Prophylaxis Protocol Research Articles

Surveillance on antimicrobial Resistance pattern of Third Generation Cephalosporins at the Benjamin Mkapa Tertiary Hospital in Tanzania

Abstract Background Antimicrobial resistance is a burden in Tanzania and the world economy, resulting in financial losses from lower production brought on by illness due to greater treatment expenses and death. Second- and third-line antibiotics like third generations of cephalosporins should be used rather than first-line, which is an expensive option, due to AMR. The direct effects of AMR include severe prolonged illnesses, prolonged hospital stays death, and (Global Action Plan on Antimicrobial Resistance., 2015) Methodology The retrospective study design was used to review AST to assess the AMR patterns from 2020-2022 for urine, pus, and blood samples as stated in the National Action Plan-Antimicrobial Resistance 2017. Results Three years (2020, 2021, and 2022) of antibiograms based on priority samples, priority pathogens and third generations of cephalosporins for both gram-negative and gram-positive bacteria see Tables 1 and 2. The surveillance identified sensitive (S), intermediate(I), and resistance(R) for tested bacteria. The N is the isolate number. Our antibiograms for third-generation cephalosporins were represented by cefotaxime, ceftazidime and ceftriaxone. The antimicrobial resistance to ceftriaxone for Acinetobacter species was 62.5% while 76% for Citrobacter. E. coli at 60.26%, Enterobacter aerogenes at 67.86%, Klebsiella species at 73.48% at 22.73%, Morganella morganii 65.75% and Staphylococcus aureus at 62.5%, Serratia marcescens 64.56%. Similar resistance trends have been observed in cefotaxime and ceftazidime. Conclusion Antimicrobial susceptibility surveillance, antimicrobial rotation and presentation of findings to clinicians for increased awareness and the promotion of a multi-disciplinary approach to successful AMS programmers is essential. Evidence found will optimize the use of antibiotics. Clinicians, pharmacists, and scientists will use obtained evidence in the development of guidelines and protocols for surgical prophylaxis, setting IPC programs, management of bacterial blood infections (septicemia and sepsis) and managing urinary tract infections by focusing on red flags antibiotics and bacteria such E. coli and K. pneumoniae. Avoiding delay of AST results by enough resources, and technology advancement. This enable identification of the causative pathogens facilitated the correct diagnosis, de-escalation, and use of targeted agents, which are necessary to promote the prudent use of antimicrobials. Antibiograms Table 1: Antibiogram of gram-negative bacteria Table 2: Antibiogram of gram-positive bacteria

An observational study on the use of low-molecular-weight heparin for venous thromboembolism prophylaxis in acute stroke patients

Venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE) are common complications post-stroke. The UK stroke guidelines recommend the early use of intermittent pneumatic compression devices (IPCDs). At our center, we noticed poor compliance with the use of these devices and sought to develop a pathway for early implementation of low-molecular-weight heparins (LMWH) instead. We retrospectively analyzed the data of 2351 patients in two separate groups and compared both groups to check the incidence of PEs and DVTs as stated on the discharge documentation. Group A consists of 1599 patients who used IPCDs as VTE prophylaxis, whereas Group B involved 752 patients who were placed on the new VTE prophylaxis protocol, which involved the early use of LMWH with enoxaparin delivered subcutaneously. It was observed that IPCDs were not well tolerated by patients, leading to poor compliance with VTE prophylaxis in Group A. VTE compliance was noted to be better in Group B in which the patients were given LMWH in the hospital. Furthermore, symptomatic DVT and PE were not found to be higher in Group B patients, but in fact, the incidence of these conditions was lower in this group. In conclusion, compared to IPCDs, LMWH appears to be well tolerated by patients during the admission period owing to acute stroke. It was observed that the incidence of VTE was reduced in patients who started on early LMWH in the post-stroke period. However, the long-term effects of LMWH prophylaxis, in terms of mortality and morbidity, need to be delineated. Therefore, an additional large trial on the early use of LMWH in comparison to IPCDs is warranted.

Development and Implementation of a Venous Thromboembolism Prophylaxis Protocol in the Rehabilitation Setting – A Completed Audit Cycle

Abstract Background 63% of all Venous Thromboembolic disease (VTE) is hospital-acquired, and 70% of hospital-acquired VTE is potentially preventable with appropriate prophylaxis. NICE recommends a VTE risk assessment for all patients admitted to acute hospitals within 24 hours. Validated risk assessment models for acute hospitals enhance provision of thromboprophylaxis, but no such protocols exist for the rehabilitation setting. The aims of this audit were to determine if VTE risk assessments are occurring on admission and during acute illness in rehabilitation wards, to assess the proportion of rehabilitation inpatients receiving VTE prophylaxis, and to develop and pilot a VTE Prophylaxis Protocol. Methods An initial audit was carried out on three rehabilitation wards in May/June 2023. A VTE Prophylaxis Protocol was developed based on the HSE VTE Prevention Program template, incorporated into the admission booklet on 3 pilot wards in February 2024, and practice re-audited in April 2024. Results Pre-intervention, 41 patient records were assessed. 0 patients (0%) had a documented VTE risk assessment on admission, 23(56%) had therapeutic anticoagulation continued, and 3(7%) commenced appropriate VTE prophylaxis on admission. 8 eligible at-risk patients did not receive prophylaxis. Post intervention, all patients (n=25) on the three pilot wards were re-audited. 10 patients (40%) had a documented VTE Risk assessment within 24 hours of admission, 9(36%) had therapeutic anticoagulation continued, and 5(20%) received appropriate VTE prophylaxis on admission (2 without a documented risk assessment). 3 at-risk patients did not receive prophylaxis (1 with a completed risk assessment), and 1 risk-assessed patient inappropriately received prophylaxis. Conclusion Implementation of a VTE Prophylaxis Protocol improved VTE risk assessment in rehabilitation. This small sample however did not demonstrate an association between prophylaxis prescription and use of the protocol. Further education and feedback is required to increase use of the protocol as part of this ongoing quality improvement project.

Association between bariatric surgery preoperative chemoprophylaxis and postoperative bleeding.

Use of chemoprophylaxis for prevention of venous thromboembolism (VTE) after bariatric surgery is a generally accepted principle; however, the optimal strategy in terms of medication type and pre- and postoperative dosing is uncertain. In our healthcare system, four hospitals performed bariatric surgery and utilized differing protocols for VTE prophylaxis. The analysis sought to evaluate the association of differing prophylaxis strategies on bleeding and VTE occurrence. Adult patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from 2018 to 2021 at four hospitals were studied. Patients were grouped by whether or not they received preoperative chemoprophylaxis. The primary outcome was postoperative bleeding, defined as requiring a blood transfusion or reoperation for bleeding within 30days. Bivariate analyses were performed with Chi-square and Wilcoxon Rank tests where applicable. Multivariate logistic regression was performed for the outcome of postoperative bleeding. A total of 2145 bariatric surgeries were evaluated (33.6% RYGB, 66.4% SG). Among 1712 patients who underwent surgery at Hospitals A, B, and C, 93.1% received preoperative VTE prophylaxis, compared with 1 patient (0.1%) among 433 patients operated on at Hospital D. Postoperative bleeding occurred more frequently in patients who received preoperative VTE prophylaxis versus those who did not (3.7% vs 1.1%; p < 0.01). After multivariable regression analysis, only RYGB (OR 3.59; p < 0.01) and preoperative VTE prophylaxis (OR 3.54; p = 0.02) were significantly associated with postoperative bleeding. Rates of VTE for patients receiving preoperative VTE prophylaxis or no prophylaxis were not significantly different (0.6% vs. 0.2%; p = 0.26). Preoperative VTE prophylaxis prior to bariatric surgery was associated with postoperative bleeding without differences in VTE occurrence. These results call into question the routine use of VTE chemoprophylaxis for all patients undergoing bariatric surgery and favor selective usage.

Antibiotic use in cesarean procedures in developing countries: current practices and improvements

Cesarean delivery, a common surgical procedure worldwide, is associated with a significantly increased risk of postoperative infections compared to vaginal births. This risk is notably higher in developing countries due to varying practices in antibiotic prophylaxis and differences in healthcare settings. This study aims to evaluate the current practices and potential improvements in antibiotic use in cesarean sections within these regions. Our analysis revealed that cesarean sections are performed at an increased rate in developing countries, with infection rates ranging from 10% to 40%, primarily due to inconsistent and often inadequate antibiotic prophylaxis. The most common postoperative infections include endometritis, wound infections, and urinary tract infections, largely influenced by factors such as the timing of antibiotic administration, the choice of antibiotic, and the presence of risk factors like prolonged labor and membrane rupture. The standard practice in many developing countries involves the administration of antibiotics post-cord clamping, which has been challenged by recent studies suggesting that preoperative administration can significantly reduce infection rates without adverse effects on neonatal outcomes. A shift towards a single dose of broad-spectrum antibiotics such as cephalosporins administered 30-60 minutes before incision is recommended based on our findings. This approach aligns with the successful reduction of infectious morbidity observed in developed countries and supports the need for standardized guidelines. Furthermore, our study underscores the importance of healthcare provider education and the establishment of clear protocols for antibiotic prophylaxis in cesarean sections. By adopting these improvements, developing countries can achieve a significant reduction in maternal morbidity and contribute to safer childbirth practices.

Novel protocol for prevention from hepatitis B reactivation following living-donor liver transplantation.

Reactivation of hepatitis B virus (HBV) after liver transplantation (LT) remains a problem; thus, development of more effective HBV reactivation prophylaxis is desirable. We evaluated the efficacy of a combination of a long-term nucleotide analog (NA), such as entecavir (ETV) or tenofovir alafenamide (TAF), and short-term hepatitis B immunoglobulin (HBIG) in preventing HBV reactivation and compared it with conventional HBV prophylaxis. Between February 1999 and August 2023, 135 patients underwent living-donor liver transplantation for liver cirrhosis or acute liver failure caused by HBV infection or received an LT from a hepatitis B core antibody-positive donor. Recipients who had undergone LT were classified as being in the first or second era (namely until September 2017 and from October 2017), respectively, and outcomes of prophylaxis against HBV reactivation were compared between the two eras. In the second era, recipients with HBV-related disease or who had received hepatitis B core antibody-positive liver received combination therapy with short-term HBIG and an NA such as TAF and ETV long-term. The duration of HBIG treatment was markedly shorter than in the first era in both categories of patients and HBIG could be discontinued in all cases. Surprisingly, we observed HBV reactivation in the first era, but not in the second era, in both groups. We have established a protocol for prophylaxis against HBV reactivation using a combination of short-term HBIG and long-term NA. This protocol was found to be sufficient to prevent HBV reactivation after LT.

VALIDAÇÃO DE WEBSITE PARA IMPLANTAÇÃO DO PROTOCOLO PERIOPERATÓRIO NA PROFILAXIA DE TROMBOEMBOLISMO VENOSO

Introduction: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the leading cause of preventable postoperative deaths. Identifying risk factors based on Virchow’s Triad (blood stasis, hypercoagulability, and endothelial injury) is crucial. Approximately 20% of surgical patients develop VTE, with 7% resulting in fatal PE. The Caprini risk score, used to assess VTE risk, is complex and has limited adherence despite its validation across various specialties. Methodology: The applied research developed the application of a perioperative protocol for VTE prophylaxis in the Vascular Surgery ward of the Hospital Municipal de Marabá. The descriptive and quantitative study was structured via website. The 2013 version of the Caprini score was adopted for risk stratification. Validation of the tool involved 16 experts with inclusion criteria focused on doctors and nurses with experience in the area, where everyone responded to the Likert scale that evaluated 2 major domains of the tool: usability and functionality. Results: Among the 16 evaluators, 56,3% were male and 43,8% female, with an average age of 32,4 years and 7,6 years of experience. The system’s functionality received 97,5% approval, 96,3% of reliability, and 91,3% regarding interface and usability. The utility was well-rated, with 98,8% approving the professional facilitation. Chi-square tests indicated that functionality perception did not vary between physicians and nurses, but utility was significantly influenced by profession. Cronbach’s alpha coefficients indicated high internal consistency: 0,85 for functionality and 0,77 for utility. Discussion: The diverse profiles of the evaluators enriched the website’s validation. Functionality was consistently positively rated, while utility varied by professional role. High internal consistency suggests that the questionnaire is reliable for measuring website performance perceptions. Conclusion: The inclusion of the Caprini protocol in the Tupan Health website demonstrated good performance and high reliability among professionals, facilitating protocol adherence and the prevention of perioperative complications.

Post-transplantation cyclophosphamide and cyclosporine A versus methotrexate and cyclosporine A for graft-versus-host disease prophylaxis after allogeneic peripheral stem cell transplantation in adult acute myeloid leukemia patients

BackgroundDifferent prophylactic protocols are available for preventing graft-versus-host disease (GVHD) after matched sibling donor (MSD) allogeneic hematopoietic cell transplantation (allo-HCT). This study aimed to compare the effectiveness of post-transplantation cyclophosphamide plus cyclosporine A (PT-CY/CSA) versus methotrexate plus CSA (MTX/CSA) as GVHD prophylaxis protocols in adult acute myeloid leukemia (AML) patients who received peripheral blood stem cells (PBSC) from fully matched donors. MethodsThe 1-year outcomes of 89 patients treated with PT-CY/CSA and 90 patients treated with MTX/CSA who had MSD allo-HCT for AML using unmanipulated mobilized PBSC were examined and compared. ResultsThe cumulative incidence of acute GVHD at 100 days was considerably lower in the PT-CY/CSA group (4% vs 19.3%, p = 0.002), however there were no statistically significant difference in the cumulative incidence of chronic GVHD at 1-year (19.6% vs 37.4%, p = 0.053). Significant delays in neutrophil and platelet engraftments were reported in the PT-CY/CSA group (17 vs 12 days) and (13 vs 12 days), respectively (p < 0.001). The cumulative incidences of relapse (19.1% vs 13.7%, p = 0.470), overall survival (79.1% vs 77.3%, p = 0.986), non-relapse mortality (16.5% vs 16.8%, p = 0.837), and the GVHD and relapse-free survival (GRFS) (53.7% vs 46.6%, p = 0.478) did not differ statistically at 1-year. ConclusionPT-CY/CSA demonstrated a significant decrease in the rate of acute GVHD. However, it was associated with engraftment delay.

Comparison of Surgical Site Infection After Instrumented Spine Surgery in Patients With High Risk of Infection According to Different Antibiotic Prophylaxis Protocols: A Cohort Study of 132 Patients With a Minimum Follow-Up of 1 year.

Observational Study. Surgical site infections (SSIs) are one of the major complications in spine surgery. Numerous factors that increase the risk of SSI have been widely described. However, clinical guidelines on antibiotic prophylaxis are usually common for all patients. There are no specific guidelines for patients with a high risk of infection. The aim of this paper is to create a specific protocol for patients at high risk of SSI. This is a three-cohort study using a prospective database. Risk patients are those who meet at least two of the following criteria: obesity, diabetes, reoperation and immunosuppression. Between October 2021 and April 2023, 132 patients were recruited.They were divided into three cohorts: cohort A, 46 patients, standard prophylaxis with cefazolin 2g/8h for 24h; cohort B, 46 patients, cefazolin 2g/8h and amikacin 500mg/12h for 24h; cohort C, 40 patients, cefazolin 2g/8h and amikacin 500mg/12h for 72h. There was a significant decrease in the infection rate depending on the prophylaxis (23.9% in cohort A, 8.7% in cohort B, and 2.5% in cohort C). When logistic regression models were applied and cohorts B and C were compared with A, the following results were obtained: OR of 0.30 (CI: 0.08 - 0.97; P = 0.057) and 0.08 (IC: 0.00 - 0.45; P = 0.019), respectively. Prophylaxis with prolonged double antibiotic therapy with cefazolin and amikacin is associated with a statistically significant decrease in the rate of SSI in patients with a high risk of infection.

Prolonged 120-h meropenem antibiotic prophylaxis in radical cystectomy compared to 24h standard antibiotic prophylaxis: Final analysis of the randomized clinical trial

ABSTRACT Background Standard 24-h antibiotic prophylaxis (AP) is widely employed to minimize the risk of infection complications (ICs) within 30 days following a radical cystectomy (RC). However, a considerable variety of prophylaxis protocols do not prevent a high ICs rate after surgery (37–67%). Therefore, antibiotic’s type and its duration are still controversial for AP.( Objective To compare standard 24-h AP with a prolonged 120-h regimen in a multicenter randomized clinical trial. Methods Patients were randomized in a 1:1 ratio to standard 24-h AP regimen (Group A) versus the prolonged meropenem AP 120-h (Group B). The primary endpoint was an event rate defined as the frequency of ICs within 30 days. The secondary endpoint were biomarker’s analysis and antibiotic re-administration rate (ArAR). Results A total of 92 patients were enrolled. The Clavien-Dindo complications rate did not differ between the groups (p = 0.065), however the overall complication rate was higher in Group A (63.0% vs. 34.8%, p = 0.007). The infection complication rate was 2.75 times higher in the standard antibiotic prophylaxis group: 47.8% compared to 17.4% cases in Group B (p = 0.002). The new prolonged antibiotic regimen decreased the risk of ICs (OR 0.23; 95% CI 0.08–.598; p = 0.003). The event-free survival for ICs of clinical interest in group A was 7.00 days and in group B was 9.00 days (HR = 0.447; 0.191–1.050, p = 0.065). The ArAR was higher in Group A -47.8%, while in Group B it was only in 17.4% of the cases. The incidence of bacteriuria before RC was the same between groups (p = 0.666), however, after stent removal the risk of a positive culture was lower in group B (RR = 0.64; 95% CI 0.37–1.08; p = 0.05). Conclusions The administration AP over 120-h appears to be safe and feasible, demonstrating a reduction in the total number of complications and ArAR. Trial registration in Clinical Trials: NCT05392634. Trial registration in Clinical Trials: NCT05392634.

Postoperative management following osteotomies around the knee: a narrative review.

The present narrative review provides a summary of postoperative therapy modalities and their effectiveness following osteotomies around the knee. The topics that are discussed in the scientific discourse include support of cartilage cell regeneration, pain management, drainage insertion, tourniquet use, pharmacological and mechanical thromboembolism prophylaxis, weight-bearing protocols and bone consolidation. There is evidence for the use of pharmacological thromboembolism prophylaxis and weight-bearing protocols. A standardized postoperative treatment concept following osteotomies around the knee cannot be derived due to lack of evidence for the other topics in current literature.

Effect measure modification in an RCT of antibiotic prophylaxis in laparoscopic cholecystectomy: A secondary analysis

Background: Antimicrobial resistance is a growing public health threat. To alleviate selective pressure which leads to the emergence and proliferation of resistance, and to preserve the utility of treatments where they are needed the most, antimicrobial stewardship programs (ASPs) could consider revising surgical antibacterial prophylaxis protocols for low-risk procedures such as laparoscopic cholecystectomy. Methods: Publicly available data was used from a well-powered randomized controlled trial conducted by Matsui and colleagues during 2007-2013 in Japan on the effectiveness of prophylactic antibacterial treatment on reducing post-operative infections following laparoscopic cholecystectomy in low-risk patients. A total of 1037 patients were randomized to receive treatment or no treatment. After randomization, laparoscopic cholecystectomies were converted to open procedures in 28 patients, 14 in each arm, constituting a deviation from the protocol and the administration of additional antibacterial treatment. The original study included both intention-to-treat and per-protocol analyses, finding statistically significant reductions in post-operative infections in the treatment vs no treatment arm (1.2% vs 6.7%, p&lt;0.0001; 1.0% vs 5.9%, p&lt;0.0001, respectively). In the present analysis I assessed the extent to which type of procedure modified the effect of antibacterial prophylaxis on post-operative infection using both additive and multiplicative interaction. Risk and risk differences were estimated using a linear-binomial model and risk ratios were estimated using a log-binomial model. Alpha was set to 0.10. The lowest risk categories for each variable, being assigned to treatment and receiving a laparoscopic procedure, defined the common reference category. Results: A 35 percentage point (pp) increase in the risk of post-op infections relative to the reference category was attributable to the joint effects of omitting prophylaxis and conversion to an open procedure (90% CI 14, 56), compared to a 5 pp increase attributable to omission of prophylaxis (90% CI 3, 7) or a 6 pp increase attributable to conversion to an open procedure (90% CI -5, 18) by themselves. The interaction contrast capturedthis super-additive 24 pp increase in risk (90% CI -1, 47). The relative excess risk due to interaction was 23.81 (90% CI -5.56, 53.19), suggesting a departure from additivity as well. Conclusions: Patients undergoing open cholecystectomies stand to benefit the most from antibacterial prophylaxis compared to patients who have laparoscopic cholecystectomies. ASPs could consider reducing or eliminating surgical prophylaxis in low-risk procedures such as laparoscopic cholecystectomy to alleviate selection pressure for antibacterial resistant organisms and preserve its effectiveness for people undergoing higher risk procedures.

A More Selective vs a Standard Risk-Stratified, Heparin-Based, Obstetric Thromboprophylaxis Protocol

In 2016, our institution adopted a pregnancy-related venous thromboembolism (VTE) prophylaxis protocol based on American College of Obstetricians and Gynecologists guidelines that recommended postpartum heparin-based chemoprophylaxis (enoxaparin) based on a risk-stratified algorithm. In response to increased wound hematomas without significant reduction in VTE using this protocol, a more selective risk-stratified approach was adopted in 2021. To evaluate outcomes of the more selective risk-stratified approach to heparin-based obstetric thromboprophylaxis (enoxaparin) protocol. Retrospective observational study of 17 489 patients who delivered at a single tertiary care center in the southeast US between January 1, 2016, and December 31, 2018 (original protocol), and between December 1, 2021, and May 31, 2023 (more selective protocol). Patients receiving outpatient anticoagulation for active VTE or high VTE risk during pregnancy were excluded. Standard risk-stratified and more selective postpartum VTE chemoprophylaxis protocols. The primary outcome was clinical diagnosis of wound hematoma up to 6 weeks pos tpartum. The secondary outcome was new diagnosis of VTE up to 6 weeks post partum. We compared baseline characteristics and outcomes between groups and estimated adjusted odds ratios with 95% CIs of primary and secondary outcomes using the original protocol group as reference. Of 17 489 patients included in the analysis, 12 430 (71%) were in the original protocol group and 5029 (29%) were in the more selective group. Rates of chemoprophylaxis decreased from 16% (original protocol) to 8% (more selective protocol). Patients in the more selective group were more likely to be older, be married, and have obesity or other comorbidities (hypertension, diabetes, cardiac disease). Compared with the original protocol, the more selective protocol was associated with a decrease in any wound hematoma (0.7% vs 0.3%; adjusted odds ratio [aOR], 0.38; 95% CI, 0.21-0.67), specifically due to a lower rate of superficial wound hematomas (0.6% vs 0.3%; aOR, 0.43; 95% CI, 0.24-0.75). There was no significant increase in VTE or individual types of VTE (0.1% vs 0.1%; aOR, 0.40; 95% CI, 0.12-1.36). A more selective risk-stratified approach to an enoxaparin thromboprophylaxis protocol for VTE was associated with decreased rates of wound hematomas without increased rates of postpartum VTE.

Maximizing Adherence and Minimizing Time to Antibiotics: A Multidisciplinary Institutional Trauma Bay Protocol for Single Antibiotic Prophylaxis in Open Fractures.

To determine if a multidisciplinary institutional protocol can optimize the time to antibiotic (Abx) administration for open fractures (openFx) and improve compliance with the administration of Abx prophylaxis during trauma activation. Retrospective pre-post study design. Single Level II Trauma Center. All patients who triggered a trauma activation with suspected openFx and were treated according to the institutional single antibiotic regimen were eligible for inclusion. Patients were excluded if fractures did not involve the appendicular skeleton. Patients treated before implementation of a standardized institutional protocol where premixed IV bags of antibiotics were stocked in automated dispensing systems within ED trauma bays (January 2021-October 2022) were defined as the "pre" group and those treated following implementation the "post" group. The primary outcome was time from trauma bay arrival to antibiotic aministration, measured in minutes, with comparisons made between preprotocol and postprotocol implementation. Secondary outcomes for comparison included rates (%) of time to Abx <60 minutes, allergic reactions, acute kidney injury, ototoxicity, surgical site infection, multi-drug-resistant organisms identified in blood or biopsy cultures in cases requiring reoperation, and Clostridium difficile infection in the gastrointestinal system, confirmed by stool test results, within 30 days. Twenty-four patients (mean age 39.5 ± 16.3 years) met the criteria after protocol implementation compared with 72 patients (mean age 34.3 ± 14.8 years) before implementation. Implementation of the institutional protocol resulted in a significant reduction in the time to Abx administration for openFx from 87.9 ± 104.6 minutes to 22.2 ± 12.8 minutes in the postprotocol group ( P < 0.001). In addition, only 53% in the preprotocol group received Abx within 60 minutes compared with 96% in postprotocol group ( P < 0.001). Post hoc power analysis revealed that the study was powered at 92% (effect size = 0.72) to detect a significant difference between the preprotocol and postprotocol groups. This study provides evidence that a multidisciplinary institutional protocol for the administration of Abx prophylaxis can be an effective strategy for optimizing the time to Abx administration in cases of suspected openFx. This protocol may be implemented in other trauma centers to optimize time to Abx administration for openFx. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surveillance of surgical site infections in orthopedic prosthetic surgery: a tool for identifying risk factors and improving clinical practice.

Surgical site infections (SSIs) are among the most frequently encountered complications in prosthetic surgery, and are associated with increased hospitalization, costs and in-hospital mortality. There is no national system for the comprehensive monitoring of the incidence of SSIs. All patients undergoing orthopedic prosthetic surgery from April 1 to June 30, 2023 were enrolled. Clinical evaluation of the surgical site was conducted at 30 days, and a follow-up telephone interview was carried out by means of a specially designed questionnaire at 90 days. A total of 59 patients were included. Surgery was performed on the knee in 71.19% and on the hip in 28.81%. The patients' mean BMI was 28.25 ± 2.97, and their mean ASA score was 2.67 ± 0.58. Six patients had diabetes mellitus. The incidence of SSIs was 5.08%; two infections occurred in knee prosthesis surgery and one in hip surgery. Analysis of the data revealed that diabetes was the main risk factor for the development of infection. Although based on a small number of patients, these results are encouraging, especially considering that the patients had an average ASA score of more than 2 and a high BMI. However, to further reduce the risk of infection, improved hygiene measures have now been implemented in the operating room and the antibiotic prophylaxis protocol has been updated to take into account the potential for MRSA colonization.

Evaluating antibiotic prophylaxis adherence: Implications for surgical site infections and wound care management

AimThis study aimed to evaluate adherence to an antibiotic prophylaxis protocol and its impact on incidence of surgical site infection (SSI). Materials and methodA prospective observational cohort study was conducted at a teaching hospital in São Paulo, Brazil, from September to November 2015. The population were adults who underwent surgery with surgical antibiotic prophylaxis. The main outcomes measured were incidence of SSI at 30-days postoperatively, protocol adherence and surgical wound complications. STROBE guidelines were followed. ResultsAmong the 527 participants recruited, a 30-day follow-up was completed by 78.7 % (n = 415). Within this cohort, 57.6 % were females aged over 60 years (36.4 %). The incidence of SSI stood at 9.4 % (n = 39), with dehiscence being the most prevalent complication at 64.1 % (n = 25), followed by increased exudate at 51.3 % (n = 20). Notably, full adherence to the antibiotic prophylaxis protocol was low at 1.7 % (n = 7). The study observed a 60 % increased risk of SSI for every protocol mistake made. Alarmingly, 17.8 % (n = 74) of participants received antibiotic treatment exceeding the stipulated protocol duration. The overall mortality rate stood at 13.5 % (n = 56), with 1 % (n = 4) of these deaths attributed to SSI. ConclusionThere is a pressing global necessity to enhance antibiotic management, as underscored by this study's revelation of low adherence to the antibiotic prophylaxis protocol. This lack of adherence correlated with a notable incidence of SSI and subsequent wound complications. Nearly 20 % of participants received prolonged antibiotic treatment. Adhering strictly to the protocol could substantially impact SSI-related outcomes and enhance global antibiotic management.

After primary shoulder arthroplasty appropriate vancomycin antibiotic prophylaxis does not lead to increased infectious complications when compared to cefazolin

INTRODUCTIONIn primary shoulder arthroplasty (SA), intravenous (IV) cefazolin has demonstrated lower rates of infectious complications when compared to IV vancomycin. However, previous analyses included SA cohorts with both complete and incomplete vancomycin administration. Therefore, it is currently unclear whether cefazolin still maintains a prophylactic advantage to vancomycin when it is appropriately indicated and sufficiently administered at the time of surgical incision. This study evaluated the comparative efficacy of cefazolin and complete vancomycin administration for surgical prophylaxis in primary shoulder arthroplasty with respect to infectious complications. METHODSA retrospective cohort study was conducted utilizing a single institution total joint registry database, where all primary SA types (hemiarthroplasty, anatomic total shoulder arthroplasty, reverse shoulder arthroplasty) performed between 2000 to 2019 for elective and trauma indications using IV cefazolin or complete vancomycin administration as the primary antibiotic prophylaxis were identified. Vancomycin was primarily indicated for patients with a severe self-reported penicillin or cephalosporin allergy and/or MRSA colonization. Complete administration was defined as at least 30 minutes of antibiotic infusion prior to incision. All included SA had at least 2 years of clinical follow-up. Multivariable Cox proportional hazard regression was used to evaluate all-cause infectious complications including survival free of prosthetic joint infection (PJI). RESULTSThe final cohort included 7,177 primary SA, 6,879 (95.8%) received IV cefazolin and 298 (4.2%) received complete vancomycin administration. Infectious complications occurred in 120 (1.7%) SA leading to 81 (1.1%) infectious reoperations. Of the infectious complications 41 (0.6%) were superficial infections and 79 were (1.1%) PJIs. When categorized by administered antibiotics, there were no differences in rates of all infectious complications (1.6% vs. 2.3%; P = .352), superficial complications (0.5% vs. 1.3%; P = .071), PJI (1.1% vs. 1.0%; P = .874), or infectious reoperations (1.1% vs. 1.0%; P = .839). On multivariable analyses, complete vancomycin infusion demonstrated no difference in rates of infectious complications compared to cefazolin administration (hazard ratio [HR], 1.50 [95% confidence interval (CI), 0.70 to 3.25]; P = .297), even when other independent predictors of PJI (male sex, prior surgery, and Methicillin-resistant Staphylococcus aureus colonization) were considered. CONCLUSIONSIn comparison to cefazolin, complete administration of vancomycin (infusion to incision time greater than 30 minutes) as the primary prophylactic agent does not adversely increase the rates of infectious complications and PJI. Prophylaxis protocols should promote appropriate indications for the use of cefazolin or vancomycin, and when necessary, ensure complete administration of vancomycin to mitigate additional infectious risks after primary SA.

Analyzing the Efficacy of Metronidazole as Additional Surgical Site Infection Prophylaxis in Patients Undergoing Hysterectomy [ID 2683482

INTRODUCTION: The American College of Obstetricians and Gynecologists recommends cefazolin for antibiotic surgical prophylaxis for hysterectomy procedures. In 2018, hysterectomy surgical site infection (SSI) data at John Peter Smith Hospital demonstrated a higher proportion of anaerobic growth identified on cultures. The addition of metronidazole with cefazolin became surgical prophylaxis protocol at our institution. The purpose of the study is to compare rates of non-superficial SSI before and after the addition of metronidazole in hysterectomy procedures. METHODS: This was a retrospective cohort study of patients who underwent hysterectomy of any surgical approach from January 2015 to July 2023. The primary exposure of interest was administration of metronidazole with additional covariates including age, body mass index, diabetes, oncology status, and wound class. The association between metronidazole administration and non-superficial SSI was examined using a logistic regression model. Appropriate waiver was received from the institutional IRB. RESULTS: Two thousand five hundred thirty-four hysterectomies were included in our cohort. 1,207 (44%) cases had metronidazole administration, with 98% of those cases occurring after the antibiotic was incorporated into the protocol. Of the patients who did not receive metronidazole, 49 (3.7%) patients had a non-superficial SSI compared to 14 (1.2%) patients that had a non-superficial SSI with metronidazole administration. After adjusting for age and oncology status, patients who did not receive metronidazole had higher odds of having a SSI compared those who did (adjusted odds ratio [aOR]: 3.6; 95% CI: 1.97, 6.3; P≤.0001). CONCLUSION: The results demonstrate potential infection prevention benefit with metronidazole to patients undergoing hysterectomy, supporting the institutional prophylaxis protocol. The findings could have further implications across hospitals with similar patient populations.

Sustained success of a Caprini postoperative venous thromboembolism prevention protocol over one decade

BackgroundThe objective of this study was to review the long-term efficacy of a post-operative venous thromboembolism (VTE) prevention program at our institution. MethodsWe performed a review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data at our hospital from January 2008–December 2022. The primary outcome was risk-adjusted VTE events. ResultsIn 2009, a postoperative general surgery patient was three times more likely to have a postoperative VTE event than predicted (O/E ratio 3.02, 95% CI 1.99–4.40). After implementing a mandatory VTE risk assessment model and a risk-commensurate prophylaxis protocol in the electronic medical record in 2011, the odds ratio of a patient developing a postoperative VTE declined to 0.70 by 2014 (95% CI 0.40–1.23). This success persisted through 2022. ConclusionsSince the implementation of a standardized postoperative VTE prevention program in 2011, our institution has sustained a desirably low likelihood of VTE events in general surgery patients.

Analysis of Aetiological Agents in Infectious Endocarditis in the Central Military Emergency University Hospital "Dr. Carol Davila" Bucharest.

Infective endocarditis (IE) is a pathological condition caused by various microbial agents that can lead to severe complications affecting the heart. Accurate diagnosis is crucial for the effective management of patients with IE. Blood culture is the gold standard for identifying the primary infectious agents, which is a key factor in diagnosing IE using the modified Duke criteria. The main objective of this study was to investigate the distribution of the etiological agents of IE and the most common secondary diagnoses associated with it. A total of 152 patients aged 23-95 years with a diagnosis of IE and proven etiology (through blood cultures or serological tests) were included in this study. The most common etiological agent identified through blood tests was Enterococcus faecalis, which was detected in 39 patients (23.5%). Staphylococcus aureus was the second most common agent and was identified in 33 patients (19.9%), followed by Staphylococcus epidermidis, which was identified in 12 patients (13.1%). Nine patients (5.8%) had high levels of anti-Coxiella burnetti IgG phase I and II antibodies. IE is a leading cause of death in the Department of Infectious Diseases. Early and accurate diagnosis, along with interdisciplinary treatment, can significantly increase the chances of patient survival. Currently, Enterococcus faecalis and Staphylococcus aureus are the dominant etiological agents of IE, highlighting the need to revise protocols for prophylaxis, diagnosis, and initial treatment of this condition.