Single Dose Of Intravenous Antibiotics Research Articles

Analysis of the use of empiric antimicrobial prophylaxis for temporary cardiac devices at a large academic medical center.

Varying rates of access site infections with temporary percutaneous cardiac devices have been reported in the literature. The purpose of this study is to determine the impact of a change in institutional practice in utilizing antimicrobial prophylaxis to prevent access site infections in patients with these devices. This observational, pre-post implementation analysis evaluated the benefit of prophylactic antimicrobial therapy in adult patients with temporary percutaneous cardiac devices admitted to cardiac intensive care units. Patients in the pre-cohort received prophylactic antibiotics for the duration of device insertion. Patients in the post-cohort received a single dose of intravenous antibiotics for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella® 5.5 device placement, and no antimicrobial prophylaxis for all other devices placed. The primary endpoint was the incidence of definitive access site infection. Secondary endpoints included the incidence of Clostridium difficile infection and initiation of broad-spectrum antibiotics. Fifty patients in the pre-cohort and 45 patients in the post-cohort were evaluated. Devices included intra-aortic balloon pumps, VA-ECMO, Impella® CP and Impella® 5.5. The median duration of device insertion was fourdays. No significant difference in the primary outcome was seen between the two groups. A significant reduction in prophylactic antimicrobial utilization and total days of antimicrobial exposure was observed in the post-implementation cohort. Based on the results of our study, the implemented guideline reduces the utilization of antimicrobial prophylaxis in patients with temporary percutaneous cardiac devices and does not result in an increased rate of infections.

Effects of an Initial Single Dose of Intravenous Antibiotics on Emergency Department Revisits Among Elderly Patients with Urinary Tract Infections.

Urinary tract infection (UTI) is the second most common infectious disease among older adults. It is important that the treatment strategy used for older patients with UTIs in the emergency department (ED) be adequate. The effectiveness of an initial single dose of intravenous antibiotics in the ED for treating UTIs has not been extensively studied. Therefore, we investigated the clinical outcomes of single-dose intravenous antibiotic administration before discharge from the ED in elderly patients with UTIs. This retrospective study was conducted among patients who visited two academic tertiary hospitals in Seoul, South Korea. We included all patients older than 65 years of age with UTI who visited the ED and were directly discharged between 1 January and 31 December 2019 (n = 429). The patients were divided into two groups according to whether they received a single dose of intravenous antibiotics before ED discharge. Patients who received intravenous antibiotics had a higher 72-hour revisit rate (43 [15.4%] vs 10 [6.7%], p = .009) and a longer mean duration of therapy (total days of antibiotics use) (11 [4.00 - 15.00] vs 5 [3.00 - 11.00], p < .001) than patients who received only oral antibiotics. However, the rate of admission after revisits did not differ significantly between the groups (27 [62.8%] vs 5 [50.0%], p = .492). Older patients with severe UTIs were prescribed intravenous antibiotics in the ED. Decisions on admission or discharge should be made carefully for older patients with UTIs who are prescribed intravenous antibiotics in the ED.

Perioperative Prophylactic Antibiotics in 1,250 Orbital Surgeries.

Intravenous antibiotic prophylaxis is used for many clean-contaminated surgeries or clean surgeries with an implant, but its value for clean orbital surgery has not been determined. This study investigated infection risks and adverse effects related to antibiotics in patients undergoing orbital surgery. A prospective, nonrandomized comparative case series of all patients undergoing orbital surgery with participating surgeons between October 1, 2013, and March 1, 2015. Types of surgery, antibiotic regimens, corticosteroid use, antibiotic side effects, and surgical site infections (SSIs) were entered into an electronic database and subsequently analyzed. Cases in which patients received postoperative oral antibiotics were analyzed separately. Of 1,250 consecutive orbital surgeries, 1,225 met inclusion criteria. A total of 1208 patients were included in the primary analysis: 603 received no antibiotic prophylaxis (group A), and 605 received a single dose of intravenous antibiotic (group B). Five patients (0.42%) developed an SSI, 3 in group A and 2 in group B. The difference in SSI rates was not statistically significant between the 2 groups (p = 0.66). Antibiotic prophylaxis, alloplastic implants, paranasal sinus entry, and corticosteroid use were not associated with differences in SSI rates. All SSIs resolved on a single course of oral antibiotics; an implant was removed in 1 case. There were no complications associated with a single dose of intravenous prophylaxis. However, 12% of 17 patients (group C) who received 1 week of oral postoperative prophylactic antibiotics developed antibiotic-related complications (diarrhea, renal injury), yielding a number needed to harm of 8.5. In this large series, antibiotic prophylaxis does not appear to have reduced the already low incidence of SSI following orbital surgery. Given the detriments of systemic antibiotics, the rarity of infections related to orbital surgery, and the efficacy of treating such infections should they occur, patients undergoing orbital surgery should be educated to the early symptoms of postoperative infection and followed closely, but do not routinely require perioperative antibiotics.

The Effects of Intravenous Antibiotic Administration during the Surgical Removal of Third Molar: Systematic Review

Intravenous antibiotics a subset of parenteral route help in reducing the post-operative infections in dento-alveolar surgery such as the removal of third molar. However, this route lacks evidential support in the literature and thus has received less attention among the oral clinicians and proportionally in pharmacologists. A systematic review was performed in the Pubmed, Pubmed Central and Scopus electronic data bases from January 2003- January 2017 with a view to express the last fifteen years performance. From the primary queries, only 74 references could be collected pertinent to antibiotic therapy in third molar surgery including the protocols laid by American Association of Oral maxillofacial Surgeons and American Academic of Pediatric Dentistry. In the final stage, a couple of articles on in vitro studies, three short discussions, one evidence-based report and a letter to editor met the required desired criteria. The results revealed that it is highly preferable to administrate intravenous antibiotics in high-risk individuals to reduce surgical site infections. From the retrieved evidences, it can be asserted that candidates with clinical signs of rapid progressive infection, total osseous impaction and compromised health deserve to receive a pre-operative single dose of intravenous antibiotics during third molar surgery on the grounds of their vulnerability to bacteremia. Key words: Antibiotics, Bacteremia, Intravenous, Oral Surgery, Impacted, Third Molar.

Usefulness of Preoperative Mechanical Bowel Preparation in Patients with Colon Cancer who Undergo Elective Surgery: A Prospective Randomized Trial Using Oral Antibiotics

Background: To prevent surgical site infection (SSI) in colorectal surgery, the combination of mechanical bowel preparation (MBP), oral antibiotic bowel preparation (OABP), and the intravenous antibiotics have been proposed as standard treatment. We conducted an RCT comparing the incidence of SSI between MBP + OABP and OABP alone after receiving a single dose of intravenous antibiotics. Methods: The study group comprised 254 patients who underwent elective surgery for colon cancer. Patients were randomly assigned to receive MBP + OABP and intravenous antibiotics (MBP + OABP group) or to receive OABP and intravenous antibiotics (OABP alone group). Results: Overall, 125 patients in MBP + OABP group and 126 patients in OABP alone group were eligible. Incisional SSI occurred in 3 patients (2.4%) in MBP + OABP group, and 8 patients (6.3%) in the OABP-alone group. Organ/space SSI developed in 0 patients (0%) and in 4 patients (3.2%) in each group respectively. The OABP-alone group was thus not shown to be noninferior to the MBP + OABP group in the incidences of incisional SSI or organ/space SSI. Other infectious complications developed in 7 patients (5.6%) and in 6 patients (4.8%) in each group, indicating the non-inferiority of OABP alone to MBP + OABP. Conclusions: MBP combined with oral antibiotics and intravenous antibiotics remains standard in elective colon cancer surgery.

Injectable loop recorder implantation in an ambulatory setting by advanced practice providers: Analysis of outcomes.

Implantable loop recorder (ILR) insertion has historically been performed in a surgical environment such as the electrophysiology (EP) lab. The newest generation loop recorder (Medtronic Reveal LINQ™, Minneapolis, MN, USA) is injectable with potential for implantation in a non-EP lab setting by advanced practice providers (APPs) facilitating improved workflow and resource utilization. We report the safety and efficacy of injectable ILR placement in the ambulatory care setting by APPs. A retrospective review was performed including all patients referred for injectable ILR placement from March 2014 to November 2015. All device placement procedures were performed in an ambulatory care setting using the standard manufacturer deployment kit with sterile technique and local anesthetic following a single dose of intravenous antibiotics. Acute procedural success and complication rates following injectable ILR placement in the ambulatory setting were reviewed. During the study period, 125 injectable ILRs were implanted. Acute procedural success with adequate sensing (R-waves ≥0.2 mV) occurred in 100% of patients. There were no acute procedural complications. Subacute complications occurred in two patients (1.6% of implantations), including one possible infection treated with oral antibiotics and one device removal due to pain at the implant site. In this retrospective single-center study, implantation of injectable ILR in an ambulatory care setting by APPs following a single dose of intravenous antibiotics and standard manufacturer technique yielded a low complication rate with high acute procedural success. Use of this implantation strategy may improve EP lab workflow while providing a safe and effective technique for device placement.

Infection Rates and Treatment of Low-Velocity Extremity Gunshot Injuries.

To determine the rates of infection in low-energy gunshot wounds (GSWs) to the extremity. Retrospective review. Level I trauma center. Patients (N = 140) with at least 90-day follow-up for extremity-only low-energy GSW injuries from 2010-2014 were retrospectively reviewed. Treatment was recorded, including type and duration of antibiotics and details of nonoperative and operative managements. The rates of superficial and deep infections. The overall infection rate was 15.7% (22 patients), and the deep infection rate was 3.6% (5 patients). Age, sex, and injury location were similar between the groups that did and did not receive antibiotic prophylaxis. Injury Severity Scores were higher in the group that did receive antibiotics. Regarding soft tissue-only injuries, antibiotic prophylaxis trended toward a lower rate of overall infection versus no antibiotic prophylaxis (6.1% vs. 25.9%, respectively, P = 0.07). Multiple doses of antibiotics did not reduce the rate of infection when compared with a single dose (14.6% vs. 12.5%, respectively, P = 1.00). No deep infections occurred in patients with nonoperatively treated fractures, regardless of antibiotic administration. All operatively treated fractures received antibiotic prophylaxis and demonstrated superficial and deep infection rates of 15.1% and 5.7%, respectively. Infections after low-energy extremity GSWs are infrequent. For soft tissue injuries without fracture, a single dose of intravenous antibiotics in the emergency department was associated with a lower rate of infection compared with no antibiotics. Operatively treated low-energy GSW fractures should receive standard perioperative antibiotics. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Use of the multiplane internal mastopexy for ptosis correction revision-augmentation mammoplasty

Aim: Augmentation mammoplasty is a commonly performed procedure with a high satisfaction rate. Multiplane pocket was described for simultaneous internal mastopexy and augmentation using inframammary crease incision for selected primary and secondary mammoplasties. The use of the technique is presented with a larger experience for correction of ptosis in a patient presenting for revision surgery following subglandular augmentation mammoplasty. Methods: A retrospectively collected data were analyzed using the Excel Spread Sheet. A total of 25 patients had multiplane augmentation with the internal mastopexy following augmentation mammoplasty in subglandular pocket. Data of 25 patients who had their revision surgery in multiplane were analyzed. Results: The group included 25 patients with a mean age of 36.6 years (range: 25-54 years) with mean implant duration of 6.4 years (range: 1.5-13 years). Twenty-three of the patients were nonsmokers, 1 smoker and 1 patient's smoking status was not mentioned. Eighteen patients presented with grade I capsular contracture, 3 patients with grade II contracture and 4 patients had a combination of grade I and II capsular contracture. Pseudoptosis was present in 6, class B ptosis in 6, A/B ptosis in 3, water-down deformity in 5 and rippling in 5 patients. Average preoperative size of implant used initially was 334.4 mL (range: 250-340 mL) and the mean implant size selected for revision surgery was 416 mL (range: 260-525 mL). Mean follow-up time was 18 months (range: 6-48 months). Of 25 patients, 21 had a bilateral procedure whereas the technique was used unilaterally in 4 patients for the correction of asymmetry. All patients had a single dose of intravenous antibiotics and followed by an oral course for 5 days, there was no infection noted in the series. In the current series, no patient required revision surgery following the multiplane internal mastopexy. Conclusion: Multiplane internal mastopexy can be useful in selected cases of revisionary augmentation mammoplasty.

Ongoing Consideration of Cavity Evaluation Devices in the Treatment of Breast Cancer

The growing popularity of brachytherapy has greatly increased the use of single-entry balloon catheter devices for delivery of accelerated partial breast radiotherapy (APBI). To facilitate delayed, postoperative, percutaneous insertion of single-entry brachytherapy catheters, many surgeons elect to place temporary, expandable cavity evaluation devices (CED) at the time of lumpectomy to preserve the surgical cavity and maintain a tract between the skin and surgical cavity. At the time of brachytherapy catheter placement, the CED may be deflated, withdrawn from the cavity, and easily replaced by a single-entry brachytherapy catheter inserted through the very same tract. In their article, ‘‘Spacer Balloons prior to Partial Breast Irradiation: Helpful or Hurtful?’’, Drs. Kuske and Zannis provide an excellent summary of the potential limitations and challenges associated with CED usage. While they have raised several important concerns, the authors’ emphasis on the potential negative aspects of CED placement misses the opportunity to provide sufficient guidance on how and when they may be properly used. Among the important concerns raised by the authors is the tendency of some surgeons to obtain multidisciplinary consultation only after CED placement. Preoperative discussion of the patient’s treatment options in a multidisciplinary setting or referring the patient to a radiation oncologist prior to surgery will provide the best opportunity for the patient and her oncologists to identify and fully discuss the options of lumpectomy, APBI, CED usage, and the implications of unsuitable pathology. This process not only helps to identify patients who are suboptimal candidates for APBI, but also allows coordination of surgery, catheter exchange, and radiation therapy planning to avoid the significant delays in the initiation of APBI that the authors identify as being contributory to devicerelated infections. Preoperative consultation also gives the patient the opportunity to discuss their potential participation in clinical trials that might be impacted by CED placement. Another compelling issue raised by the authors is the higher incidence of wound infection associated with intraoperative placement of a brachytherapy catheter (the open-cavity technique) compared with postoperative, percutaneous brachytherapy catheter placement (the closedcavity technique). However, the association between CED placement and infection is far from clear. In referencing the 2-year outcome data of the MammoSite Registry, the authors acknowledge that CED usage was not specifically addressed in the publication. Although it is reasonable for the authors to infer that intraoperative placement of a CED is analogous to open-cavity placement of a brachytherapy catheter in terms of its risk of infection, the results of the MammoSite Registry are confounded by the lack of clear guidelines regarding the use of antibiotics. In fact, only 71% of MammoSite Registry participants received antibiotics. Perhaps patients who had catheters placed intraoperatively were less likely to be prescribed oral antibiotics because they were routinely given a single dose of intravenous antibiotics preoperatively. Alternatively, it could be that patients who had catheters placed postoperatively were more likely to be prescribed postprocedural oral antibiotics because they did not receive the benefit of preprocedural intravenous antibiotics? The MammoSite Registry update does not elucidate these factors. Furthermore, since there is a finite risk (1–4%) of surgical-site infection after breast-conserving surgery, to what degree does the higher incidence of infection after the open-cavity technique reflect the combined result of postlumpectomy infection and catheter-related infection. Interestingly, the Society of Surgical Oncology 2011

Incidence of Perioperative Urinary Tract Infection After Single-dose Antibiotic Therapy for Midurethal Slings

A recent Best Practice Statement published by the American Urological Association (AUA) recommends that antibiotic therapy in patients undergoing midurethral synthetic slings (MUS) should be 24 hours or less. Subjects at our institution are routinely administered a single dose of intravenous antibiotics before MUS surgery. We prospectively evaluated urinary tract infection (UTI) rates and risk factors for UTI in subjects undergoing MUS who receive single-dose antibiotic therapy. Adult female patients who were undergoing MUS for stress or mixed urinary incontinence were prospectively included and received a single-dose of an intravenous antibiotic in accordance with the AUA Best Practice Statement. Subjects requiring additional procedures for prolapse were excluded. Baseline characteristics and preoperative and postoperative postvoid residual (PVR) were documented. Subjects were contacted within 1 week of surgery, and seen in the office at 1 month, when a urinalysis was performed, and urine culture sent if subjects were symptomatic. A total of 101 subjects underwent solitary MUS and received a single dose of intravenous antibiotics. Overall, 6 (5.9%) subjects developed a UTI within 1 month of surgery. Patients who developed a UTI were more likely to have elevated PVRs at the preoperative office visit (62.2 vs 26.8 mL, P = .004). Our study has demonstrated that the rate of perioperative UTI after MUS with one perioperative dose of intravenous antibiotics is low. Patients with an elevated preoperative PVR may be at an increased risk of developing a UTI. Single-dose antibiotic administration is safe and effective at preventing perioperative UTI in subjects undergoing solitary MUS.

Optimal duration of prophylactic antibiotic administration for elective colon cancer surgery: A randomized, clinical trial

Procedures for perioperative infection prophylaxis in elective colon cancer surgery consist of preoperative mechanical preparation, chemical preparation with oral antibiotic administration, perioperative intravenous antibiotic administration, and others. However, the optimal combination of these procedures and drugs and their durations of administration have not yet been established. A randomized study was conducted to determine the optimal duration of perioperative antibiotic administration with use of mechanical and chemical preparation. A total of 370 patients who were to undergo elective colon cancer surgery were randomized into 2 groups. After mechanical and chemical preparations, a single, 1-g dose of flomoxef was administered immediately before surgery to patients in group A. Flomoxef 1 g was administered twice daily for a total of 4 days from the day of surgery to postoperative day 3 to patients in group B. Comparison was performed between 179 patients in group A and 181 patients in group B with analyzable data. The incidences of incisional surgical site infections (SSIs), organ/space SSIs, and remote infections (RIs) were 15 patients (8.4%), 1 patient (0.6%), and 8 patients (4.5%), respectively, in group A, and 13 patients (7.2%), 2 patients (1.1%), and 6 patients (3.3%), respectively, in group B. There were no differences in the incidence of incisional SSIs, organ/space SSIs, or RIs between groups A and B. It was shown that a single dose of intravenous antibiotic immediately before surgery is sufficient as perioperative infection prophylaxis in elective colon cancer surgery when mechanical and chemical preparation is performed.

Outcome of accidental peritoneal dialysis catheter holes or tip exposure

Pediatric peritoneal dialysis (PD) patients are at risk for acute peritonitis. One risk factor is accidental exposure of the catheter to a non-sterile surface. We studied catheter exposures in 17 pediatric patients receiving PD who developed 16 holes and 12 other accidental exposures. The rate of exposures was 3.7 events/100 patient-months. After exposure, the mean counts (+ or - standard error) of white blood cells (WBC), red blood cells, and neutrophils were 39.8 + or - 19.3, 9.5 + or - 7.1, and 24.2 + or - 5.3/mm(3), respectively. There was a trend towards higher peritoneal fluid WBC in patients with holes than in those with exposures (60.1 + or - 34.8 vs. 15.4 + or - 5.1/mm(3), respectively; p = 0.2). The initial peritoneal fluid WBC count was significantly higher if there was a positive culture than a negative culture (165.0 + or - 132.6 vs. 20.3 + or - 6.4/mm(3), respectively; p = 0.01). The percentage of neutrophils was higher in patients with a positive culture than in those with a negative culture (54.7 + or - 14.1 vs. 19.1 + or - 4.9%, respectively; p = 0.01). Of the 28 patients, 27 received a single dose of intravenous antibiotics, as per the protocol at that time. Among those treated, 7% developed a positive culture (all staphylococcal species) while 93% had a negative culture. We conclude that following accidental exposure of the peritoneal dialysis catheter: (1) the prevalence of peritonitis is low; (2) measuring peritoneal fluid WBC provides treatment guidance; (3) if treatment is initiated, it should be applied intraperitoneally and include activity against Gram-positive organisms.

Breast Augmentation, Antibiotic Prophylaxis, and Infection: Comparative Analysis of 1,628 Primary Augmentation Mammoplasties Assessing the Role and Efficacy of Antibiotics Prophylaxis Duration

Infections after augmentation mammoplasty are not uncommon, and prophylactic antibiotics are routinely administered to minimize infection. However, there is paucity of information on the relationship between the length of prophylaxis cover and its benefits in primary augmentation mammoplasty. A retrospective analysis of different antibiotic cover regimens, their effectiveness in preventing infections, and the management of infection in established cases is reviewed. A retrospective chart analysis of periprosthetic infections in primary augmentation mammoplasties performed over the past 10 years was conducted. Periprosthetic infection was determined by the presence of pain, swelling, redness, and discharge. Each breast was taken as an individual unit in 1,628 patients, and data for 3,256 breasts were analyzed. The patients had their augmentation in the partial submuscular plane (214 breasts in 107 patients), the subglandular plane (1,548 breasts in 774 patients), and the muscle-splitting biplane (1,494 breasts in 747 patients). All the patients had soft round cohesive gel silicone implants. Of the 3,256 implants, 3,218 were textured, and 38 were smooth surfaced. The patients received antibiotics as a single intravenous dose of cephalosporin (474 breasts in 237 patients), a single intravenous dose plus an oral dose for 24 h (344 breasts in 172 patients), or a single intravenous dose plus an oral course for 5 days (2,438 breasts in 1,219 patients). Infection was recorded as superficial (e.g., wound breakdown, stitch extrusion, stitch abscess) or deep (periprosthetic). The patients with established periprosthetic infections, determined clinically by the presence of pain, discharge, swelling, and redness of the breasts, were managed either conservatively using antibiotics, passive wound drainage, and healing of the wound with secondary intention or by explantation and replacement after 3 to 4 months. In selected cases of periprosthetic infection, the implants were removed after a course of antibiotics and negative swab cultures. The cavity was washed thoroughly with betadine and saline, and new implants were simultaneously reimplanted. The incidence of infection was lowest with a single perioperative dose of intravenous antibiotic compared with a combination of intravenous and oral antibiotics. Superficial infection was seen in 38 breasts (all unilateral), with an incidence of 1.2%, and periprosthetic infection was observed in 17 breasts (13 unilateral and 2 bilateral), giving an infection incidence of 0.52% (p = 0.002). In patients with a single intravenous dose of antibiotic, superficial and periprosthetic infection was seen in four breasts (0.8%) and no breasts, respectively. The difference was not significant (p = 0.13). The patients receiving a single intravenous antibiotic and a 24-h oral antibiotic had superficial and periprosthetic infection rates of 2.3% (8 breasts) and 0.3% (1 breast), respectively, and the difference between the two sub-groups was significantly higher (p = 0.04). The patients receiving an intravenous antibiotic and 5 days of oral antibiotics had superficial and periprosthetic infection rates of 1.1% (26 breasts) and 0.65% (14 breasts), respectively. The difference between the two subgroups was not significant (p = 0.09). Of the 17 periprosthetic infections in 15 patients (13 unilateral and 2 bilateral), 11 breasts (1 bilateral and 9 unilateral) were treated conservatively using antibiotics, passive drainage, and wound healing with secondary intention. Capsular contracture developed in two of the conservatively treated breasts, requiring capsulotomies with change of implants. Of the six periprosthetic infections in six patients, requiring surgical intervention, two implants were treated using explantation with immediate replacement after a course of antibiotics and a negative culture, and two implants were explanted followed by reimplantation later. One patient had both implants removed after unilateral infection, and no reimplantation was performed. One patient had a bilateral infection. In this case, one implant was explanted and the other was treated conservatively. The patient had bilateral reimplantion 6 months later, and bilateral Baker 4 capsular contracture developed in both breasts within 6 months. No other complications were seen in the patients who underwent surgery. A single dose of intravenous antibiotic is adequate for prophylaxis in breast augmentation surgery, and the extra duration of antibiotic cover does not result in reduced superficial or periprosthetic infections. Infection can be managed in more than one way depending on the nature, degree, and extent of infection.

The Role of Local Steroid Injections in an Operational Field Hospital Setting

ObjectivesTo assess the safety and effectiveness of administering local steroid injections in an operational field hospital environment.MethodA prospective study of patients presenting to the physiotherapy department at the British Military...

Clinical outcome of cadaveric renal allografts contaminated before transplantation

This analysis was performed to define the incidence of pretransplant microbial contamination of donor kidneys, and to assess the resultant morbidity including infections requiring therapy, and graft loss. Case records of all 638 renal allograft recipients patients transplanted in our centre during the period June 1990 to October 2000 were studied. All the recipients were given a single dose of intravenous antibiotics at the time of induction of anaesthesia. A total of 775 microbiology reports on perfusion fluid, kidney swabs and ureteric tissue were retrieved. Fifty-eight of 638 (9.1%) patients were transplanted with a graft that showed preoperative contamination. 18 of these 58 patients (31%) subsequently required antibiotic treatment. Thirty of 32 patients who received kidney contaminated with skin flora had a benign course (i.e. no unexplained, no positive blood cultures or graft infection). By contrast, seven of nine recipients with grafts whose perfusion fluid yielded lactose fermenting coliforms (LFCs) required antibiotics and three of nine of them suffered graft loss as a result. Two of these patients had bacteraemia caused by LFC, and one died. Three of five patients with positive cultures due to yeast required treatment with antifungals. None of the four patients who had graft contaminated by Staphylococcus aureus became infected. One-year 49/58 (85%) of these patients survived with functioning graft. Overall 1-year patient survival was 53/55 (92%). These data suggest that contamination of renal allografts by LFCs or yeasts need to be treated preemptively before the onset of clinical manifestations. By contrast, contamination with skin contaminants does not pose a risk to the graft.

Antibiotic prophylaxis for post-operative wound infection in clean elective breast surgery

Antibiotic prophylaxis has been used to good effect in the prevention of post-operative wound infections in patients undergoing gastrointestinal operations. We have assessed the use of a single dose of intravenous antibiotic (Augmentin 1.2 g), given with induction of anaesthesia as prophylaxis, against post-operative wound infection in women undergoing clean, elective breast surgery. Three hundred and thirty-four patients were recruited. Of the 164 receiving antibiotic prophylaxis 29 (17.7%) had wound infections compared with 32 (18.8%) in the placebo group (P=0.79). There were no significant differences in any other post-operative infective complications. Antibiotic prophylaxis is probably not required in clean, elective breast surgery.

Audit of infective morbidity following caesarean section at a district general hospital

This paper sets out to audit infectious morbidity before and after introduction of a policy of antibiotic prophylaxis following emergency and elective caesarean section in a district general hospital in Scotland with approximately 3800 deliveries a year. In the first 'loop of audit', case notes of 200 consecutive patients managed during 1992 were studied. Audit loop was completed by studying 224 patients prospectively in 1993-94 following the introduction of new guidelines, which required the intraoperative administration of a single dose of intravenous antibiotic, following delivery of the baby. A significantly greater proportion of women received prophylactic antibiotics in 1993 compared with 1992 (81% vs. 14%; Diff= 67%; 95% CI 60%, 74%). The incidence of infection related morbidity was significantly reduced after routine antibiotic prophylaxis (28,5% vs. 16%; Diff= 12.5%, 95% CI=(4.60%,20.4%). The incidence of wound infection was halved in 1993 (9% vs. 17.5% in 1992). None of the patients in 1993 had a serious postoperative infection. Postnatal stay was significantly shorter in 1993 compared with 1992 ( P 0.0001). Although the target of adherence to the guidelines of 90% coverage was not met, this audit demonstrates the benefits of antibiotic prophylaxis for emergency and elective caesarean sections. Further reduction in morbidity may be obtained by strictly implementing the guidelines, and also by considering the use of multiple doses of antibiotics.

ENDOSCOPY

Current antibiotic prophylaxis for endoscopic retrograde cholangiopancreatography (ERCP) is not standardized and may be inadequate. We aimed to evaluate the efficacy of 3 days of additional oral antibiotics in the prevention of ERCP-related sepsis. One hundred and fifty-six patients were randomized prospectively to receive either intravenous ticarcillin and clavulinic acid (Timentin; SmithKline Beecham, Dandenong, Victoria, Australia), pre-ERCP (group I) or Timentin and 3 days of oral amoxycillin and clavulinic acid (Augmentin; SmithKline Beecham, Dandenong, Victoria, Australia), group II). Blood cultures were taken 30 min after the procedure. The occurrence of sepsis, defined as a temperature over 38 degrees C, occurring in the first 7 days was recorded and the risk factors for the development of sepsis were evaluated. Four patients had significant positive blood cultures despite the prior administration of Timentin. Sepsis occurred in 10% of group I patients, but only 3% of group II patients (relative risk 3.30; 95% confidence intervals 0.74-14.8). The performance of sphincterotomy and the presence of common bile duct stones were significant risk factors for the development of sepsis. We would recommend 3 days of additional oral Augmentin after a single dose of intravenous antibiotics in patients at increased risk of sepsis, which would include those with bile duct stones and/or those undergoing a therapeutic procedure.