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Impact of Antibiotic Prophylaxis on Surgical Site Infections in Cardiac Surgery. Antibiotics (Basel) 2023; 12:antibiotics12010085. [PMID: 36671286 PMCID: PMC9854463 DOI: 10.3390/antibiotics12010085] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/06/2023] Open
Abstract
(1) Background: Cephalosporins (CA) are the first-line antibiotic prophylaxis recommended to prevent surgical site infection (SSI) after cardiac surgery. The combination of vancomycin/gentamicin (VGA) might represent a good alternative, but few studies have evaluated its efficacy in SSI prevention. (2) Methods: A single-centre retrospective study was conducted over a 13-year period in all consecutive adult patients undergoing elective cardiac surgery. Patients were stratified according to the type of antibiotic prophylaxis. CA served as the first-line prophylaxis, and VGA was used as the second-line prophylaxis. The primary endpoint was SSI occurrence at 90 days, which was defined as the need for reoperation due to SSI. (3) Results: In total, 14,960 adult patients treated consecutively from 2006 to 2019 were included in this study, of whom 1774 (12%) received VGA and 540 (3.7%) developed SSI. VGA patients had higher severity with increased 90-day mortality. Nevertheless, the frequency of SSI was similar between CA and VGA patients. However, the microbiological aetiologies were different, with more Gram-negative bacteria noted in the VGA group. (4) Conclusions: VGA seems to be as effective as CA in preventing SSI.
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2
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van Oostveen RB, Romero-Palacios A, Whitlock R, Lee SF, Connolly S, Carignan A, Mazer CD, Loeb M, Mertz D. Prevention of Infections in Cardiac Surgery study (PICS): study protocol for a pragmatic cluster-randomized factorial crossover pilot trial. Trials 2018; 19:688. [PMID: 30558680 PMCID: PMC6296086 DOI: 10.1186/s13063-018-3080-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/26/2018] [Indexed: 11/26/2022] Open
Abstract
Background A wide range of prophylactic antibiotic regimens are used for patients undergoing open-heart cardiac surgery. This reflects clinical equipoise in choice and duration of antibiotic agents. Although individual-level randomized control trials (RCT) are considered the gold standard when evaluating the efficacy of an intervention, this approach is highly resource intensive and a cluster RCT can be more appropriate for testing clinical effectiveness in a real-world setting. Methods/design We are conducting a factorial cluster-randomized crossover pilot trial in cardiac surgery patients to evaluate the feasibility of this design for a definite trial to evaluate the optimal duration and choice of perioperative antibiotic prophylaxis. Specifically, we will evaluate: (a) the non-inferiority of a single preoperative dose compared to prolonged prophylaxis and (b) the potential superiority of adding vancomycin to routine cefazolin in terms of preventing deep and organ/space sternal surgical site infections (s-SSIs). There are four strategies: (i) short-term cefazolin, (ii) long-term cefazolin, (iii) short-term cefazolin + vancomycin, and (iv) long-term cefazolin + vancomycin. These strategies are delivered in a different order in each health-care center participating in the trial. The centers are randomized to an order, and the current strategy becomes the standard operating procedure in that center during the study. The three feasibility outcomes include: (1) the proportion of patients receiving preoperative, intra-operative, and postoperative antibiotics according to the study protocol, (2) the proportion of completed follow-up assessments, and (3) a full and final assessment of the incidence of s-SSIs by the outcome adjudication committee. Discussion We believe that a cluster-randomized factorial crossover trial is an effective and feasible design for these research questions, allowing an evaluation of the clinical effectiveness in a real-world setting. A waiver of individual informed consent was considered appropriate by the research ethics boards in each participating site in Canada as long as an information letter with an opt-out option was provided. However, a waiver of consent was not approved at two sites in Germany and Switzerland, respectively. Trial registration Clinicaltrials.gov, NCT02285140. Registered on 15 October 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-3080-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rachel B van Oostveen
- Population Health Research Institute (PHRI), Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Richard Whitlock
- Population Health Research Institute (PHRI), Hamilton Health Sciences, Hamilton, ON, Canada.,McMaster University, Hamilton, ON, Canada
| | - Shun Fu Lee
- Population Health Research Institute (PHRI), Hamilton Health Sciences, Hamilton, ON, Canada
| | - Stuart Connolly
- Population Health Research Institute (PHRI), Hamilton Health Sciences, Hamilton, ON, Canada.,McMaster University, Hamilton, ON, Canada
| | - Alex Carignan
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - C David Mazer
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Mark Loeb
- McMaster University, Hamilton, ON, Canada
| | - Dominik Mertz
- Population Health Research Institute (PHRI), Hamilton Health Sciences, Hamilton, ON, Canada. .,McMaster University, Hamilton, ON, Canada. .,Juravinski Hospital and Cancer Center, 711 Concession Street, Section M, Level 1, Room 3, Hamilton, ON, L8V 1C3, Canada.
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Serban G, Stanasel O, Serban E, Bota S. 2-Amino-1,3,4-thiadiazole as a potential scaffold for promising antimicrobial agents. Drug Des Devel Ther 2018; 12:1545-1566. [PMID: 29910602 PMCID: PMC5987787 DOI: 10.2147/dddt.s155958] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pathogenic microorganisms are causative agents for different types of serious and even lethal infectious diseases. Despite advancements in medication, bacterial and fungal infections continue to be a growing problem in health care. As more and more bacteria become resistant to antibiotics used in therapy and an increasing number of invasive fungal species become resistant to current antifungal medications, there is considerable interest in the development of new compounds with antimicrobial activity. The compounds containing a heterocyclic ring play an important role among organic compounds with biological activity used as drugs in human and veterinary medicine or as insecticides and pesticides in agriculture. Thiadiazoles belong to the classes of nitrogen-sulfur heterocycles with extensive application as structural units of biologically active molecules and as useful intermediates in medicinal chemistry. The potency of the thiadiazole nucleus is demonstrated by the drugs currently used. 1,3,4-Thiadiazoles and some of their derivatives are extensively studied because of their broad spectrum of pharmacological activities. The aim of this review was to highlight the main antimicrobial properties exhibited by derivatives possessing 2-amino-1,3,4-thiadiazole moiety. Many of the reported 2-amino-1,3,4-thiadiazole derivatives can be considered as lead compounds for drug synthesis, and several of them have demonstrated higher antimicrobial activity in comparison to standard drugs. Furthermore, taking into account the reactivity of the amine group in the derivatization process, 2-amino-1,3,4-thiadiazole moiety may be a good scaffold for future pharmacologically active 1,3,4-thiadiazole derivatives.
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Affiliation(s)
- Georgeta Serban
- Pharmaceutical Chemistry Department, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
| | - Oana Stanasel
- Chemistry Department, Faculty of Sciences, University of Oradea, Oradea, Romania
| | - Eugenia Serban
- Faculty of Environmental Protection, University of Oradea, Oradea, Romania
| | - Sanda Bota
- Chemistry Department, Faculty of Sciences, University of Oradea, Oradea, Romania
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Affiliation(s)
- Siew S.C. Goh
- Department of Cardiothoracic Surgery; Liverpool Hospital; NSW Australia
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Olsson DP, Holzmann MJ, Sartipy U. Reply to Letter From Sebastian J. Baxter and Siax I. Jaggar Entitled, "Teicoplanin, Acute Kidney Injury and Surgical-Site Infection in Cardiac Surgery". J Cardiothorac Vasc Anesth 2016; 30:e4-5. [PMID: 26847752 DOI: 10.1053/j.jvca.2015.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel P Olsson
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Departments of Anesthesiology, Surgical Services and Intensive Care Medicine, Stockholm, Sweden
| | - Martin J Holzmann
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrik Sartipy
- Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Routine Surveillance Versus Independent Assessment by an Outcome Adjudication Committee in Assessing Patients for Sternal Surgical Site Infections After Cardiac Surgery. Infect Control Hosp Epidemiol 2016; 37:600-2. [PMID: 26782707 DOI: 10.1017/ice.2015.347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Based on a cohort of 966 patients, routine surveillance data were not sufficiently accurate for use in clinical trials investigating surgical site infections. Surveillance data can only be used if adequate 90-day follow-up is provided and if cases identified by surveillance are independently reviewed by a blinded outcome adjudication committee.
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Olsson DP, Holzmann MJ, Sartipy U. Antibiotic Prophylaxis by Teicoplanin and Risk of Acute Kidney Injury in Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:626-31. [DOI: 10.1053/j.jvca.2014.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Indexed: 11/11/2022]
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De Maria E, Diemberger I, Vassallo PL, Pastore M, Giannotti F, Ronconi C, Romandini A, Biffi M, Martignani C, Ziacchi M, Bonfatti F, Tumietto F, Viale P, Boriani G. Prevention of infections in cardiovascular implantable electronic devices beyond the antibiotic agent. J Cardiovasc Med (Hagerstown) 2015; 15:554-64. [PMID: 24838036 DOI: 10.2459/jcm.0000000000000008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The increase in incidence/prevalence of infections of implantable pacemakers and defibrillators (implantable cardioverter defibrillator, ICD) is outweighing that of the implanting procedures, mainly favored by the changes in patient profile. Despite the high impact on patient's outcome and related costs for healthcare systems, we lack specific evidence on the preventive measures with the exception of antibiotic prophylaxis. The aim of this study is to focus on common approaches to pacemaker/ICD implantation to identify the practical preventive strategies and choices that can (potentially) impact on the occurrence of this feared complication. After a brief introduction on clinical presentation, pathogenesis, and risk factors, we will present the results from a survey on the preventive strategies adopted by different operators from the 25 centers of the Emilia Romagna region in the northern Italy (4.4 million inhabitants). These data will provide the basis for reviewing available literature on this topic and identifying the gray areas. The last part of the article will cover the available evidence about pacemaker/ICD implantation, focusing on prophylaxis of pacemaker/ICD infection as a 'continuum' starting before the surgical procedure (from indications to patient preparation), which follows during (operator, room, and techniques) and after the procedure (patient and device follow-up). We will conclude by evaluating the relationship between adherence to the available evidence and the volume of procedures of the implanting centers or operators' experience according to the results of our survey.
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Affiliation(s)
- Elia De Maria
- aCardiology Unit, 'Ramazzini Hospital', Carpi, Modena bInstitute of Cardiology, University of Bologna cCardiology Unit, 'Santa Maria della Scaletta Hospital', Imola, Bologna dCardiology Unit, 'San Secondo Hospital', Fidenza, Parma eCardiology Unit, Hospital of Ravenna, Ravenna fCardiology Unit, 'Infermi Hospital', Rimini gInstitute of Cardiology, University of Ancona, Ancona hClinic of Infective Diseases, University of Bologna, Bologna, Italy *Elia De Maria and Igor Diemberger contributed equally to the writing of the article
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Miller LG, McKinnell JA, Vollmer ME, Spellberg B. Impact of Methicillin-Resistant Staphylococcus aureus Prevalence among S. aureus Isolates on Surgical Site Infection Risk after Coronary Artery Bypass Surgery. Infect Control Hosp Epidemiol 2015. [DOI: 10.1086/522269] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective.Cephalosporins are recommended for antibiotic prophylaxis to prevent cardiothoracic surgical site infections (SSIs) except in patients withβ-lactam allergy or in settings with a “high” prevalence of methicillin-resistantStaphylococcus aureus(MRSA) among S.aureusisolates (hereafter, “MRSA prevalence”); however, “high” remains undefined. We sought to identify the MRSA prevalence at which glycopeptide prophylaxis would minimize SSIs relative toβ-lactam prophylaxis.Methods.We developed a decision analysis model to estimate SSI likelihood when either glycopeptides orβ-lactams were used for prophylaxis in cardiothoracic surgery. Event probabilities were derived from a systematic literature review. A similar cost-minimization model was also developed.Results.At 0% MRSA prevalence, SSI probability was 3.64% with glycopeptide prophylaxis and 3.49% withβ-lactam prophylaxis. At MRSA prevalences of 10%, 20%, 30%, or 40%, SSI probabilities with glycopeptide prophylaxis did not change, but they were 3.98%, 4.48%, 4.97%, and 5.47% withβ-lactam prophylaxis. The threshold of MRSA prevalence at which glycopeptide prophylaxis minimized SSI probability and cost was 3%. In sensitivity analyses, variations in most model estimates only modestly affected the threshold.Conclusion.Glycopeptide prophylaxis minimizes the risk of SSIs and cost when MRSA prevalence exceeds 3%. At very low MRSA prevalence (between 3% and 10%), the SSI minimization provided by glycopeptide prophylaxis is small and may be within the error of the model. Given the current MRSA prevalence in most community and healthcare settings, clinicians should consider routine prophylaxis with vancomycin. Our findings may have important policy implications, as benefits in cardiothoracic surgery antibiotic prophylaxis must be weighed against the limitations of increased glycopeptide use.
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Glycopeptides Versus β-Lactams for the Prevention of Surgical Site Infections in Cardiovascular and Orthopedic Surgery. Ann Surg 2015; 261:72-80. [DOI: 10.1097/sla.0000000000000704] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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11
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Sandoe JAT, Barlow G, Chambers JB, Gammage M, Guleri A, Howard P, Olson E, Perry JD, Prendergast BD, Spry MJ, Steeds RP, Tayebjee MH, Watkin R. Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. Report of a joint Working Party project on behalf of the British Society for Antimicrobial Chemotherapy (BSAC, host organization), British Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS), British Heart Valve Society (BHVS) and British Society for Echocardiography (BSE). J Antimicrob Chemother 2014; 70:325-59. [PMID: 25355810 DOI: 10.1093/jac/dku383] [Citation(s) in RCA: 249] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Infections related to implantable cardiac electronic devices (ICEDs), including pacemakers, implantable cardiac defibrillators and cardiac resynchronization therapy devices, are increasing in incidence in the USA and are likely to increase in the UK, because more devices are being implanted. These devices have both intravascular and extravascular components and infection can involve the generator, device leads and native cardiac structures or various combinations. ICED infections can be life-threatening, particularly when associated with endocardial infection, and all-cause mortality of up to 35% has been reported. Like infective endocarditis, ICED infections can be difficult to diagnose and manage. This guideline aims to (i) improve the quality of care provided to patients with ICEDs, (ii) provide an educational resource for all relevant healthcare professionals, (iii) encourage a multidisciplinary approach to ICED infection management, (iv) promote a standardized approach to the diagnosis, management, surveillance and prevention of ICED infection through pragmatic evidence-rated recommendations, and (v) advise on future research projects/audit. The guideline is intended to assist in the clinical care of patients with suspected or confirmed ICED infection in the UK, to inform local infection prevention and treatment policies and guidelines and to be used in the development of educational and training material by the relevant professional societies. The questions covered by the guideline are presented at the beginning of each section.
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Affiliation(s)
| | - Gavin Barlow
- Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | | | | | - Philip Howard
- University of Leeds/Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ewan Olson
- Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - Michael J Spry
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Richard P Steeds
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Gurusamy KS, Koti R, Wilson P, Davidson BR. Antibiotic prophylaxis for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) related complications in surgical patients. Cochrane Database Syst Rev 2013:CD010268. [PMID: 23959704 DOI: 10.1002/14651858.cd010268.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Risk of methicillin-resistant Staphylococcus aureus (MRSA) infection after surgery is generally low, but affects up to 33% of patients after certain types of surgery. Postoperative MRSA infection can occur as surgical site infections (SSIs), chest infections, or bloodstream infections (bacteraemia). The incidence of MRSA SSIs varies from 1% to 33% depending upon the type of surgery performed and the carrier status of the individuals concerned. The optimal prophylactic antibiotic regimen for the prevention of MRSA after surgery is not known. OBJECTIVES To compare the benefits and harms of all methods of antibiotic prophylaxis in the prevention of postoperative MRSA infection and related complications in people undergoing surgery. SEARCH METHODS In March 2013 we searched the following databases: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); NHS Economic Evaluation Database (The Cochrane Library); Health Technology Assessment (HTA) Database (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. SELECTION CRITERIA We included only randomised controlled trials (RCTs) that compared one antibiotic regimen used as prophylaxis for SSIs (and other postoperative infections) with another antibiotic regimen or with no antibiotic, and that reported the methicillin resistance status of the cultured organisms. We did not limit our search for RCTs by language, publication status, publication year, or sample size. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion in the review, and extracted data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for comparing binary outcomes between the groups and planned to calculated the mean difference (MD) with 95% CI for comparing continuous outcomes. We planned to perform meta-analysis using both a fixed-effect model and a random-effects model. We performed intention-to-treat analysis whenever possible. MAIN RESULTS We included 12 RCTs, with 4704 participants, in this review. Eleven trials performed a total of 16 head-to-head comparisons of different prophylactic antibiotic regimens. Antibiotic prophylaxis was compared with no antibiotic prophylaxis in one trial. All the trials were at high risk of bias. With the exception of one trial in which all the participants were positive for nasal carriage of MRSA or had had previous MRSA infections, it does not appear that MRSA was tested or eradicated prior to surgery; nor does it appear that there was high prevalence of MRSA carrier status in the people undergoing surgery.There was no sufficient clinical similarity between the trials to perform a meta-analysis. The overall all-cause mortality in four trials that reported mortality was 14/1401 (1.0%) and there were no significant differences in mortality between the intervention and control groups in each of the individual comparisons. There were no antibiotic-related serious adverse events in any of the 561 people randomised to the seven different antibiotic regimens in four trials (three trials that reported mortality and one other trial). None of the trials reported quality of life, total length of hospital stay or the use of healthcare resources. Overall, 221/4032 (5.5%) people developed SSIs due to all organisms, and 46/4704 (1.0%) people developed SSIs due to MRSA.In the 15 comparisons that compared one antibiotic regimen with another, there were no significant differences in the proportion of people who developed SSIs. In the single trial that compared an antibiotic regimen with placebo, the proportion of people who developed SSIs was significantly lower in the group that received antibiotic prophylaxis with co-amoxiclav (or cefotaxime if allergic to penicillin) compared with placebo (all SSI: RR 0.26; 95% CI 0.11 to 0.65; MRSA SSI RR 0.05; 95% CI 0.00 to 0.83). In two trials that reported MRSA infections other than SSI, 19/478 (4.5%) people developed MRSA infections including SSI, chest infection and bacteraemia. There were no significant differences in the proportion of people who developed MRSA infections at any body site in these two comparisons. AUTHORS' CONCLUSIONS Prophylaxis with co-amoxiclav decreases the proportion of people developing MRSA infections compared with placebo in people without malignant disease undergoing percutaneous endoscopic gastrostomy insertion, although this may be due to decreasing overall infection thereby preventing wounds from becoming secondarily infected with MRSA. There is currently no other evidence to suggest that using a combination of multiple prophylactic antibiotics or administering prophylactic antibiotics for an increased duration is of benefit to people undergoing surgery in terms of reducing MRSA infections. Well designed RCTs assessing the clinical effectiveness of different antibiotic regimens are necessary on this topic.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Department of Surgery, Royal Free Campus, UCL Medical School, Royal Free Hospital,, Rowland Hill Street, London, UK, NW3 2PF
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Yamamoto S, Kanamaru S, Kunishima Y, Ichiyama S, Ogawa O. Perioperative Antimicrobial Prophylaxis in Urology: a Multi-Center Prospective Study. J Chemother 2013; 17:189-97. [PMID: 15920905 DOI: 10.1179/joc.2005.17.2.189] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Since there are few published reports regarding the impact of urologic surgery on perioperative infections, an epidemiologic analysis was performed on data from 1,156 open or laparoscopic operations in urology collected by the 21 hospitals participating in this study between September 2002 and August 2003. Prophylactic antibiotics were administered intravenously according to our protocol designed on the basis of the invasiveness and contamination levels. The surgical site infection (SSI) rates following clean, clean-contaminated and contaminated surgery were 1.2%. 5.8% and 23.4%, respectively, while the remote infection (RI) rates were 3.5%. 7.1% and 35.9%, respectively. Methicillin-resistant Staphylococcus aureus (MRSA) was most frequently isolated from SSIs as well as RIs, whereas Enterococcus faecalis and Pseudomonas aeruginosa were more frequently discovered in RIs than in SSIs. Several risk factors for SSI and/or RI, such as older age, high ASA score, obesity, diabetes, preoperative chemotherapy, long operation time and much blood loss, were identified by univariate analysis.
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Affiliation(s)
- S Yamamoto
- Department of Urology, Hyogo College of Medicine, Japan.
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Schweizer M, Perencevich E, McDanel J, Carson J, Formanek M, Hafner J, Braun B, Herwaldt L. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis. BMJ 2013; 346:f2743. [PMID: 23766464 PMCID: PMC3681273 DOI: 10.1136/bmj.f2743] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2013] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate studies assessing the effectiveness of a bundle of nasal decolonization and glycopeptide prophylaxis for preventing surgical site infections caused by Gram positive bacteria among patients undergoing cardiac operations or total joint replacement procedures. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed (1995 to 2011), the Cochrane database of systematic reviews, CINAHL, Embase, and clinicaltrials.gov were searched to identify relevant studies. Pertinent journals and conference abstracts were hand searched. Study authors were contacted if more data were needed. ELIGIBILITY CRITERIA Randomized controlled trials, quasi-experimental studies, and cohort studies that assessed nasal decolonization or glycopeptide prophylaxis, or both, for preventing Gram positive surgical site infections compared with standard care. PARTICIPANTS Patients undergoing cardiac operations or total joint replacement procedures. DATA EXTRACTION AND STUDY APPRAISAL: Two authors independently extracted data from each paper and a random effects model was used to obtain summary estimates. Risk of bias was assessed using the Downs and Black or the Cochrane scales. Heterogeneity was assessed using the Cochran Q and I(2) statistics. RESULTS 39 studies were included. Pooled effects of 17 studies showed that nasal decolonization had a significantly protective effect against surgical site infections associated with Staphylococcus aureus (pooled relative risk 0.39, 95% confidence interval 0.31 to 0.50) when all patients underwent decolonization (0.40, 0.29 to 0.55) and when only S aureus carriers underwent decolonization (0.36, 0.22 to 0.57). Pooled effects of 15 prophylaxis studies showed that glycopeptide prophylaxis was significantly protective against surgical site infections related to methicillin (meticillin) resistant S aureus (MRSA) compared with prophylaxis using β lactam antibiotics (0.40, 0.20 to 0.80), and a non-significant risk factor for methicillin susceptible S aureus infections (1.47, 0.91 to 2.38). Seven studies assessed a bundle including decolonization and glycopeptide prophylaxis for only patients colonized with MRSA and found a significantly protective effect against surgical site infections with Gram positive bacteria (0.41, 0.30 to 0.56). CONCLUSIONS Surgical programs that implement a bundled intervention including both nasal decolonization and glycopeptide prophylaxis for MRSA carriers may decrease rates of surgical site infections caused by S aureus or other Gram positive bacteria.
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Affiliation(s)
- Marin Schweizer
- University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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15
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Does duration of perioperative antibiotic prophylaxis matter in cardiac surgery? Ann Surg 2013; 257:e24. [PMID: 23665976 DOI: 10.1097/sla.0b013e3182942dac] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Reply to letter: "Does duration of perioperative antibiotic prophylaxis matter in cardiac surgery?". Ann Surg 2013; 257:e25. [PMID: 23629528 DOI: 10.1097/sla.0b013e3182942dd0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kunicki PK, Waś J. Simple HPLC method for cefazolin determination in human serum - validation and stability testing. J Chromatogr B Analyt Technol Biomed Life Sci 2012; 911:133-9. [PMID: 23217316 DOI: 10.1016/j.jchromb.2012.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 10/11/2012] [Accepted: 11/05/2012] [Indexed: 11/26/2022]
Abstract
The paper presents an HPLC method for cefazolin determination in human serum. The preparation step was based on serum protein precipitation with acetonitrile followed by supernatant evaporation and sample reconstitution in water before injection. The separation of cefazolin and internal standard cefamandole was performed at ambient temperature under isocratic conditions on LiChrosorb RP8-5 column (250mm×4.6mm) using the mixture: CH(3)CN:H(2)O:0.5M KH(2)PO(4) (100:894:6, v/v) as a mobile phase with a flow rate of 1.5mL/min. UV detection was performed at 272nm with LLOQ of 0.2μg/mL. The precision was satisfactory in the whole range tested with RSD of 2.3-12.5% (accuracy: from -2.3% to +3.6%) and of 1.7-7.1% (accuracy: from -3.5% to +1.1%) for intra- and inter-assay, respectively. The method stability was confirmed in a series of experiments including: freeze-thaw and short- and long-term stability testing. Finally, the procedure described was found resistant to potential human errors.
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Affiliation(s)
- Paweł K Kunicki
- Clinical Pharmacology Unit, Department of Clinical Biochemistry, Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland.
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Cove ME, Spelman DW, MacLaren G. Infectious complications of cardiac surgery: a clinical review. J Cardiothorac Vasc Anesth 2012; 26:1094-100. [PMID: 22765993 DOI: 10.1053/j.jvca.2012.04.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Indexed: 12/28/2022]
Affiliation(s)
- Matthew E Cove
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, DiSesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg 2012; 143:4-34. [PMID: 22172748 DOI: 10.1016/j.jtcvs.2011.10.015] [Citation(s) in RCA: 197] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, DiSesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. Anesth Analg 2012; 114:11-45. [DOI: 10.1213/ane.0b013e3182407c25] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lador A, Nasir H, Mansur N, Sharoni E, Biderman P, Leibovici L, Paul M. Antibiotic prophylaxis in cardiac surgery: systematic review and meta-analysis. J Antimicrob Chemother 2011; 67:541-50. [PMID: 22083832 DOI: 10.1093/jac/dkr470] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Antibiotic prophylaxis is recommended in cardiac surgery. Current debate concerns the type of antibiotic(s), dosing and the duration of prophylaxis. METHODS Systematic review of randomized controlled trials comparing one antibiotic regimen versus another in cardiac surgery. We searched The Cochrane Library, PubMed, LILACS, conference proceedings and bibliographies. Two reviewers independently extracted the data. The primary outcome was deep sternal wound infections (DSWIs). Meta-analysis was performed using the Mantel-Haenszel fixed-effect method. Risk ratios (RRs) with 95% confidence intervals (95% CIs) are reported. RESULTS Fifty-nine trials were included. There were no significant differences in DSWI or all other categories of surgical site infections (SSIs) for antibiotic prophylaxis with β-lactams comprising a Gram-negative spectrum of coverage versus prophylaxis targeting Gram-positive bacteria, but the former led to a significantly lower rate of post-operative pneumonia (RR 0.68, 95% CI 0.51-0.90) and all-cause mortality (RR 0.66, 95% CI 0.47-0.92). In trials comparing different antibiotic regimens for different durations, prophylaxis duration of ≤24 h post-operation led to higher rates of DSWI (RR 1.83, 95% CI 1.25-2.66), any sternal SSI, surgical interventions for SSI and endocarditis compared with longer duration prophylaxis. There was no advantage of regimens lasting >48 h post-operation. In the comparison of glycopeptides versus β-lactams, an advantage of glycopeptides was observed when comparators were given for similar duration and for β-lactams when given for a longer duration than the glycopeptides. There was no significant advantage of high antibiotic dosing. CONCLUSIONS Evidence supports second- or third-generation cephalosporins for cardiac surgery prophylaxis and points at a possible advantage of prophylaxis prolongation up to 48 h post-operatively.
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Affiliation(s)
- Adi Lador
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2610-42. [PMID: 22064600 DOI: 10.1161/cir.0b013e31823b5fee] [Citation(s) in RCA: 332] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 575] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 423] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Lin MH, Pan SC, Wang JL, Hsu RB, Lin Wu FL, Chen YC, Lin FY, Chang SC. Prospective randomized study of efficacy of 1-day versus 3-day antibiotic prophylaxis for preventing surgical site infection after coronary artery bypass graft. J Formos Med Assoc 2011; 110:619-26. [DOI: 10.1016/j.jfma.2011.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 06/24/2010] [Accepted: 07/05/2010] [Indexed: 10/17/2022] Open
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Does duration of perioperative antibiotic prophylaxis matter in cardiac surgery? A systematic review and meta-analysis. Ann Surg 2011; 254:48-54. [PMID: 21412147 DOI: 10.1097/sla.0b013e318214b7e4] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE We aimed to compare the efficacy of short-term (<24 hours) versus longer-term antibiotic prophylaxis (≥24 hours) in open heart surgery. BACKGROUND The optimal duration of antibiotic prophylaxis for adults undergoing cardiac surgery is unknown and guideline recommendations are inconsistent. METHODS We searched MEDLINE, EMBASE, CINAHL, and CENTRAL for parallel-group randomized trials comparing any antibiotic prophylaxis administered for <24 hours to any antibiotic prophylaxis for ≥24 hours in adult patients undergoing open heart surgery. Reference lists of selected articles, clinical practice guidelines, review articles, and congress abstracts were searched. Study selection, data extraction and assessment of risk of bias were performed independently by 2 reviewers. RESULTS Of the 1338 citations identified by our search strategy, 12 studies involving 7893 patients were selected. Compared with short-term antibiotic prophylaxis, longer-term antibiotic prophylaxis reduced the risk of sternal surgical site infection (SSI) by 38% (risk ratio 1.38, 95% confidence interval (CI) 1.13-1.69, P = 0.002) and deep sternal SSI by 68% (risk ratio 1.68, 95% CI 1.12-2.53, P = 0.01). There were no statistically significant differences in mortality, infections overall and adverse events. Eleven of the trials were at high risk for bias due to limitations in study design. CONCLUSIONS Perioperative antibiotic prophylaxis of ≥24 hours may be more efficacious in preventing sternal SSIs in patients undergoing cardiac surgery compared to shorter regimens. The findings however are limited by the heterogeneity of antibiotic regimens used and the risk of bias in the published studies.
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Miller LG, McKinnell JA, Vollmer ME, Spellberg B. Impact of methicillin-resistant Staphylococcus aureus prevalence among S. aureus isolates on surgical site infection risk after coronary artery bypass surgery. Infect Control Hosp Epidemiol 2011; 32:342-50. [PMID: 21460485 DOI: 10.1086/658668] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Cephalosporins are recommended for antibiotic prophylaxis to prevent cardiothoracic surgical site infections (SSIs) except in patients with β-lactam allergy or in settings with a "high" prevalence of methicillin-resistant Staphylococcus aureus (MRSA) among S. aureus isolates (hereafter, "MRSA prevalence"); however, "high" remains undefined. We sought to identify the MRSA prevalence at which glycopeptide prophylaxis would minimize SSIs relative to β-lactam prophylaxis. METHODS We developed a decision analysis model to estimate SSI likelihood when either glycopeptides or β-lactams were used for prophylaxis in cardiothoracic surgery. Event probabilities were derived from a systematic literature review. A similar cost-minimization model was also developed. RESULTS At 0% MRSA prevalence, SSI probability was 3.64% with glycopeptide prophylaxis and 3.49% with β-lactam prophylaxis. At MRSA prevalences of 10%, 20%, 30%, or 40%, SSI probabilities with glycopeptide prophylaxis did not change, but they were 3.98%, 4.48%, 4.97%, and 5.47% with β-lactam prophylaxis. The threshold of MRSA prevalence at which glycopeptide prophylaxis minimized SSI probability and cost was 3%. In sensitivity analyses, variations in most model estimates only modestly affected the threshold. CONCLUSION Glycopeptide prophylaxis minimizes the risk of SSIs and cost when MRSA prevalence exceeds 3%. At very low MRSA prevalence (between 3% and 10%), the SSI minimization provided by glycopeptide prophylaxis is small and may be within the error of the model. Given the current MRSA prevalence in most community and healthcare settings, clinicians should consider routine prophylaxis with vancomycin. Our findings may have important policy implications, as benefits in cardiothoracic surgery antibiotic prophylaxis must be weighed against the limitations of increased glycopeptide use.
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Affiliation(s)
- Loren G Miller
- Infectious Diseases Clinical Outcomes Research Unit (ID-CORE), Division of Infectious Diseases, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Los Angeles, California, USA.
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Chambers D, Worthy G, Myers L, Weatherly H, Elliott R, Hawkins N, Sculpher M, Eastwood A. Glycopeptide vs. non-glycopeptide antibiotics for prophylaxis of surgical site infections: a systematic review. Surg Infect (Larchmt) 2011; 11:455-62. [PMID: 20815758 DOI: 10.1089/sur.2009.055] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients receive prophylactic antibiotics against surgical site infections (SSIs) before or during many procedures. Glycopeptide antibiotics are effective against most strains of methicillin-resistant Staphylococcus aureus (MRSA), but their wider use risks increasing resistance. Our objective was to review the evidence for clinical effectiveness that might help to determine whether there is a threshold of MRSA prevalence at which switching from non-glycopeptide to glycopeptide antibiotic prophylaxis might be justified. METHODS We performed a systematic review of randomized trials comparing a glycopeptide with an alternative antibiotic regimen for SSI prophylaxis in adults undergoing clean or clean-contaminated surgical procedures. The evidence was used to inform development of a decision-analytic model. We subsequently updated the review to May 2008. RESULTS Fourteen studies were identified that provided evidence concerning clinical effectiveness. The studies were too heterogeneous clinically for meta-analysis. Only one of 12 trials found that glycopeptides reduced SSIs significantly at 30 days compared with non-glycopeptide antibiotics. Of the two trials that reported on MRSA infection, neither found a significant difference between glycopeptide and comparator drugs. CONCLUSIONS This systematic review did not find any evidence to support the use of glycopeptides in preference to other antibiotics for the prevention of MRSA infections and SSIs. The limitations of the evidence make it difficult to identify a threshold at which a switch from non-glycopeptide to glycopeptide prophylaxis should be recommended. Given the difficulties of addressing this issue through randomized trials, further research should focus on hospital infection control policies, MRSA screening, and the isolation and treatment of anyone infected with MRSA prior to surgery.
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Kusaba T. Safety and Efficacy of Cefazolin Sodium in the Management of Bacterial Infection and in Surgical Prophylaxis. ACTA ACUST UNITED AC 2009. [DOI: 10.4137/cmt.s2096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cefazolin sodium is a first-generation cephalosporin antibiotic and has been used worldwide since the early 1970s. It is used for the treatment of bacterial infections in various organs, such as the respiratory tract, skin and skin structure, genital tract, urinary tract, biliary tract, and bone and joint infections. It has also been used for septicemia due to susceptible gram-positive cocci (except Enterococcus), some gram-negative bacilli including E. coli, Proteus, and Klebsiella may be susceptible, and for perioperative prophylaxis. After the introduction of penicillins and other cephalosporins, occasional outbreaks of methicillin-resistant Staphylococcus aureus were noted. As a result, vancomycin use was increased; however, very recently and most alarmingly, vancomycin-resistant strains have been described. In this setting, to avoid the risk of the development of vancomycin-resistant strains further, vancomycin use should be curtailed. In consideration of this historical background, the appropriate use of antibiotics, such as dosage, dosage intervals, and the duration of administration is required not only for the protection of patients’ health but also for the prevention of the development of drug resistance. Cefazolin has been used in clinical practice for about 40 years, and a large body of evidence has been accumulated, and its efficacy and safety are well established compared with other antibiotics. Therefore, cefazolin has been chosen as a first-line anti-microbial for prophylaxis after various surgical procedures, including cardiovascular surgery, hysterectomy, arthroplasty and so on. Based on these facts, especially for the prophylaxis of surgical site infections, the first-generation cephalosporin, cefazolin, is now being “re-visited”.
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Affiliation(s)
- Tetsuro Kusaba
- Division of Nephrology kyoto First Red Cross Hospital, kyoto, Japan
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Tamayo E, Gualis J, Flórez S, Castrodeza J, Eiros Bouza JM, Álvarez FJ. Comparative study of single-dose and 24-hour multiple-dose antibiotic prophylaxis for cardiac surgery. J Thorac Cardiovasc Surg 2008; 136:1522-7. [DOI: 10.1016/j.jtcvs.2008.05.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Revised: 04/16/2008] [Accepted: 05/04/2008] [Indexed: 10/21/2022]
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Lied B, Sundseth J, Helseth E. Immediate (0-6 h), early (6-72 h) and late (>72 h) complications after anterior cervical discectomy with fusion for cervical disc degeneration; discharge six hours after operation is feasible. Acta Neurochir (Wien) 2008; 150:111-8; discussion 118. [PMID: 18066487 DOI: 10.1007/s00701-007-1472-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2006] [Accepted: 11/13/2007] [Indexed: 01/11/2023]
Abstract
OBJECTIVES The introduction of minimally invasive techniques and total intravenous anaesthesia has led to reports of the performance of anterior cervical discectomy and fusion as an outpatient. The safety of this approach, requires information about the complications presenting within this period. The aim of this study was to assess the rates and types of immediate (0-6 h), early (6-72 h) and late (>72 h) complications after anterior cervical discectomy with fusion. METHODS We prospectively studied complications after anterior cervical discectomy with fusion in patients with degenerative cervical disc disease. There were 390 consecutive operations: 278 fused with autologous iliac crest bone graft and 112 with a PEEK (Polyetheretherketone) graft. RESULTS No patient died. Thirty seven patients (9%) experienced one or more complications that could be related to the operation. These presented in the immediate, early and late periods in 17, 1 and 19 patients, respectively. Thus, 18/37 complications were detected before discharge from the neurosurgical department 48-72 h after operation and of these 17 (4.2%) were detected within the first 6 h after surgery. Each of the five potentially life-threatening neck hematomas was detected within 6 h (immediate). CONCLUSIONS After anterior cervical discectomy and fusion, a 6 h postoperative observation period followed by discharge from the neurosurgical unit is likely to be as safe as observation as an inpatient for a longer period.
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Affiliation(s)
- B Lied
- Department of Neurosurgery, Rikshospitalet HF, Oslo, Norway.
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A national survey of antimicrobial prophylaxis in adult cardiac surgery across Canada. Can J Infect Dis 2007; 13:21-7. [PMID: 18159370 DOI: 10.1155/2002/370389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2001] [Accepted: 04/19/2001] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To characterize national and regional patterns of antimicrobial prophylaxis in adult cardiac surgery across Canada. DESIGN Retrospective, cross-sectional analysis. SETTING Thirty-three adult cardiac surgical centres across Canada. INTERVENTIONS A one-page questionnaire collecting information regarding institutional demographics and antimicrobial prophylaxis regimens for adult cardiac surgical procedures was mailed to all adult surgical centres across Canada. If a response was not received within one month, a second survey was mailed, followed by a telephone reminder within two weeks of the second mailing. MAIN RESULTS The Overall response rate was 100%. Prophylactic antimicrobials were used in all the adult cardiac centres; single-agent prophylaxis was used in 97% (32 of 33) of centres; Single-dose antimicrobial prophylaxis was used in only 3% (one of 33) of centres. Preoperative and postoperative antimicrobial prophylaxis regimens varied both between provinces and within provinces across Canada. Cefazolin was the antimicrobial used in 88% (38 of 43) and 87% (33 of 38) of the reported pre-operative and post-operative prophylaxis regimens, respectively. Antimicrobial prophylaxis was initiated in the operating room 72% (26 of 36) of the time and intra-operative supplemental antimicrobial doses were administered for cardiac procedures longer than a median of 4 hours (range 4 to 8 hr). Overall, the median duration of antimicrobial prophylaxis was 36 hours (range 8 to 96 hr). CONCLUSIONS Despite the availability of various published guidelines, our survey identified several areas for improvement with respect to antimicrobial prophylaxis in adult cardiac surgery across Canada.
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In Vivo Microdialysis to Measure Antibiotic Penetration Into Soft Tissue During Cardiac Surgery. Ann Thorac Surg 2007; 84:1605-10. [DOI: 10.1016/j.athoracsur.2007.06.052] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2007] [Revised: 06/16/2007] [Accepted: 06/19/2007] [Indexed: 11/22/2022]
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Atahan E, Gul M, Ergun Y, Eroglu E. Vascular Graft Infection by Staphylococcus aureus: Efficacy of Cefazolin, Teicoplanin and Vancomycin Prophylaxis Protocols in a Rat Model. Eur J Vasc Endovasc Surg 2007; 34:182-7. [PMID: 17481929 DOI: 10.1016/j.ejvs.2007.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2006] [Accepted: 03/03/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Prophylactic efficiencies of cefazolin, teicoplanin and vancomycin in a dacron graft infection model caused by methicillin-susceptible (MSSA) or -resistant Staphylococcus aureus (MRSA) were investigated. DESIGN Prospective, randomized, controlled animal study. MATERIALS AND METHODS Infections were established subcutaneously in the back of rats by implantation of Dacron prostheses followed by topical inoculation onto grafts of MSSA or MRSA. Experimental groups were as follows: Uncontaminated group (control), MSSA- or MRSA-contaminated and untreated groups, MSSA- or MRSA-contaminated groups treated with cefazolin, teicoplanin or vancomycin by one of three regimens (one day, two days, or three days regimen). Grafts were removed 7 days after the implantation and evaluated by using sonication and quantitative blood agar culture. RESULTS Contaminated groups demonstrated graft infections. Cefazolin, teicoplanin and vancomycin profoundly prevented the graft infections in MSSA- or MRSA-contaminated groups. For each antibiotic regimen, the most effective prevention was achieved by the drugs given as three days regimen. For MSSA and MRSA, the order of the effectiveness was as follows: teicoplanin>vancomycin>cefazolin. CONCLUSION As a prophylactic agent, teicoplanin seems to be more effective than vancomycin and cefazolin against vascular graft infections caused by MSSA and MRSA in rats.
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Affiliation(s)
- E Atahan
- Department of Cardiovascular Surgery, School of Medicine, Kahramanmaras Sutcu Imam University, 46100, Turkey.
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Engelman R, Shahian D, Shemin R, Guy TS, Bratzler D, Edwards F, Jacobs M, Fernando H, Bridges C. The Society of Thoracic Surgeons practice guideline series: Antibiotic prophylaxis in cardiac surgery, part II: Antibiotic choice. Ann Thorac Surg 2007; 83:1569-76. [PMID: 17383396 DOI: 10.1016/j.athoracsur.2006.09.046] [Citation(s) in RCA: 253] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Revised: 09/02/2006] [Accepted: 09/14/2006] [Indexed: 12/31/2022]
Affiliation(s)
- Richard Engelman
- Baystate Medical Center, Division of Cardiac Surgery, 759 Chestnut St, Springfield, MA 01199, USA.
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Alphonso N, Anagnostopoulos PV, Scarpace S, Weintrub P, Azakie A, Raff G, Karl TR. Perioperative antibiotic prophylaxis in paediatric cardiac surgery. Cardiol Young 2007; 17:12-25. [PMID: 17244387 DOI: 10.1017/s1047951107000066] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2006] [Indexed: 11/05/2022]
Affiliation(s)
- Nelson Alphonso
- Paediatric Heart Center, University of California San Francisco Children's Hospital, San Francisco, California 94143-0117, USA
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Edwards FH, Engelman RM, Houck P, Shahian DM, Bridges CR. The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic Prophylaxis in Cardiac Surgery, Part I: Duration. Ann Thorac Surg 2006; 81:397-404. [PMID: 16368422 DOI: 10.1016/j.athoracsur.2005.06.034] [Citation(s) in RCA: 193] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2005] [Revised: 05/21/2005] [Accepted: 06/03/2005] [Indexed: 01/08/2023]
Affiliation(s)
- Fred H Edwards
- Division of Cardiothoracic Surgery, University of Florida, Jacksonville, Florida 32209, USA.
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Pea F, Furlanut M, Stellini R, Bonardelli S, Signorini L, Pavan F, Matheis A, Portolani N, Lorenzotti S, Giulini SM, Viale P, Carosi G. Pharmacokinetic–pharmacodynamic aspects of antimicrobial prophylaxis with teicoplanin in patients undergoing major vascular surgery. Int J Antimicrob Agents 2006; 27:15-9. [PMID: 16343858 DOI: 10.1016/j.ijantimicag.2005.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2005] [Accepted: 09/09/2005] [Indexed: 10/25/2022]
Abstract
A prospective, two-arm, open study assessing plasma exposure to teicoplanin with two different prophylactic regimens (Group A (n = 23), 800 mg pre-operatively versus Group B (n = 24), 400 mg pre-operatively plus two doses of 200 mg 24 h apart) was carried out in patients undergoing major vascular surgery. The intent was to define the feasibility and the possible advantages of the single pre-operative high dose in ensuring therapeutically effective plasma concentrations (>10 mg/L) of teicoplanin even during long-lasting operations. At the end of the intervention, mean teicoplanin concentrations (+/-S.D.) were 14.05 +/- 5.13 mg/L and 5.39 +/- 2.13 mg/L in Groups A and B, respectively. At 24 h, average teicoplanin levels were 5.10 +/- 1.25 mg/L and 2.08 +/- 0.73 mg/L in Groups A and B, respectively; at 48 h they declined to 2.86 +/- 0.70 mg/L in Group A, whereas they rose to 2.67 +/- 0.82 mg/L after administration of 2.63 +/- 0.51 mg/kg at 24 h in Group B. Single pre-operative high-dose teicoplanin may ensure effective plasma levels even in cases of very long-lasting operations (>8 h) with no need for intraoperative re-dosing and may enable more appropriate prophylactic exposure than that achievable with the same total dose given in three administrations 24 h apart.
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Affiliation(s)
- Federico Pea
- Institute of Clinical Pharmacology & Toxicology, Department of Experimental and Clinical Pathology and Medicine, Medical School, University of Udine, Italy.
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Bolon MK, Morlote M, Weber SG, Koplan B, Carmeli Y, Wright SB. Glycopeptides are no more effective than beta-lactam agents for prevention of surgical site infection after cardiac surgery: a meta-analysis. Clin Infect Dis 2004; 38:1357-63. [PMID: 15156470 DOI: 10.1086/383318] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2003] [Accepted: 12/21/2003] [Indexed: 01/28/2023] Open
Abstract
A meta-analysis was performed to investigate whether a switch from beta-lactams to glycopeptides for cardiac surgery prophylaxis should be advised. Results of 7 randomized trials (5761 procedures) that compared surgical site infections (SSIs) in subjects receiving glycopeptide prophylaxis with SSIs in those who received beta -lactam prophylaxis were pooled. Neither agent proved to be superior for prevention of the primary outcome, occurrence of SSI at 30 days (risk ratio [RR], 1.14; 95% confidence interval [CI], 0.91-1.42). In subanalyses, beta-lactams were superior to glycopeptides for prevention of chest SSIs (RR, 1.47; 95% CI, 1.11-1.95) and approached superiority for prevention of deep-chest SSIs (RR, 1.33; 95% CI, 0.91-1.94) and SSIs caused by gram-positive bacteria (RR, 1.36; 95% CI, 0.98-1.91). Glycopeptides approached superiority to beta-lactams for prevention of leg SSIs (RR, 0.77; 95% CI, 0.58-1.01) and were superior for prevention of SSIs caused by methicillin-resistant gram-positive bacteria (RR, 0.54; 95% CI, 0.33-0.90). Standard prophylaxis for cardiac surgery should continue to be beta-lactams in most circumstances.
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Affiliation(s)
- Maureen K Bolon
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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Fellinger EK, Leavitt BJ, Hebert JC. Serum levels of prophylactic cefazolin during cardiopulmonary bypass surgery. Ann Thorac Surg 2002; 74:1187-90. [PMID: 12400766 DOI: 10.1016/s0003-4975(02)03916-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Controversy exists regarding the appropriate prophylactic dose of cefazolin for coronary artery bypass grafting (CABG) surgery requiring cardiopulmonary bypass (CPB) because the effect of CPB on serum drug levels is poorly understood. Current standards of prophylaxis are based primarily on empiric studies. Few studies have attempted to quantify serum cefazolin levels in either cardiac or noncardiac surgeries. This study was conducted to measure and assess the adequacy of the intraoperative serum levels of prophylactic cefazolin in CPB surgery. METHODS This prospective study serially measured six intraoperative serum cefazolin levels in 10 subjects undergoing elective and urgent CABG surgery. We compared the serum levels with the minimum inhibitory concentrations (MIC90) for the most common organisms causing postoperative infection. RESULTS Serum-free cefazolin levels fluctuated considerably during the operation but remained above the MIC90, for Staphylococcus aureus and S. epidermidis. The serum levels fell below the MIC90 for Enterobacter, Serratia, Escherichia coli, and Proteus mirabilis. CONCLUSIONS Serum cefazolin levels during CPB remained consistently above the MIC for two of the three main organisms causing postoperative infection but were suboptimal for the remainder. Additional studies are needed to assess the intraoperative serum levels of single-dose cefazolin prophylaxis and to explore alternate dosing methods that minimize intraoperative fluctuations in serum cefazolin levels.
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Affiliation(s)
- Erika K Fellinger
- Department of Surgery, University of Vermont College of Medicine, Burlington, USA
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