Recommendations For Prophylaxis Research Articles

Chemotherapy-induced nausea and vomiting : Current recommendations for prophylaxis

The chemotherapy-induced nausea and vomiting (CINV) is one of the most frequent side effects in cytostatic therapy and aprofound challenge during the therapy of cancer patients. Therefore, standardized guideline-orientated prophylaxis is essential and afundamental contribution for the success of treatment. This review summarizes the current recommendations for CINV of the Multinational Association of Supportive Care in Cancer (MASCC) and European Society of Medical Oncology (ESMO), the American Society for Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN) and the S3-guideline Supportive Therapie of the Leitlinienprogramm Onkologie and shall facilitate its use in the daily routine.

Overuse of antimicrobial prophylaxis in low-risk patients undergoing transurethral resection of the prostate

To evaluate the current antimicrobial prophylaxis practices for low-risk patients undergoing transurethral resection of the prostate (TURP) or photoselective vaporisation of the prostate (PVP) in comparison with the antimicrobial prophylaxis recommendations of the European Association of Urology (EAU), which have been shown to effectively reduce infectious complications and antimicrobial resistance rates. In May 2017, we sent an anonymous online -survey to board-certified urologists in Germany, Austria and Switzerland, by use of the database directory of the respective urology associations. Besides demographical questions, urologists were asked about their sources of information on antimicrobial prophylaxis prescription and their prescribing patterns before, during and after surgery in patients without an indwelling catheter or significant bacteriuria undergoing TURP or PVP. Overall, 374 of 5825 urologists responded, of whom 76% (286/374) performed TURP and 16% (60/374) PVP. For TURP and PVP, respectively: (i) 42% (119/286) and 33% (20/60) reported routine use of preoperative antimicrobial prophylaxis, which does not conform to guideline recommendations; (ii) 43% (124/286) and 52% (31/60) reported prescribing non-recommended perioperative antimicrobial prophylaxis regimens; and (iii) 60% (172/286) and 65% (39/60) routinely extended antimicrobial prophylaxis after surgery for up to one week. In summary, of the urologists who responded to the questionnaire, 74% (211/286) reported nonadherence to guidelines on antimicrobial prophylaxis for TURP. A low adherence to guidelines for low-risk patients undergoing TURP or PVP was reported. Given these preliminary data, there is an urgent need to monitor adherence to antimicrobial prophylaxis guidelines in urology to reduce antimicrobial resistance rates.

Venous Thromboembolism Prophylaxis in Hospitalized Patients With Inflammatory Bowel Disease: Are We Falling Short?

BACKGROUND: Venous Thromboembolism (VTE) in hospitalized Inflammatory Bowel Disease (IBD) patients increases length of stay by 48% and leads to a 59% increase in hospital charges1. Analyses show30% of gastroenterologists are unaware of ACG guidelines for VTE prophylaxis in hospitalized IBD patients; only 34% reported they would give prophylaxis to patients with an active flare2. We hypothesize that we under-prescribe prophylaxis in IBD patients due to misguided fear of poor outcomes such as bleeding. Our primary objective is to determine if Lankenau Medical Center adheres to guidelines set forth by gastroenterology societies as well as the American College of Chest Physicians in implementing VTE prophylaxis among hospitalized IBD patients. METHODS: We conducted a retrospective cohort study reviewing inpatient medical records for admissions to Lankenau Medical Center from January 1st, 2009 to December 31st, 2014 with an ICD diagnosis of IBD. Patients were evaluated regardless of admitting diagnosis. Exclusion criteria included age <18 and >90, and patients on long term systemic anticoagulation for any reason, including those with a history of VTE. We subsequently excluded charts from 2009 secondary to a lack of data within the electronic medical record. We collected data on IBD diagnosis (UC vs Crohns), and choice of VTE prophylaxis including enoxaparin, unfractionated heparin, sequential compression devices, Aspirin 81mg BID or none. Additional variables were collected for future analysis. We categorized VTE prophylaxis on admission as follows: a.) Appropriate VTE prophylaxis with heparin or Lovenox; b.) Inappropriate VTE prophylaxis, with sequential compression devices or aspirin; or c.) No VTE prophylaxis. RESULTS: 568 inpatient charts were evaluated. 182 of these met exclusion criteria; 386 were included. 99% (N=384) had a confirmed diagnosis of Crohn's disease while 1% (N=4) had Ulcerative Colitis. 49% of patients were placed on appropriate pharmacologic VTE prophylaxis (N= 189). Subcutaneous heparin was implemented in 12% while 37% were started on enoxaparin. The remaining 50% of our population was started on either inappropriate VTE prophylaxis or no prophylaxis at all. Of those started on inappropriate VTE prophylaxis on admission 20% received sequential compression devices while 2% received twice daily aspirin therapy. 27% of our study population was not started on any VTE prophylaxis on admission. CONCLUSION(S): Appropriate VTE prophylaxis in hospitalized IBD patients has been shown to decrease morbidity, length of stay, and cost. Nevertheless, even experts remain unaware of guideline recommendations for VTE prophylaxis in this population. We showed that our institution is currently falling short of recommendations. Further analysis will determine any significant variables influencing use of VTE prophylaxis in the 50% of our population with inadequate therapy; we hope to define the barriers to VTE prophylaxis initiation, in order to develop a comprehensive intervention to improve our compliance with these guidelines.

Evaluation of Prophylactic Antibiotic Use for Delayed Sternal Closure After Cardiothoracic Operation

Clinical practice guidelines provide recommendations for surgical prophylaxis in patients undergoing cardiothoracic procedures. However, currently no recommendations guide the management of antibiotic prophylaxis in patients who require delayed sternal closure after cardiothoracic operation. This is a single-center, retrospective analysis. Data were extracted from The Society of Thoracic Surgery database and electronic medical record from July 2011 through January 2016. Patients included are adults (≥18 years old) after cardiothoracic operation with delayed sternal closure. A total of 167 patients were included for analysis. The majority of patients (131, 78.4%) were continued on routine antibiotics and 36 patients (21.6%) were switched to broad-spectrum antibiotics for prophylaxis. Of patients on routine antibiotic prophylaxis, 6 (4.6%) experienced a sternal surgical site infection, whereas 3 patients (8.3%) switched to broad-spectrum agents before chest closure experienced a sternal surgical site infection (p= 0.407). Eleven patients (6.6%) received an abbreviated duration of antibiotics, 52 patients (31.1%) were continued on antibiotics until the time of sternal closure, and 104 patients (62.3%) were continued on antibiotics past the time of sternal closure. The incidence of infection based on duration of prophylactic antibiotic was 0, 1 (1.9%), and 8 (7.7%), respectively (p= 0.352). Substantial variation was found in the duration and selection of antibiotic prophylaxis for patients with delayed sternal closure after cardiothoracic operation. Broad-spectrum antimicrobial agents and extended durations of antibiotic prophylaxis were not associated with benefits in the incidence of sternal wound infection and may increase the risk of adverse effects.

Predisposing factors and protocols for prevention of surgical site infections following spine surgery: A review of literature

Surgical site infections (SSIs) following spinal surgery and its treatment are highly debated topics over decades, constituting one of the major causes of morbidity in patients undergoing spine surgery. The importance of this topic lies in the fact that, if ignored, it can lead to high morbidity and mortality, which may require prolonged hospitalization. This review deals with rates of SSI in various spine surgeries, then dwells on few studies exploring causes and prevention of SSI, provides a summary of SSI preventive protocols by various organizations, recommendations for antibiotic prophylaxis, and finally on medical management of established postoperative infections.

Anti-D Alloimmunization after RhD-Positive Platelet Transfusion in RhD-Negative Women under 55 Years Diagnosed with Acute Leukemia: Results of a Retrospective Study

Background: Anti-D alloimmunization can occur when platelets from RhD-positive donors are transfused to RhD-negative patients, due to red blood cell residues in the platelet concentrates. Methods: Our objective was to analyze the anti-D alloimmunization rate in a selected group of women under 55 years of age diagnosed with acute leukemia over an 18-year period. We focused the analysis on RhD-negative patients who received RhD-positive platelet transfusions. Results: From January 1998 to October 2016, 382 women under 55 years were diagnosed with acute leukemia. A total of 56 patients were RhD-negative, and 48 (85.7%) received RhD-positive platelets. The median number of platelet concentrates transfused per patient was 23, and 48% of all platelet transfusions were RhD-positive. The 48 RhD-negative patients received a total of 949 RhD-positive platelet concentrates. Two patients developed anti-D: a 36-year-old woman with M3 acute myeloblastic leukemia and a 52-year-old patient with a secondary acute myeloblastic leukemia. Conclusion: We conclude that there is a need for agreement in the transfusion guidelines on the recommendation of anti-D alloimmunization prophylaxis. We suggest a possible benefit in favor of anti-D prophylaxis in childbearing women with acute leukemia.

21 - Single institution analysis of pneumocystis jirovecii pneumonia in patients undergoing treatment for lung cancer: recommendations for PJP prophylaxis

21 - Single institution analysis of pneumocystis jirovecii pneumonia in patients undergoing treatment for lung cancer: recommendations for PJP prophylaxis

Patients with Coexistence of Circulating Hepatitis B Surface Antigen and Its Antibody May Have a Strong Predisposition to Virus Reactivation During Immunosuppressive Therapy: A Hypothesis.

Hepatitis B virus (HBV) reactivation is a well-recognized complication in patients who undergo immunosuppressive drug therapy. Although the recommendation of antiviral prophylaxis made by the American Gastroenterological Association in 2015 focuses on the risk stratification of different immunosuppressive drugs, risk factors for HBV reactivation are also worth identifying in clinical practice. Recent studies have shown that the uncommon serological pattern of coexistent circulating HBV surface antigen (HBsAg) and its antibody (anti-HBs) was associated with double mutations (A1762T/G1764A) in the basal core promoter (BCP) region of the HBV genome, which is critical for HBV replication. Here, we depicted rheumatoid arthritis (RA) patients with coexistent HBsAg and anti-HBs in our medical center, who developed HBV reactivation during immunosuppressive drug therapy. DNA sequencing analysis of the HBV genome revealed triple mutations (A1762T, G1764A, and T1753V) in the BCP region, which could further enhance the ability of HBV replication. Hence, a novel hypothesis is advanced for the first time that patients with coexistent HBsAg and anti-HBs may have a strong predisposition to HBV reactivation due to specific BCP mutations. This hypothesis would, if correct, justify the concurrent detection of HBsAg and anti-HBs in HBV screening in patients with rheumatic diseases and quickly recognize patients with high risk of HBV reactivation. Further controlled studies are needed to confirm this hypothesis.

A Comparison of Recommendations for Pharmacologic Thromboembolism Prophylaxis After Caesarean Delivery From 3 Major Guidelines

(BJOG. 2016;123:2157–2162) Venous thromboembolism (VTE) is a leading cause of maternal morbidity and mortality. Women undergoing cesarean delivery, especially those with other risk factors such as obesity, are considered at increased risk. Mechanical VTE prophylaxis with pneumatic compression devices is recommended for all women undergoing cesarean delivery. The use of postcesarean pharmacologic thromboprophylaxis, either unfractionated or low-molecular weight heparin, has been recommended in women with additional risk factors. However, the optimal clinical strategy for postcesarean pharmacologic prophylaxis is unclear, and the criteria for identifying patients who should receive this prophylaxis differ substantially among the recommendations provided by major medical societies. The aim of this cross-sectional analysis was to determine the impact these varying guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG), the American Congress of Obstetricians and Gynecologists (ACOG), and the American College of Chest Physicians (Chest) would have on the rate of anticoagulation prophylaxis in women undergoing cesarean delivery at the authors’ academic medical center.

Intrauterine Growth Restriction. Guideline of the German Society of Gynecology and Obstetrics (S2k-Level, AWMF Registry No. 015/080, October 2016).

Aims The aim of this official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG) was to provide consensus-based recommendations obtained by evaluating the relevant literature for the diagnostic treatment and management of women with fetal growth restriction. Methods This S2k guideline represents the structured consensus of a representative panel of experts with a range of different professional backgrounds commissioned by the Guideline Committee of the DGGG. Recommendations Recommendations for diagnostic treatment, management, counselling, prophylaxis and screening are presented.

Preventable Surgical Harm in Gynecologic Oncology: Optimizing Quality and Patient Safety

Preventable medical adverse events are a leading cause of death in the USA. The most common adverse events include medication errors, perioperative complications, venous thromboembolism, infection, and readmission. Patients requiring care with a gynecologic oncologist are at increased risk for all of these adverse events, which are both clinically undesirable and now also represent targets for reduced hospital reimbursement. The goal of this review is to identify areas of preventable harm that occur in the perioperative period on a gynecologic oncology service and identify mechanisms to minimize harm. Recognizing that gynecologic oncology surgical patients often present with advanced age, medical comorbidities, obesity, and diagnoses requiring radical procedures involving multi-organ resection, they are particularly at risk for perioperative complications, some preventable. Recent studies have examined evidence-based methods for minimizing many areas of preventable harm in gynecologic oncology surgical patients. Multiple studies have implemented bundles of care to successfully decrease surgical site infections. New data on risk of venous thromboembolism (VTE) specifically in gynecologic oncology patients guide recommendations for perioperative and extended VTE prophylaxis. Enhanced recovery after surgery programs explore a multitude of factors, many in a bundle format, to minimize overall perioperative complications and decrease length of stay. Additionally, new data are available on rates of hospital readmissions and risk factors for readmission. There is already a wealth of information available regarding incidence of complications in gynecologic oncology surgical patients. Fortunately, there is a shift in the USA toward recognizing patient risk factors and implementing interventions to decrease the rate of preventable adverse events.

Congenital Heart Disease.

1. Kriti Puri, MD* 2. Hugh D. Allen, MD* 3. Athar M. Qureshi, MD*,† 1. *Department of Pediatrics, 2. †CE Mullins Cardiac Catheterization Laboratories, The Lillie Frank Abercombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX * Abbreviations: ASD: : atrial septal defect AVSD: : atrioventricular septal defect CHD: : congenital heart disease CHF: : congestive heart failure CoA: : coarctation of the aorta EKG: : electrocardiogram HLHS: : hypoplastic left heart syndrome IAA: : interrupted aortic arch IVC: : inferior vena cava LV: : left ventricle mBTT: : modified Blalock-Taussig-Thomas PAPVD: : partial anomalous pulmonary venous drainage PDA: : patent ductus arteriosus RV: : right ventricle SBE: : subacute bacterial endocarditis TAPVD: : total anomalous pulmonary venous drainage VSD: : ventricular septal defect Congenital heart disease (CHD) is present in about 9 of every 1,000 live-born children. (1)(2)(3)(4)(5) Children with CHD are surviving longer, and better understanding of the long-term complications of CHD is continuously emerging. Hence, it is important to be comfortable with the primary care requirements for these children, including physical manifestations prior to surgery and interventional cardiac catheterizations, as well as those concerning for potential need for reintervention, the latest recommendations for endocarditis prophylaxis, respiratory precautions and immunization considerations, and close monitoring of development and behavior. In this article, we will discuss the common types of cyanotic (“blue”) and acyanotic (“pink”) CHD and the role of the primary care physician in the health care of these children before and after surgery and interventional cardiac catheterizations. After completing this article, readers should be able to: 1. Describe newborn pulse oximetry screening for congenital heart disease (CHD) and clinical features of CHD during the newborn period. 2. Describe the clinical presentations and briefly outline management strategies of infants and children with different types of CHD. 3. Discuss single-ventricle palliation by using hypoplastic left heart syndrome as the model lesion. 4. Describe the evaluation and primary care management factors (including endocarditis prophylaxis, immunizations, and exercise restriction) in children with different types of CHD. Newborns with critical congenital heart disease (CHD) may present with symptoms of cyanosis, congestive heart failure (CHF), poor pedal pulses, or a failed newborn CHD pulse oximetry screen prior to discharge. CHD lesions that are dependent on a patent ductus arteriosus (PDA) to support flow either to the systemic circulation or to the pulmonary circulation …

A 6-month follow-up of disability, quality of life, and depressive and anxiety symptoms in pediatric migraine with magnesium prophylaxis.

Magnesium is frequently used for pediatric migraine prophylaxis. The aim of this study was to evaluate to which extent the disability levels, quality of life (QOL), and anxiety and depressive symptoms change after 6-month magnesium prophylaxis in pediatric migraine. This is a follow-up study of 34 children aged 7-17 years with migraine treated with oral magnesium. Disability due to migraine was assessed by the Pediatric Migraine Disability Assessment tool (PedMIDAS), QOL was assessed by the KIDSCREEN-27, and anxiety and depressive symptoms were assessed by the Revised Child Anxiety and Depression Scale (RCADS). PedMIDAS scores significantly decreased from baseline to end-point (F(df, dferror)=11.10 (1.63, 50.49), p<0.001), as well as anxiety (F(df, dferror)=8.95 (1.64, 50.67), p=0.001) and depressive symptoms (F(df, dferror)=8.91 (1.59, 49.29), p=0.001). Considering the KIDSCREEN-27, scores for physical and psychological well-being and social support domain significantly increased from baseline to end-point (p≤0.01). After 6 months of magnesium prophylaxis, disability due to migraine significantly decreased, whereas physical and psychosocial well-being improved. Children also reported fewer anxiety and depressive symptoms. More follow-up and randomized controlled clinical trials are needed to propose clinical recommendations for magnesium prophylaxis in pediatric migraine.

The conundrum of deep vein thrombosis prophylaxis in burns in India and review of literature.

Objective:The aim is to assess the practice of deep vein thrombosis (DVT) prophylaxis among the plastic surgeons attending National Academy of Burns India Conference 2012 (NABICON 2012).Background:DVT prophylaxis in burns is a controversial issue as there is no consensus among the community of burn surgeons about the prevalence of DVT, the incidence of pulmonary embolism, the indications for DVT prophylaxis, dosage and duration of low molecular weight heparins (LMWH) and the complications related to DVT and LMWH.Methodology:A survey was conducted among plastic surgeons attending the NABICON 2012 held at New Delhi, by circulating a questionnaire. The respondents were divided into two groups based on whether burns constituted more than or less than 50% of their practice. The data thus collected were tabulated and analysed.Results:Almost 70% of all the respondents practice some form of DVT prophylaxis. There was significantly higher incidence of complications related to the use of LMWH among the surgeons whose practice of burns was >50%. There was no significant difference between the two groups in relation to the incidence and complication of DVT or recommendation of DVT prophylaxis.Conclusion:Majority of plastic surgeons practice DVT prophylaxis routinely and consider multiple criteria such as percentage of burns, age, lower limb involvement, the degree of burns and associated co-morbidities for starting the LMWH.

ИЗМЕНЕНИЯ ПОКАЗАТЕЛЕЙ ПЛАЗМЕННОГО ЗВЕНА ГЕМОСТАЗА В ДОРОДОВОМ И ПОСЛЕРОДОВОМ ПЕРИОДАХ У ЖЕНЩИН, РОДОРАЗРЕШЕННЫХ ПУТЕМ ОПЕРАЦИИ КЕСАРЕВА СЕЧЕНИЯ

Введение. Выделение группы риска венозных тромбоэмболических осложнений (ВТЭО) является непростой задачей. На сегодняшний день врачи пользуются балльными шкалами риска, которые учитывают только анамнестические данные и никак не показатели лабораторных тестов гемостаза. Цель исследования. Провести сравнительную оценку показателей плазменного звена гемостаза в дородовом и послеродовом периодах у женщин, родоразрешенных путем операции кесарева сечения, в группах высокого, среднего и низкого риска ВТЭО. Материалы и методы. Обследовано 235 беременных в возрасте 21–45 лет. Отбор проб крови проводили в 4 точках: точка 1 — непосредственно до кесарева сечения; точка 2 — через 3–5 часов после окончания операции; точка 3 — через 2 суток после окончания операции; точка 4 — через 4 суток после окончания операции. Измеряли содержание фибриногена и Д-димера, протромбина по Квику и активированное частичное тромбопластиновое время. Риск ВТЭО оценивали согласно шкале RCOG Green-top Guidelines №{37a; cтепень риска развития ВТЭО определяли по сумме баллов. Результаты. Выявлено, что степени риска развития ВТЭО у женщин в послеродовом периоде, определенные из анализа анамнестических данных и лабораторных показателей системы гемостаза, дают различную картину состояния пациенток, что может нести дополнительную информацию о состоянии системы свертывания конкретной пациентки. Заключение. Д-димер может быть использован как маркер тромботической готовности у женщин после операции кесарева сечения, так как все остальные проанализированные параметры изменялись в пределах референтных диапазонов, характерных для послеродового периода. Introduction. To select a risk group of venous thromboembolic complications (VTE) is not a simple task. Today doctors use scales of risk scores that take into account only anamnestic data, and do not take into account hemostatic laboratory tests. The aim of study: comparative assessment of plasma hemostatic parameters in prenatal and postnatal periods in women delivered by Cesarean section with high, medium and low VTE risks. Materials and methods. We examined 235 pregnant women aged 21–45 years. Blood hemostatic parameters analyzed at 4 points: point 1 — before Cesarean section; point 2–3–5 hours after the end of operation; point 3–2 days after operation; point 4–4 days after operation. We measured fi brinogen and D-dimer levels, prothrombin (Quick’s value) and activated partial thromboplastin time. VTE risk assessed according to RCOG scale Green-top Guidelines №{37a; degree of VTE risk development determined by the sum of scores. Results. It was revealed that VTE risk at women in postnatal period obtained from the analysis of anamnestic data and hemostatic tests gave a diff erent picture of patients’ state which can provide additional information about hemostasis of a particular patient. Conclusion. D-dimer can be used as a marker of thrombotic readiness in women after Cesarean section, since all other analyzed parameters varied within reference ranges typical for postpartum.

Spleen Australia guidelines for the prevention of sepsis in patients with asplenia and hyposplenism in Australia and New Zealand.

People with asplenia/hyposplenism are at increased risk of fulminant sepsis, which carries a high mortality rate. A range of preventive measures is recommended although there is ongoing evidence that knowledge of and adherence to these strategies is poor. There have been significant changes in recommended vaccinations since the previously published recommendations in 2008. We provide current recommendations to help Australian and New Zealand clinicians in the prevention of sepsis in patients with asplenia and hyposplenia. The guideline includes Australian epidemiological data, preferred diagnostic techniques and recommendations for optimal antimicrobial prophylaxis and vaccination protocols.

Antimicrobial Resistance in Gram-Negative Rods Causing Bacteremia in Hematopoietic Stem Cell Transplant Recipients: Intercontinental Prospective Study of the Infectious Diseases Working Party of the European Bone Marrow Transplantation Group.

This intercontinental study aimed to study gram-negative rod (GNR) resistance in hematopoietic stem cell transplantation (HSCT). GNR bacteremias occurring during 6 months post-HSCT (February 2014-May 2015) were prospectively collected, and analyzed for rates and risk factors for resistance to fluoroquinolones, noncarbapenem anti-Pseudomonas β-lactams (noncarbapenems), carbapenems, and multidrug resistance. Sixty-five HSCT centers from 25 countries in Europe, Australia, and Asia reported data on 655 GNR episodes and 704 pathogens in 591 patients (Enterobacteriaceae, 73%; nonfermentative rods, 24%; and 3% others). Half of GNRs were fluoroquinolone and noncarbapenem resistant; 18.5% carbapenem resistant; 35.2% multidrug resistant. The total resistance rates were higher in allogeneic HSCT (allo-HSCT) vs autologous HSCT (auto-HSCT) patients (P < .001) but similar in community-acquired infections. Noncarbapenem resistance and multidrug resistance were higher in auto-HSCT patients in centers providing vs not providing fluoroquinolone prophylaxis (P < .01). Resistance rates were higher in southeast vs northwest Europe and similar in children and adults, excluding higher fluoroquinolone- and β-lactam/β-lactamase inhibitor resistance rates in allo-HSCT adults. Non-Klebsiella Enterobacteriaceae were rarely carbapenem resistant. Multivariable analysis revealed resistance risk factors in allo-HSCT patients: fluoroquinolone resistance: adult, prolonged neutropenia, breakthrough on fluoroquinolones; noncarbapenem resistance: hospital-acquired infection, breakthrough on noncarbapenems or other antibiotics (excluding fluoroquinolones, noncarbapenems, carbapenems), donor type; carbapenem resistance: breakthrough on carbapenem, longer hospitalization, intensive care unit, previous other antibiotic therapy; multidrug resistance: longer hospitalization, breakthrough on β-lactam/β-lactamase inhibitors, and carbapenems. Inappropriate empiric therapy and mortality were significantly more common in infections caused by resistant bacteria. Our data question the recommendation for fluoroquinolone prophylaxis and call for reassessment of local empiric antibiotic protocols. Knowledge of pathogen-specific resistance enables early appropriate empiric therapy. Monitoring of resistance is crucial. NCT02257931.

An Evaluation of Introduction of Rapid HIV Testing in a Perinatal Program.

This study was conducted to evaluate the roll-out of rapid HIV testing as part of an emergency Prevention of Perinatal HIV Transmission Program. Specifically, HIV prevalence in this population, the reason(s) for performing the rapid HIV test, and compliance with recommendations for antiretroviral prophylaxis were assessed. Since November 2011, all women presenting to a tertiary labour and delivery unit with unknown HIV status or with ongoing risk of HIV infection since their last HIV test were offered rapid HIV testing. Through retrospective chart review, demographic data, HIV risk and prior testing history, and antiretroviral prophylaxis, data were collected and descriptive statistics were performed. One hundred fourteen rapid HIV tests were conducted and there were two preliminary reactive rapid results (one true positive, one false positive). None of the infants was HIV infected. Sixty-three percent of women had multiple risk factors for HIV acquisition, most commonly intravenous drug use (54%). Forty-four percent of women were within the 4-week seroconversion window at the time of delivery; 25% of these women and 52% of their infants received prophylactic drug therapy. Rapid HIV testing identified a high-risk cohort and enabled aggressive management of a newly diagnosed HIV-positive pregnancy, successfully preventing perinatal HIV transmission. Risk factors for HIV acquisition were ongoing within the seroconversion window for over half of the women, impacting the utility of the test in eliminating unnecessary antiretroviral prophylaxis in this population because prophylaxis is recommended despite a negative rapid HIV test in these cases.

Are adults with congenital heart disease informed about their risk for infective endocarditis and treated in accordance to current guidelines?

BackgroundAdults with congenital heart disease (ACHD) have an increased risk for infective endocarditis (IE). In the last decade, the recommendations for IE prophylaxis have changed substantially. The knowledge level of patients about IE and IE prophylaxis has not been studied. MethodsPatients recruited via the German National Register for Congenital Heart Defects were invited to an online survey about IE. Patients were divided into two groups based on ESC guidelines: high IE risk (antibiotic prophylaxis recommended) and low IE risk (prophylaxis not recommended). ResultsOverall, 1458 patients participated and out of these 1211 (age 30.5±11.8years, female=54.2%) with detailed clinical information were further analyzed. 343 patients had a high IE risk, whereas 868 had a low risk. Overall, 74.5% (n=902) stated to know what IE is (low IE risk: 71.3%, high IE risk: 82.5%) Out of these who stated to know what IE is (n=902), 76.5% (n=690) chose the correct answer in a multiple choice question (low IE risk: 76.4%; high IE risk: 76.7%). Antibiotic prophylaxis was known to 66.2% (low IE risk: 59.9%; high IE risk: 82.2%). Out of these who stated to know what antibiotic prophylaxis is (n=802), 83.8% (n=672) chose the correct answer in a multiple choice question (low IE risk: 82.9%; high IE risk: 85.5%). ConclusionsThis study reveals important knowledge gaps regarding IE and antibiotic prophylaxis in ACHD patients. A discussion about IE and antibiotic prophylaxis should take place with every ACHD patient during regular clinical contacts to close this knowledge gap.

Clinical practice guideline adherence during Operation Inherent Resolve.

The Joint Trauma System (JTS) clinical practice guidelines (CPGs) contributed to the decrease in battlefield mortality over the past 15 years. However, it is unknown to what degree the guidelines are being followed in current military operations. A retrospective review was performed of all patients treated at three separate US Army Role II facilities during the first 10 months of Operation Inherent Resolve in Iraq. Charts were reviewed for patient demographics, clinical care, and outcomes. Charts were also reviewed for compliance with JTS CPGs and Tactical Combat Casualty Care recommendations. A total of 114 trauma patients were treated during the time period. The mean age was 26.9 ± 10.1 years, 90% were males, and 96% were host nation patients. The most common mechanisms of injury were blast (49%) and gunshot (42%). Records were compliant with documenting a complete set of vitals in 58% and a pain score in 50% of patients. Recommendations for treatment of hypothermia were followed for 97% of patients. Tranexamic acid was given outside guidelines for 6% of patients, and for 40%, it was not determined if the guidelines were followed. Recommendations for initial resuscitative fluid were followed for 41% of patients. Recommendations for antibiotic prophylaxis were followed for 40% of intra-abdominal and 73% of soft tissue injuries. Recommendations for tetanus prophylaxis were followed for 90% of patients. Deep vein thrombosis prophylaxis was given to 32% of patients and contraindicated in 27%. The recommended transfusion ratio was followed for 56% of massive transfusion patients. Recommendations for calcium administration were followed for 40% of patients. When composite scores were created for individual surgeons, there was significant variability between surgeons with regard to adherence to guidelines. There is significant deviation in the adherence to the CPGs. Epidemiologic study, level IV.