Prophylaxis Guidelines Research Articles

Time for an Update? A Look at Current Guidelines for Venous Thromboembolism Prophylaxis After Hip and Knee Arthroplasty and Hip Fracture.

Venous thromboembolism is a well-established complication of total hip and knee arthroplasty and hip fracture surgery. Clinical practice guidelines have been proposed to help clinicians provide prophylaxis against this risk. However, most guidelines reference data that are becoming outdated because of new advances in perioperative protocols. Recent data would suggest that aspirin may be appropriate for most patients after total hip and knee replacement and a more potent chemoprophylaxis for higher risk patients. Low-molecular-weight heparin remains the recommended choice after hip fracture surgery, although there is a paucity of recent literature in this patient population. There are randomized trials currently underway in the arthroplasty population that may guide clinicians in the appropriate choice of chemoprophylaxis. These studies should inform updates to the current clinical practice guidelines.

High-Risk Patients with Infected Puncture Wounds and Appropriate Tetanus Prophylaxis.

We sought to evaluate clinicians' compliance with national guidelines for tetanus vaccination prophylaxis in patients with high-risk feet. We retrospectively evaluated 114 consecutive patients between June 1, 2011, and March 31, 2019, who presented to the emergency department with a foot infection resulting from a puncture injury. Eighty-three patients had diabetes mellitus and 31 patients did not have diabetes mellitus. Electronic medical records were used to collect a broad range of study data on patient demographics, medical history, tetanus immunization history and tetanus status on presentation to the emergency department, peripheral arterial disease, sensory neuropathy, laboratory values, and clinical/surgical outcomes. Of the 114 patients who presented to the emergency department with a puncture wound, 53 (46.5%) did not have up-to-date tetanus immunization. Of those patients, 79.2% received a tetanus-containing vaccine booster, 3.8% received intramuscular tetanus immunoglobulin, 3.8% received both a tetanus-containing vaccine booster and tetanus immunoglobulins, and 20.8% received no form of tetanus prophylaxis. Comparing data between patients with and without diabetes mellitus, there were no statistically significant differences in tetanus prophylaxis. Guidelines for tetanus prophylaxis among high-risk podiatric medical patients in this study center are not followed in all patients. Patients with diabetes mellitus are at high risk for exposure to tetanus; therefore, we recommend that physicians take a detailed tetanus immunization history and vaccinate patients if the tetanus history is unclear.

The Impact of a Multidisciplinary Approach Protocol and Integrated Guidelines for Antibiotic Prophylaxis in Plastic Surgery Procedures

The Impact of a Multidisciplinary Approach Protocol and Integrated Guidelines for Antibiotic Prophylaxis in Plastic Surgery Procedures

Bacterial Resistance in Ophthalmology – Resistance Profile, Influencing Factors and Prevention Methods. A Review

Ocular infections vary greatly in severity. Studies have tried to identify certain patterns related to the ocular microbiome in the studied populations in order to identify risk populations, new treatments and prophylaxis guidelines. However, it is critical to determine which antibiotics should be used in various situations and where alternatives to antibiotics are appropriate. Results of many studies show that high levels of antibiotic resistance in ophthalmology and multidrug resistance continue to be a reality and a challenge today. Iodine-povidone and chlorhexidine are two major antiseptics used in ophthalmology. It is hoped that future reports show good results without the use of antibiotics will encourage ophthalmologists to limit the use of topical antibiotics, reducing the rate of antimicrobial resistance.

Adherence to Stress Ulcer Prophylaxis Guideline in Medicine Unit at Soba University Hospital: A Descriptive Retrospective Study

Although several guidelines for Stress Ulcer Prophylaxis (SUP) have been published, Acid-Suppressive Therapy (AST) remains largely prescribed in hospitalized patients. Thus, our study aimed to evaluate the current practice surrounding SUP in Soba University Hospital (Khartoum, Sudan). This descriptive cross-sectional hospital-based retrospective study was conducted in the medicine unit of Soba University Hospital. The sample size was 317 participants, and data were collected from medical records from January to December 2018 using a validated checklist. SPSS was applied for data analysis. The mean age of patients was 53 ± 16.8 years, and 170 (54%) of them were female. The mean duration of hospital stay was 10 ± 7.4 days. Seventy-four percent of patients who received prophylaxis did not have an indication for SUP. The majority (116; 36.5%) of patients who were administered parenteral drugs can tolerate oral medications. Overall, the dose of acid-suppressant drugs was optimal in all patients. Proton Pump Inhibitors (PPIs), especially pantoprazole, are the dominant AST used (314; 99.1%). Moreover, 315 (99.4%) of the study population were taking medication during hospitalization and two (1%) patients were discharged with AST. The study concluded that SUP was administered to noncritically ill hospitalized patients who lacked or had few risk factors for gastrointestinal bleeding. PPIs were the overwhelming choice among practitioners. Collectively, the study showed low adherence to guidelines when prescribing (AST) outside critical care settings. Therefore, there is an urgent need for implementation of practical guidelines in noncritical care settings.

The prescription pattern and awareness about antibiotic prophylaxis and resistance among a group of Egyptian pediatric and general dentists: a cross sectional study

BackgroundThe use of antibiotics in dentistry as prophylaxis and treatment is frequent. Their misuse has led to a major public health problem globally known as antibiotic resistance. This study aimed to assess the pattern of antibiotic prescription and its prophylactic use for systemic conditions. Besides, this study evaluated the awareness and adherence to antibiotic prescription guidelines and antibiotic prophylaxis guidelines along with awareness of antibiotic resistance across pediatric and general dentists.MethodsAn overall of 378 pediatric and general dentists meeting the required eligibility criteria, fulfilled a pre-designed validated questionnaire. Data were collected, tabulated, and statistically analyzed.ResultsA significant statistical difference was found among the pediatric and general dentists regarding antibiotics prescription for most of the oral conditions where Amoxicillin with clavulanic acid was the most frequently prescribed antibiotic among the two groups (53% pediatric dentist and 52% general dentist). The majority of pediatric and general dentists, on the other hand, were aware of antibiotic resistance and prescribing recommendations.ConclusionsThe present study showed a tendency to overprescribe and overuse antibiotics in certain dental conditions among the participants. The vast majority of dentists, especially general dentists do not have adherence to professional guidelines for antibiotics prescription in children despite their awareness of antibiotic resistance and prescription guidelines.

Differences in Infection Prophylaxis between Pediatric AML Study Groups within the International BFM Study Group

BackgroundPediatric patients with acute myeloid leukemia (AML) are at high risk of severe infections. Prophylaxis of infections is of obvious relevance, but recommendations are often non-specific and supported by low-quality evidence. Despite appeals by experts and working groups in the field to harmonize guidelines, many divergent regimens among hospitals and study groups seem to exist. Whereas previous surveys on this matter mainly focused on hospital-based recommendations, the aim of the current study was to gain insight in all nationally available infection prophylaxis guidelines for pediatric AML patients within the international Berlin-Frankfurt-Munster (I-BFM) study group.MethodsUsing a web-based survey, we inquired the infection prophylaxis guidelines of 22 pediatric AML study groups within the I-BFM consortium. The survey included questions on the use of both pharmacological measures, i.e. antibiotics, antifungal medication, antiviral prophylaxis, granulocyte colony stimulating factor (G-CSF), and non-pharmacological measures, e.g. the use of isolation rooms, out-patient clinic visits and food or social restrictions. In order to check for discordant answers or inconsistencies, a copy of the formal study group guidelines (if available) was requested.In order to evaluate differences in daily practice among hospitals within one study group, hospital representatives (n =27) from the NOPHO-DBH AML Study Group participated in a slightly modified survey.Descriptive statistics are presented.ResultsAlmost all participating study groups prescribe Pneumocystis Jiroveci pneumonia prophylaxis with sulfonamides (n =21, 95%). About 32% of the study groups (n =7) advise gram-negative antibiotic prophylaxis, mainly with fluoroquinolones (n =6, 86%). Gram-positive prophylaxis is prescribed by 36% of the study groups (n =8), of whom 2 study groups only prescribe this in specific situations, for example after high-dose cytarabine. The majority of the study groups do not recommend the use of G-CSF (n =10, 46%) or recommend it only in specific cases of severe infections and/or prolonged neutropenia (n =7, 32%).Over 60% of the study group prescribe food and social restrictions, but the specific topics and strictness differed largely between all groups. Most frequently reported food restrictions included consumption of raw meat and raw seafood (n =16, 76%), unpasteurized milk products (n =14, 67%) and dishes with undercooked eggs (n =13, 62%). Frequently reported social restrictions included visiting indoor crowded places (n =13, 62%), using public transportation (n =12, 57%) and visiting daycare/kindergarten/pre-school (n =12, 57%). Study groups who recommend antibiotic prophylaxis were comparable stringent with regard to social or food restrictions and outpatient management.According to the hospital-based survey, sites roughly complied with the common study group guidelines. However, the use of any gram-negative antibiotic prophylaxis, the specific prophylactic antifungal agent and the strictness of the food and social restrictions differed substantially between the hospitals.ConclusionThis study gives an overview of the currently applied international recommendations on infection prophylaxis for pediatric AML patients. Despite a long history of close collaboration within the I-BFM consortium, many differences are still present between the affiliated pediatric AML study groups. Differences between study groups, as well as the discrepancies between hospital practices, are probably explained by generally formulated guidelines based on conflicting results of previous studies, and the lack of solid clinical evidence. Fortunately major efforts are now being undertaken to answer several of the remaining issues on infection prophylaxis. Furthermore, an update of the international guidelines on management of pediatric oncology patients with fever and neutropenia was recently published. The results of this survey provide an appropriate baseline measure to study the impact of these and emerging guidelines in the future. DisclosuresKaspers:Janssen-Cilag: Research Funding.

Prioritizing Research Informing Antibiotic Prophylaxis Guidelines for Knee Arthroplasty Patients.

Guidelines for routine antibiotic prophylaxis (AP) before dental procedures to prevent periprosthetic joint infection (PJI) have been hampered by the lack of prospective clinical trials. To apply value-of-information (VOI) analysis to quantify the value of conducting further clinical research to reduce decision uncertainty regarding the cost-effectiveness of AP strategies for dental patients undergoing total knee arthroplasty (TKA). An updated decision model and probabilistic sensitivity analysis (PSA) evaluated the cost-effectiveness of AP and decision uncertainty for 3 AP strategies: no AP, 2-y AP, and lifetime AP. VOI analyses estimated the value and cost of conducting a randomized controlled trial (RCT) or observational study. We used a linear regression meta-modeling approach to calculate the population expected value of partial perfect information and a Gaussian approximation to calculate population expected value of sample information, and we subtracted the cost for research to obtain the expected net benefit of sampling (ENBS). We determined the optimal trial sample sizes that maximized ENBS. Using a willingness-to-pay threshold of $100,000 per quality-adjusted life-year, the PSA found that a no-AP strategy had the highest expected net benefit, with a 60% probability of being cost-effective, and 2-y AP had a 37% probability. The optimal sample size for an RCT to determine AP efficacy and dental-related PJI risk would require approximately 421 patients per arm with an estimated cost of $14.7 million. The optimal sample size for an observational study to inform quality-of-life parameters would require 2,211 patients with an estimated cost of $1.2 million. The 2 trial designs had an ENBS of approximately $25 to $26 million. Given the uncertainties associated with AP guidelines for dental patients after TKA, we conclude there is value in conducting further research to inform the risk of PJI, effectiveness of AP, and quality-of-life values. The results of this value-of-information analysis demonstrate that there is substantial uncertainty around clinical, health status, and economic parameters that may influence the antibiotic prophylaxis guidance for dental patients with total knee arthroplasty. The analysis supports the contention that conducting additional clinical research to reduce decision uncertainty is worth pursuing and will inform the antibiotic prophylaxis debate for clinicians and dental patients with prosthetic joints.

Antimicrobial prescribing in the surgical and medical wards at a private hospital in KwaZulu-Natal, South Africa, 2019.

Appropriate antimicrobial use is imperative owing to the misuse of antimicrobials, which has resulted in a growing burden of antimicrobial resistance. Evidence-based guidelines should be adhered to in order to ensure the sustainability of effective antimicrobials. To assess the appropriateness of antimicrobial prescribing at a private hospital in Durban, KwaZulu-Natal, South Africa. The records of patients admitted to the surgical and medical wards over a 2-month period were reviewed to assess the choice, dose and duration of prescribed antimicrobials. The guidelines used to determine the appropriateness of the prescriptions were: the Standard Treatment Guidelines and Essential Medicines List for South Africa - Hospital Level Adults, 2015 edition, the antimicrobial indications and prescribing instructions in the South African Medicines Formulary, the South African Antibiotic Stewardship Programme guidelines and the evidence-based surgical prophylaxis guidelines adopted by the hospital group where the research was conducted. During the study period, 466 patients were admitted and prescribed an antimicrobial, of whom 220 (47.2%) were admitted to the surgical ward and 246 (52.8%) to the medical wards. A total of 779 antimicrobials were prescribed. Of the 660 antimicrobials prescribed for empirical treatment, 305 (46.2%) were appropriately prescribed based on drug choice, dose and duration. Of the 38 antimicrobials that were classified as targeted, 36 (94.7%) were prescribed at the correct dose and 33 (86.8%) for the correct duration. Of the 81 antimicrobials prescribed for surgical prophylaxis, only 32 (39.5%) met the criteria for appropriateness in terms of drug choice, dose and duration. Our findings suggest that compliance with evidence-based guidelines for the use of antimicrobials is not optimal in hospitals in the private sector. Antimicrobials are prescribed inappropriately for empirical treatment and for surgical prophylaxis. Private hospital groups should consider adopting antimicrobial prescribing guidelines that are mandatory for doctors to adhere to in order to promote rational antimicrobial prescribing, and thereby reduce the burden of antimicrobial resistance.

Practices concerning sleeve gastrectomy in Turkey: A survey of surgeons.

BACKGROUNDLaparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgical procedure. LSG is a restrictive procedure and in this operation stomach volume is greatly reduced. When the details of the procedure are examined, it is seen that there are many different methods surgery.AIMTo analyze approaches of surgeons performing LSG.METHODSA questionnaire consist of 44 questions was sent by e-mail to the surgeons performing bariatric surgery. Approaches of surgery about preoperative period, surgical techniques and postoperative period was questioned.RESULTSDifferent approaches about antibiotic prophylaxis, stapler line reinforcement utilization, application of intraoperative and postoperative leakage test, approach to the crus and hiatal hernia repair were detected. It was observed that a few partipicipants applied contrary to the guidelines of antibiotic prophlaxis and thromboembolism prophylaxis. Approaches about other subjects were generally similar.CONCLUSIONIn this study, approaches about LSG that most common bariatric surgical procedure in our country was learned. According to these results, knowing the approaches in our country will be beneficial in terms of determining the training programs in bariatric surgery, improving surgical results and reducing the complications.

A quality improvement initiative to reduce venous thromboembolism on a gynecologic oncology service

ObjectiveTo describe and evaluate the effects of implementation of a venous thromboembolism (VTE) prophylaxis quality improvement (QI) initiative on a gynecologic oncology service at a single institution. MethodsPrior to 2018, no consensus gynecologic oncology VTE prophylaxis protocol existed at the authors' academic institution. Published, evidence-based guidelines were reviewed to create a standardized VTE risk stratification algorithm. Interventions to improve perioperative heparin administration and sequential compression device (SCD) compliance as well as provider/patient education efforts were introduced in January 2018. Initial efforts included nursing and patient SCD education, internal dissemination of VTE prophylaxis guidelines, and creation of a VTE ‘dashboard’ to track performance. During a second phase, VTE prophylaxis guidelines were reviewed and further refined, non-compliant operative cases reviewed weekly, and guidelines incorporated into the electronic medical record. Performance was measured using Tableau data software (www.tableau.com) and by separately evaluating adherence to the developed guidelines in three retrospective cancer-enriched surgical cohorts (2016–2017, 2018, 2019). ResultsCompared to the baseline period, we observed a reduction in VTE rate during the 2018–2019 VTE QI implementation period from 2.1% (19/905) to 1.0% (20/2015, p = 0.02) among gynecologic oncology inpatients. In the retrospective cancer-enriched cohorts, adherence to evidence based guidelines improved: 31.0% in 2016–2017, 69.1% in 2018, and 82.4% in 2019 (p < 0.001). There were no significant differences in rates of peri-operative blood transfusion, surgical site infections, hematomas, or vaginal cuff dehiscences. ConclusionsImplementation of a robust VTE prophylaxis QI initiative has resulted in improved VTE prophylaxis guideline adherence and higher rates of pre-operative heparin administration.

Prophylactic Dose of Oxytocin for Uterine Atony during Caesarean Delivery: A Systematic Review.

Objective—to overview, compare and generalize results of randomized clinical trials analyzing different oxytocin doses to prevent postpartum hemorrhage, initiate and maintain uterine contraction after Caesarean delivery. Methods—‘PubMed’, ‘EMBASE’, ‘CENTRAL’, and ‘CINAHL’ electronic databases were searched for clinical trials analyzing the effectiveness of different dose of oxytocin given intravenously during surgery for uterine contraction and to reduce postpartum hemorrhage. A systematic review of relevant literature sources was performed. Results—our search revealed 813 literature sources. A total of 15 randomized clinical trials, comparing different doses of oxytocin bolus and infusion used after caesarean delivery have met the selection criteria. Conclusion—oxytocin bolus 0.5–3 UI is considered an effective prophylactic dose. Recommended effective prophylactic oxytocin infusion dose is 7.72 IU/h, but it is unanswered whether we really need a prophylactic infusion of oxytocin if we choose effective bolus dose size and rate. Adverse hemodynamic effects were observed when a 5 UI oxytocin bolus was used. However, topics such as bolus dose size, infusion dose size and requirement as well as bolus injection rate, still remain unanswered. The doses that are recommended in the guidelines of peripartum hemorrhage prophylaxis are not confirmed by randomized controlled double-blind trials and more research should cover this topic.

683 A Quality Improvement Project (QIP) To Increase Compliance with Peri-Operative Antibiotic Guidelines in Colorectal Surgery (CS)

Abstract Introduction In CS, the correct use of antibiotics is important in order to reduce the risk of surgical site and intra-abdominal infections, whilst balancing risks from overuse of antibiotics. The Commissioning for Quality and Improvement (CQUIN) of 2019/20 identified that antibiotic prophylaxis guideline compliance could be enhanced in CS. This QIP aimed to improve local CS antibiotic prophylaxis and extension guideline compliance. Method In December 2019, an educational session was held to highlight the details of the local guideline and prescribing discrepancies. A3 posters of the guideline were created for accessible reference in operating theatres. Perioperative antibiotic prescription data from all colorectal elective cases in January 2020 were extracted and analysed using descriptive methods. Results Out of 93 cases in the sample, 70 (75.3%) were compliant with the prophylaxis guideline. However, metronidazole was commonly used in perianal surgery, which is not recommended. 13 cases required extension of the antibiotic course, of which seven were compliant (53.8%). The main issues included: use of agents and course durations which were not indicated; and a lack of antibiotic switch after a pause in therapy. Conclusions To further improve compliance with antibiotic guidelines, targeting historic practice, increasing awareness, and making systemic change is required for the next cycle.

Utilization of Pneumococcal Vaccine and Penicillin Prophylaxis in Sickle Cell Disease in Three African Countries: Assessment among Healthcare Providers in SickleInAfrica

Sickle cell disease is a genetic disease with a predisposition to infections caused by encapsulated organisms, especially Streptococcus pneumoniae. Pneumococcal vaccines and prophylactic penicillin have reduced the rate of this infection and mortality in sickle cell disease. However, implementation of these interventions is limited in Africa. The objectives of the study were to assess health care providers’ behaviors with the implementation of pneumococcal vaccination and penicillin prophylaxis and to identify barriers to their use. A 25-item online questionnaire was administered through SickleinAfrica: a network of researchers, and healthcare providers, in Ghana, Nigeria, and Tanzania, working to improve health outcomes of sickle cell disease in Africa. Data was collected and managed using the Research Electronic Data Capture (REDCap), tools and data analysis was done using STATA version 13 and R statistical software. Eighty-two medical practitioners responded to the questionnaire. Only 54.0 and 48.7% of respondents indicated the availability of published guidelines on sickle cell disease management and pneumococcal vaccine use, respectively, at their facilities. The majority (54.0%) perceived that the vaccines are effective but over 20.0% were uncertain of their usefulness. All respondents from Ghana and Tanzania affirmed the availability of guidelines for penicillin prophylaxis in contrast to 44.1% in Nigeria. Eighty-five percent of respondents affirmed the need for penicillin prophylaxis but 15.0% had a contrary opinion for reasons including the rarity of isolation of Streptococcus pneumoniae in African studies, and therefore, the uncertainty of its benefit. Lack of published guidelines on the management of sickle cell disease and doubts about the necessity of prophylactic measures are potential barriers to the implementation of effective interventions.

Impact of Intrapartum Antibiotic Prophylaxis for Group B Streptococcus on the Term Infant Gut Microbiome: A State of the Science Review.

Since the implementation of screening and prophylaxis guidelines for group B streptococcus (GBS) in the early 1990s there has been considerable advancement in scientific knowledge about the gut microbiome and its role in both health and disease processes. Research assessing early influences during the development of the infant gut microbiome has advanced considerably in the last 15 years. It is now widely accepted that early introduction of antibiotics in infancy is associated with increased risk for illness later in life. Research on antibiotic administration to pregnant individuals during labor for GBS colonization and its potential impact on the developing gut microbiome of term infants is now emerging. Despite the growing body of evidence of the negative impact of antibiotics on the gut microbiome, the guidelines for GBS prophylaxis among pregnant individuals have not changed significantly since their inception in the 1990s. This state of the science review examines the association between intrapartum antibiotic administration and alterations in the gut microbiome of term infants born vaginally, specifically in relation to microbial composition; the occurrence of and effect on antibiotic resistance genes in the infant gut; and the factors that may compound or mitigate these effects.

Bicuspid Aortic Valve in Infants, Children, and Adolescents: A Review for Primary Care Providers.

1. Talha Niaz, MBBS* 2. Jonathan N. Johnson, MD*,† 3. Frank Cetta, MD*,† 4. Timothy M. Olson, MD*,† 5. Donald J. Hagler, MD*,† 1. *Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, and 2. †Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN * Abbreviations: AHA : : American Heart Association BAV : : bicuspid aortic valve TTE : : transthoracic echocardiography Bicuspid aortic valve is the most common congenital heart defect in children, adolescents, and adults. Primary care providers play an important role in screening, referral, and follow-up of these patients and should be aware of the family screening guidelines, sports participation recommendations, and periodic follow-up requirements for adequate surveillance of the complications that arise from bicuspid aortic valve. After reading this article, readers should be able to: 1. Describe the epidemiology and anatomy of bicuspid aortic valve (BAV). 2. Understand the clinical presentation and diagnosis of BAV in infants, children, and adolescents. 3. Identify the various complications of BAV disease. 4. Discuss the management and follow-up requirements for BAV. 5. Analyze the family screening and sports participation guidelines for patients with BAV. Bicuspid aortic valve (BAV) is the most common congenital heart defect in children, adolescents, and adults. (1) It is a heterogeneous disease that affects both the aortic valve and the aorta. It can lead to many complications, including aortic valve stenosis, regurgitation, or endocarditis. (2)(3) It also can lead to dilation of the aorta, predisposing individuals to a significantly higher risk of aortic aneurysm and dissection. (4) Although most individuals with BAV present with these long-term complications during adulthood, a considerable number of patients may also present during childhood and adolescence with early-onset disease; that may require interventions in up to 12% to 15% of the patients. (5)(6) Therefore, patients with BAV require lifelong follow-up and surveillance. BAV has multiple implications in terms of sports participation and family screening, making it an important subject for primary care providers. This article reviews the anatomy, genetics, presentation, diagnosis, …

Primary prophylaxis of bacterial infections and Pneumocystis jirovecii pneumonia in patients with hematologic malignancies and solid tumors: 2020 updated guidelines of the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology (AGIHO/DGHO)

Hematologic and oncologic patients with chemo- or immunotherapy-related immunosuppression are at substantial risk for bacterial infections and Pneumocystis jirovecii pneumonia (PcP). As bacterial resistances are increasing worldwide and new research reshapes our understanding of the interactions between the human host and bacterial commensals, administration of antibacterial prophylaxis has become a matter of discussion. This guideline constitutes an update of the 2013 published guideline of the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Medical Oncology (DGHO). It gives an overview about current strategies for antibacterial prophylaxis in cancer patients while taking into account the impact of antibacterial prophylaxis on the human microbiome and resistance development. Current literature published from January 2012 to August 2020 was searched and evidence-based recommendations were developed by an expert panel. All recommendations were discussed and approved in a consensus conference of the AGIHO prior to publication. As a result, we present a comprehensive update and extension of our guideline for antibacterial and PcP prophylaxis in cancer patients.

Periprosthetic Joint Infection Prophylaxis in the Elderly after Hip Hemiarthroplasty in Proximal Femur Fractures: Insights and Challenges.

We review antibiotic and other prophylactic measures to prevent periprosthetic joint infection (PJI) after hip hemiarthroplasty (HHA) surgery in proximal femoral fractures (PFFs). In the absence of specific guidelines, those applied to these individuals are general prophylaxis guidelines. Cefazolin is the most widely used agent and is replaced by clindamycin or a glycopeptide in beta-lactam allergies. A personalized antibiotic scheme may be considered when colonization by a multidrug-resistant microorganism (MDRO) is suspected. Particularly in methicillin-resistant Staphylococcus aureus (MRSA) colonization or a high prevalence of MRSA-caused PJIs a glycopeptide with cefazolin is recommended. Strategies such as cutaneous decolonization of MDROs, mainly MRSA, or preoperative asymptomatic bacteriuria treatment have also been addressed with debatable results. Some areas of research are early detection protocols in MDRO colonizations by polymerase-chain-reaction (PCR), the use of alternative antimicrobial prophylaxis, and antibiotic-impregnated bone cement in HHA. Given that published evidence addressing PJI prophylactic strategies in PFFs requiring HHA is scarce, PJIs can be reduced by combining different prevention strategies after identifying individuals who will benefit from personalized prophylaxis.

Thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs comparing 2 reduced guidelines for pharmacological prophylaxis

ObjectiveTo determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing two guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC. MethodsCohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg/day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg/day for BMI of 35–40 and 60mg/day for BMI 40–60. Results675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010−2015 and 321 with Enoxaparin-Clexane® during the period 2016−2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g/dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months. ConclusionsThe combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding.

Plasma Concentrations of Cefazolin in Pediatric Patients Undergoing Cardiac Surgery

Background:The guideline for antibiotic prophylaxis in pediatric cardiac surgery is currently unavailable, and the effects of cardiopulmonary bypass (CPB) may result in low plasma cefazolin concentrations and subsequent postoperative surgical site infections (SSIs).Aims:To demonstrate the calculated-unbound plasma concentrations of cefazolin during uncomplicated pediatric cardiac surgery.Settings and Design:A prospective observational study that included 18 patients <seven years of age, undergoing elective cardiac surgery with CPB.Materials and Methods:An intravenous infusion of cefazolin (25 mg.kg-1) was administered to patients over 30 minutes within 1 hour before skin incision (first dose). Another 25 mg.kg-1 infusion was administered to the CPB prime volume (second dose). Blood samples were obtained at eight time points: 15 minutes after the first dose (T1); before aortic cannulation (T2); immediately after CPB initiation (T3); 30 (T4), 60 (T5), and 120 (T6) minutes after CPB; 15 minutes after CPB discontinuation (T7), and at skin closure (T8). The total plasma cefazolin concentrations were measured using liquid chromatography tandem mass spectrometry.Results:The unbound cefazolin concentrations were calculated assuming 80%-protein binding. The median cefazolin levels were 18.1 (range 4.3-27.0), 11.9 (2.8-24.1), 31.4 (18.3-66.1), 23.4 (13.7-35.9), 20.2 (15.4-24.9), 17.7 (14.8-18.0), 15.6 (9.8-26.2), and 13.3 (8.3-24.6) μg.mL-1 from T1-T8, respectively. The cefazolin levels remained four times above the minimum inhibitory concentrations (MICs) for Methicillin-sensitive S. aureus (MSSA) and S. epidermidis in most patients, but they were inadequate for Enterobacter and E. coli.Conclusion:This regimen produced adequate plasma cefazolin concentrations for common organisms that cause SSIs after cardiac surgery.