimal timing for the preoperative administration of most commonly used antibiotics. Aims and Objectives: To obtain precise information on the optimal time window for surgical antimicrobial prophylaxis (SAP). Methodology: A retrospective observational study design was used to investigate the effect of timing of SAP on the risk of surgical site infection (SSI) from September 2021 until September 2022. Patients with Inguinal hernia who performed elective inguinal hernia repair were eligible for enrollment in the study. The risk of SSI was compared between patients, categorized by the time interval between SAB administration and incision, and adjusted for confounding through Univariate Analysis logistic regression. Hakeem data base was used to collect the required data. This study was performed in King Hussein Medical Center (KHMC) at the Royal Medical Services in Amman/Jordan. Results: Data included in the current study was collected for the period between September 2021 until September 2022, in which 500 patients were randomly assigned into two arms; Patients in arm A received the in a time window of 60 to 30 minutes before the scheduled incision while Patients in arm B received the antibiotics in time window of less than 30 minutes to 0 minutes before the scheduled incision. In 52% of the procedures, SAP was administered within 60 minutes before incision Inpatient and ...........

Incidence and Characteristics of Facial and Ophthalmic Injuries From Domestic Mammal Bites: Parts of the data in the manuscript were presented at the American Academy of Ophthalmology Annual Meeting, 2022.

To determine population-based incidence and characteristics of facial and ophthalmic injuries from domestic mammal bites in Olmsted County, Minnesota. Retrospective, population-based cohort study. The Rochester Epidemiology Project (REP) was used to identify all potential cases of facial injuries from domestic mammal bites in Olmsted County, Minnesota from January 1, 1999, to December 31, 2015. Subjects were categorized into 2 cohorts: the ophthalmic cohort, which included persons with ocular and periocular injuries with or without facial injuries, and the non-ophthalmic cohort, which included persons with facial injuries only. The incidence and characteristics of facial and ophthalmic injuries from domestic mammal bites were assessed. There were 245 patients with facial injuries, 47 ophthalmic and 198 non-ophthalmic. The overall age- and sex-adjusted incidence of facial injuries was 9.0 (CI=7.9-10.1) per 100,000 persons per year, 1.7 (CI=1.2-2.2) ophthalmic and 7.3 (CI=6.3-8.3) non-ophthalmic. Rates of facial injuries were highest in patients younger than 5 years and lowest in patients 50 years or older, 49.1 (CI=41.3-61.6) and 1.3 (CI=0.7-2.5), respectively (P < .001). All facial injuries were caused by either dog (92%) or cat (8%) bites. Patients with ophthalmic injuries received more intravenous prophylactic antibiotics (18% vs 1%, P < .001), wound closure (83% vs 58%, P < .001), and hospital admission (6% vs 0%, P=.007) than patients with non-ophthalmic injuries. Facial injury complications were infrequent (14, 6%) and included soft tissue infection and prominent scar. Although domestic mammal bites to the face are quite common, ocular injury occurs in a minority of cases.

MP62-16 FACTORS ASSOCIATED WITH VIRGIN INFLATABLE PENILE PROSTHESIS INFECTION: 10 YEARS OF DATA IN A LARGE HEALTH CARE SYSTEM

You have accessJournal of UrologyCME1 Apr 2023MP62-16 FACTORS ASSOCIATED WITH VIRGIN INFLATABLE PENILE PROSTHESIS INFECTION: 10 YEARS OF DATA IN A LARGE HEALTH CARE SYSTEM Nancy Ye, Joanie Chung, Polina Reyblat, Irene Chen, Eugene Rhee, and George Abdelsayed Nancy YeNancy Ye More articles by this author , Joanie ChungJoanie Chung More articles by this author , Polina ReyblatPolina Reyblat More articles by this author , Irene ChenIrene Chen More articles by this author , Eugene RheeEugene Rhee More articles by this author , and George AbdelsayedGeorge Abdelsayed More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) is the recommended treatment for erectile dysfunction refractory to medical management. Device infection is a dreaded complication leading to significant patient morbidity and increased healthcare costs. This study aims to determine factors associated with device infection in a large fully integrated healthcare system. METHODS: IPPs implanted between 2009 and 2019 at Kaiser Permanente Southern California were retrospectively reviewed. Perioperative and intra-operative variables were assessed to identify factors associated with device infection. Particular attention was paid to patient demographics, co-morbid conditions, surgeon volume, intra-operative antibiotics, operative time, and concurrent procedures. Univariate and multivariable logistic regression analyses were performed. RESULTS: 978 virgin IPPs were implanted in the study period by 66 different implanters. Overall device infection rate was 4.5% (44/978). We identified four surgeons, who performed >100 IPP surgeries within the study period, as high-volume implanters (HVI). They collectively implanted 441 IPPs (45%). Patients who had IPPs placed by HVI were significantly less likely to develop a device infection compared to other surgeons (OR 0.49, p<0.05). On multivariable logistic regression analysis, hemoglobin A1c, body mass index, operative time, anti-coagulation, prior pelvic surgery, radiation, or spinal cord injury were not associated with device infection. Yet, patients who received prophylactic intravenous (IV) antibiotics per American Urological Association (AUA) Best Practice Statement were less likely to have a device infection than patients who received other antibiotics (OR 0.35, p<0.05). Additionally, IPP placement via penoscrotal approach was associated with greater likelihood of device infection compared to infrapubic approach (OR 4.67, p<0.05). Mean follow-up was 4.9 years. CONCLUSIONS: Device infection was associated with non-high-volume implanters as well as prophylactic IV antibiotics outside of AUA recommendations. Operative time, long considered to be associated with device infections, was not associated with device infection on either univariate or multivariable logistic regression analysis in this large cohort with long term follow up. Greater understanding of patient and surgeon factors associated with device infection may help decrease patient morbidity and better prepare implanters. Source of Funding: n/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e868 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nancy Ye More articles by this author Joanie Chung More articles by this author Polina Reyblat More articles by this author Irene Chen More articles by this author Eugene Rhee More articles by this author George Abdelsayed More articles by this author Expand All Advertisement PDF downloadLoading ...

Intrawound application of vancomycin reduces the proportion of fracture-related infections in high-risk tibial plateau fractures

IntroductionDespite the improvements in surgical techniques and the use of prophylactic intravenous antibiotics, the fracture-related infection (FRI) incidence after high-risk tibial plateau fractures remains high. This study aimed to evaluate the clinical effect of the intrawound application of vancomycin on the FRI after high-risk tibial plateau fracture surgery. MethodsA total of 243 patients who underwent high-risk tibial plateau fracture surgery from May 2013 to June 2021 were retrospectively reviewed. Of these, 233 cases were enrolled. Considering the preoperative patient condition, surgeons applied vancomycin powder directly into the surgical site before wound closure in 105 cases (intrawound application of vancomycin powder with preoperative intravenous cephalosporin). The remaining 128 cases served as the control group (preoperative intravenous cephalosporin alone). Clinical data and surgical details were recorded. The Cox proportional hazards regression analysis was used to assess risk factors for FRI. The Kaplan-Meier method and the log rank test illustrated the infection status of patients based on the application of intrawound vancomycin. The primary outcome was an FRI within one year. Secondary outcomes included bacterial culture and vancomycin-related complications. ResultsOur study demonstrated a significant difference in the incidence of FRI between the vancomycin group and the control group (3.8% versus 10.9%; p=0.041). Multivariable Cox regression showed the intrawound application of vancomycin powder decreased the rate of FRI. There were no complications related to intrawound vancomycin observed during follow-up. The presence of Gram-positive FRI was higher in the control group compared with the vancomycin group. ConclusionsIntrawound application of vancomycin was associated with a significant lower rate of FRI after high-risk tibial plateau fracture surgery compared to the control group.

Study protocol for PREPARE: a phase II feasibility/safety randomised controlled trial on PeRiopErative Penicillin AlleRgy TEsting

IntroductionPatient-reported antibiotic allergy labels (AALs) are common. These labels have been demonstrated to have a negative impact on use of appropriate antibiotics and patient-related health outcomes. These patients are more...

Current methods of preventing infectious disease and managing febrile neutropenia in childhood cancer patients: a nationwide survey in Japan

Preventing infection and managing febrile neutropenia (FN) is mandatory for children with cancer undergoing chemotherapy. However, the current situation in Japan is unknown. We conducted a nationwide web-based questionnaire survey in 153 institutions treating childhood cancer in Japan. We asked about the type prophylaxis used to prevent infectious disease and manage FN. If patients with childhood cancer were managed by both pediatricians and surgeons at the same institution, we asked both to reply. We received replies from 117 departments at 111 centers: of these, 108 were from pediatricians. Laminar air flow for neutropenic patients, and frequent hand sanitization with ethanol, were widespread. Twenty-eight percent and forty percent of departments performed active surveillance by taking cultures from patients and the environment, respectively, before initiation of chemotherapy. Forty-four percent of departments administered prophylactic intravenous antibiotics according to patient status. Many departments measured serum (1,3)-β-D glucan, procalcitonin, and aspergillus galactomannan at the onset of FN. Twenty-eight percent of departments used carbapenem as empirical therapy for FN. Some departments used prophylactic granulocyte-colony stimulating factor for acute leukemia. Seventy-two percent of departments used prophylactic immunoglobulin for hypogammaglobinemia caused by chemotherapy. Palivizumab was administered widely for respiratory syncytial virus prophylaxis in immunocompromised infants. As a whole, intensive care for infectious prophylaxis or FN is applied in Japan; however, the methods vary among centers, and some are excessive or inadequate. Therefore, it is desirable to conduct clinical trials and establish adequate care protocols for infection in children with cancer in Japan.

Clinical Findings Predicting Posttraumatic Endophthalmitis after Repair of Open Globe Injuries

ABSTRACT Background To evaluate risk factors for developing endophthalmitis after repair of open globe injuries. Methods Retrospective chart analysis of 1303 patients from May 1996 till December 2019. Results All patients received prophylactic intravenous broad-spectrum antibiotics for 5–7 days. Endophthalmitis was clinically suspected in 37 (2.8%) eyes and was culture proven in 14 of these eyes (1.1%). Univariate analysis identified poor initial visual acuity at presentation, rural setting of injury, contaminated wound and lens injury as significant predictors for the development of clinically suspected endophthalmitis. Intravitreal antibiotics at the time of primary repair in eyes with high-risk characteristics decreased risk of developing endophthalmitis (OR: 2.28;95% CI,1.07–4.86; p = .033). Conclusions Poor initial visual acuity, rural setting of injury, contaminated wound, and lens injury increased risk of suspected posttraumatic endophthalmitis. Prophylactic intravitreal antibiotics at the time of primary repair in eyes with high-risk characteristics reduced the risk of posttraumatic endophthalmitis.

Factfinders for patient safety: Antibiotics for disc access and spinal cord stimulation trials

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding the use of antibiotics for disc access and spinal cord stimulation trials.The evidence in support of the following facts is presented: (1) There is a low but nonzero risk of discitis due to percutaneous intervertebral disc access. Strategies to mitigate this risk include use of strict aseptic technique, use of a needle stylet, and prophylactic intravenous or intra-discal antibiotics. (2) In low-risk patients, it may not be necessary to continue antibiotics throughout the percutaneous or staged trial period; however, in high-risk patients, or in trials lasting more than five days, antibiotics should be considered on a case-by-case basis.

Cochlear Implant Salvage in Case of Grounding Wire Extrusion.

Cochlear implantation (CI) is a safe and effective procedure for hearing rehabilitation, with few major complications. Device exposure or extrusion is a rare but major complication that often necessitates explantation due to wound dehiscence or infection. The objective of this report is to present a previously undescribed case in which the cochlear implant grounding wire extruded in 16-month-old patient 3 months post-operatively in the absence of trauma or infection. We reviewed the case report and the pertinent literature. A 16-month old male suffered extrusion of his left cochlear implant grounding wire without known etiology 86 days post-operatively after bilateral cochlear implantation. The patient was taken for surgery, and the electrode was reimplanted without complication followed by 48 hours of prophylactic intravenous antibiotics. Nine month follow up revealed the implant functioning appropriately, with no further major complications encountered. We present this unique case to demonstrate that a cochlear implant grounding wire extrusion is not necessarily an indication for explantation in the absence of infection.

Effectiveness of Single vs Multiple Doses of Prophylactic Intravenous Antibiotics in Implant-Based Breast Reconstruction

Multiple-dose antibiotic prophylaxis is widely used to prevent infection after implant-based breast reconstruction despite the lack of high-level evidence regarding its clinical benefit. To determine whether multiple-dose antibiotic prophylaxis is superior to single-dose antibiotic prophylaxis in preventing surgical site infection (SSI) after implant-based breast reconstruction. This prospective, multicenter, randomized clinical superiority trial was conducted at 7 hospitals (8 departments) in Sweden from April 25, 2013, to October 31, 2018. Eligible participants were women aged 18 years or older who were planned to undergo immediate or delayed implant-based breast reconstruction. Follow-up time was 12 months. Data analysis was performed from May to October 2021. Multiple-dose intravenous antibiotic prophylaxis extending over 24 hours following surgery, compared with single-dose intravenous antibiotic. The first-choice drug was cloxacillin (2 g per dose). Clindamycin was used (600 mg per dose) for patients with penicillin allergy. The primary outcome was SSI leading to surgical removal of the implant within 6 months after surgery. Secondary outcomes were the rate of SSIs necessitating readmission and administration of intravenous antibiotics, and clinically suspected SSIs not necessitating readmission but oral antibiotics. A total of 711 women were assessed for eligibility, and 698 were randomized (345 to single-dose and 353 to multiple-dose antibiotics). The median (range) age was 47 (19-78) years for those in the multiple-dose group and 46 (25-76) years for those in the single-dose group. The median (range) body mass index was 23 (18-38) for the single-dose group and 23 (17-37) for the multiple-dose group. Within 6 months of follow-up, 30 patients (4.3%) had their implant removed because of SSI. Readmission for intravenous antibiotics because of SSI occurred in 47 patients (7.0%), and 190 women (27.7%) received oral antibiotics because of clinically suspected SSI. There was no significant difference between the randomization groups for the primary outcome implant removal (odds ratio [OR], 1.26; 95% CI, 0.69-2.65; P = .53), or for the secondary outcomes readmission for intravenous antibiotics (OR, 1.18; 95% CI, 0.65-2.15; P = .58) and prescription of oral antibiotics (OR, 0.72; 95% CI, 0.51-1.02; P = .07). Adverse events associated with antibiotic treatment were more common in the multiple-dose group than in the single-dose group (16.4% [58 patients] vs 10.7% [37 patients]; OR, 1.64; 95% CI, 1.05-2.55; P = .03). The findings of this randomized clinical trial suggest that multiple-dose antibiotic prophylaxis is not superior to a single-dose regimen in preventing SSI and implant removal after implant-based breast reconstruction but comes with a higher risk of adverse events associated with antibiotic treatment. EudraCT 2012-004878-26.

Leaving the Placenta In Situ in Placenta Accreta Spectrum Disorders: A Single-Center Case Series.

The most common treatment for placenta accreta spectrum (PAS) disorders is planned primary cesarean hysterectomy. However, other management strategies may improve outcomes and/or allow fertility preservation. The objective of this study was to describe the course and outcomes of patients with PAS managed by leaving the placenta in situ. This is a series of 11 patients with PAS managed by leaving the placenta in situ at a single academic center in the United States from 2015 to 2022. The approach described involves delivery of the fetus via cesarean, no attempt at placental removal, closure of the hysterotomy, prophylactic intravenous antibiotics for up to 1 week, and close outpatient follow-up until the uterus is empty. The uterus was successfully preserved in six (55%), minimally invasive hysterectomy was performed in four (36%), and abdominal hysterectomy was performed in 1 (9%). During cesarean delivery, the median estimated blood loss was 650mL (range: 200-1,000mL). The majority of patients had no vaginal discharge for several weeks after delivery, followed by brown or bloody discharge, and intermittent mild-to-moderate cramping. The median time to resolution of PAS was 18 weeks in patients with successful uterine preservation (range: 5-25 weeks). Indications for hysterectomy included hemorrhage (n=1), coagulopathy (n=1), endomyometritis (n=2), and pain (n=1), and these occurred at a median of 5 weeks postpartum (range: 1-25 weeks). Four patients had subsequent pregnancies of whom three were live births at or near term and one was a spontaneous abortion at 19 weeks. Leaving the placenta in situ may be an appropriate management strategy for some carefully selected and counseled patients with PAS. · Overall, 55% had uterine preservation (6/11).. · Minimally invasive approach in 80% of hysterectomies (4/5).. · Of patients, 67% with uterine preservation had subsequent pregnancies (4/6)..

Postoperative Prophylactic Antibiotic Use in Breast Reduction Mammoplasty: A Single Centre Retrospective Cohort Study.

Introduction: Breast reduction mammoplasty (BRM) is a common procedure performed by plastic surgeons treating patients with hypermastia. It is customary to give preoperative prophylactic intravenous antibiotics for BRM, followed by several days of postoperative prophylactic oral antibiotics, despite the lack of evidence of their effectiveness in preventing surgical site infections (SSIs). The purpose of this study is to determine if the addition of prophylactic postoperative antibiotics is more effective in preventing SSIs in comparison to a single dose of preoperative prophylactic antibiotics in BRM. Methods: A retrospective analysis of 124 elective BRM cases by a single senior plastic surgeon was completed. Two study groups were formed based on the location of surgery and each group was assigned a different antibiotic regimen. The first antibiotic regimen consisted of a single preoperative intravenous dose of antibiotics (group 1), while the second regimen consisted of a preoperative intravenous dose followed by a 5-day course of oral antibiotics (group 2). Results: Overall SSI rate was 5.6%. Infection rate in group 1 was 8.1% in comparison to 3.2% for group 2 (P value .44). Overall, the incidence of complications was 29.0%; 38.7% in group 1 and 19.4% in group 2 (P value .03). Complications consisted of 35 cases of delayed wound healing, 7 SSIs and 2 hematomas requiring evacuation. Conclusion: Study results demonstrated that the use of postoperative prophylactic antibiotics for BRM had no significant effect on the rate of SSIs.

Can We Improve Our Approach to Antibiotic Prophylaxis in Shoulder Arthroplasty?: Commentary on an article by Erick M. Marigi, MD, et al.: "Antibiotic Prophylaxis with Cefazolin Is Associated with Lower Shoulder Periprosthetic Joint Infection Rates Than Non-Cefazolin Alternatives".

Commentary Periprosthetic joint infections (PJIs) following arthroplasties are relatively rare, occurring at rates of approximately 1% to 2% in both the upper and lower extremities1,2. However, these infections, when they do occur, wreak havoc on patient outcomes and are demoralizing to patients and surgeons alike. Several strategies are known to reduce the risk of surgical site infection in arthroplasties, including perioperative intravenous antibiotics3. In the lower extremity, the most common pathogens in PJIs are Staphylococcus aureus and Staphylococcus epidermidis, both gram-positive anaerobes that are sensitive to cephalosporin antibiotics, in particular, cefazolin. However, PJIs after shoulder arthroplasty are often characterized instead by Cutibacterium acnes, which is also gram-positive, but can be aerotolerant. C. acnes is also considered to be sensitive to cefazolin. Therefore, prophylactic coverage for shoulder arthroplasties is similar to those recommended for hip and knee arthroplasties: gram-positive coverage plus extended-spectrum gram-negative coverage, both provided by cephalosporin4. However, challenges arise when patients cannot take cephalosporin due to reasons including penicillin and cephalosporin allergies. The second-line antibiotic choices in these cases are typically clindamycin or vancomycin, both of which provide coverage that is similar, but not a perfect match, to cephalosporin. In both lower-extremity and upper-extremity arthroplasties, studies have found that second-line antibiotics are not as effective in preventing PJIs5,6. However, the available evidence is observational in nature, which can be confounded by patient and surgeon factors. Prospective randomized studies have yet to confirm these findings. In their study, Marigi et al. report on a large number of patients who underwent shoulder arthroplasty and had registry data. The overall PJI rate was 1.3%, with the most common causative organism reported to be C. acnes. The authors found that the administration of prophylactic intravenous antibiotics other than cefazolin (clindamycin, vancomycin, and other) was an independent risk factor for PJI, with >2-fold increase in the rate of infection. This finding was even more pronounced with the diagnosis of a C. acnes infection. Despite the risk of unknown confounding variables in this observational study, the data represent higher-level evidence than in previously published studies and corroborate the conclusion that cefazolin provides the best prophylactic coverage in shoulder arthroplasty. There is a growing body of evidence that there is extremely low cross-reactivity between penicillin and later-generation cephalosporins7. Many surgeons believe that it is safe to administer cefazolin even in patients with penicillin allergies, as long as there is no documented history of angioedema or anaphylaxis. The recently published Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial that randomized 604 patients undergoing lower-extremity oncologic endoprosthetic reconstruction to 1 or 5 days of postoperative prophylactic intravenous cephalosporin did not exclude patients with penicillin allergies unless there was a history of anaphylaxis or angioedema8. There were no documented serious unexpected adverse reactions reported, despite the fact that patients with penicillin allergies were included on the basis of surgeon comfort with the protocol. Marigi et al. suggest that all patients with penicillin allergies be tested preoperatively or be given a test dose of cefazolin intraoperatively to monitor for an adverse reaction. This is a very reasonable suggestion, as it could benefit both surgical patients and the health-care system by avoiding PJIs that occur due to insufficient antimicrobial prophylactic coverage. In addition, patients with a remote history of a penicillin allergy, most likely related to historical drug preparations, or a history of a rash due to penicillin, could be automatically considered candidates for intravenous cefazolin9. All attempts should be made to provide the best infection prophylaxis, according to the available evidence, in patients undergoing shoulder arthroplasty. At this time, the available evidence points to cephalosporin. Given the consistent findings of the superior efficacy of cephalosporin in the published literature, albeit through observational data, it may be challenging to design a randomized study that would be considered acceptable and ethical to orthopaedic surgeons. For now, the study by Marigi et al. provides some of the strongest evidence to date for the use of intravenous cephalosporin in PJI prophylaxis in shoulder arthroplasty.

Prevalence of Primary Immunodeficiency Diseases and Related Risk Factors Among Children Attending a Hospital in Ahvaz, Iran

Background and Objectives Primary immunodeficiency (PI) diseases are those occur because of a primary disorder in the immune system. Subjects and Methods This retrospective study was conducted on 70 children with PI diseases referred to the allergy and immunology department of Abuzar Children Hospital in Ahvaz, Iran from 2015 to 2018. Results The most common PI diseases in the majority of male children (56.92%) were severe combined immunodeficiency disease (21.42%) and chronic granulomatous disease (8.57%). Parents in most of patients (83%) were blood relatives. About 66.67% of all death cases (9.23%) was due to severe combined immunodeficiency disease; hypogammaglobulinemia and Griscelli syndrome accounted for about 16.67% of deaths. The most common manifestations were pneumonia, fever, diarrhea, and sepsis. Based on the family history, 33 children had allergies, 9 had malignancy, one had autoimmune disease, and 39 had mothers with a history of abortion. Most of children were under treatment with intravenous immunoglobulin and prophylactic antibiotics, (99.88% and 88.99%, respectively), while 2.81% were under interferon-gamma therapy and transplantation, and 1.40% were receiving corticosteroids and granulocyte colony-stimulating factor therapy. Conclusion The severe combined immunodeficiency disease, chronic granulomatous disease, and Bruton disease are the most common PI diseases in children living in Ahvaz.