Prospective study of Clostridium difficile intestinal colonization and disease following single-dose antibiotic prophylaxis in surgery

Reevaluating Surgical Antibiotic Prophylaxis in Pediatric Pyloromyotomy: Insights from the NSQIP-Pediatric Database

BACKGROUND

Pyloromyotomy is a clean surgical procedure with a low risk of surgical site infections (SSIs). Despite this, surgical antibiotic prophylaxis (SAP) is often administered, raising concerns about unnecessary antibiotic exposure and antimicrobial resistance. This study aims to evaluate whether SAP reduces SSI rates in infants undergoing pyloromyotomy for hypertrophic pyloric stenosis and to propose a guideline for selective SAP omission.

METHODS

This retrospective cohort study analyzed data from the National Surgical Quality Improvement Program-Pediatric database. Infants undergoing pyloromyotomy between January 1, 2021 and December 31, 2023 were included. The primary outcome was the occurrence of SSIs within 30 days postoperatively. Secondary outcomes included stratified rates of superficial, deep incisional, and organ/space SSIs.

RESULTS

Among 4,917 infants (age <1 year; 84.26% male), 49.48% received SAP. Additionally, 81 patients (1.65%) received post-operative antibiotics beyond the intraoperative period. The overall SSI rate was 1.42%, primarily comprised of superficial SSIs. There was no significant difference in SSI rates between infants receiving SAP (1.15%) and those not receiving SAP (1.69%) (p = 0.110). The rate of unplanned readmission and unplanned return to the operating room within 30 days was 2.44% and 1.04%, respectively, with no significant difference between those who received post-operative antibiotics and those who did not (p>0.2 for both comparisons).

CONCLUSIONS

Routine SAP administration in pyloromyotomy is unnecessary given the low risk of SSIs. SAP in ASA Class I or II infants undergoing isolated pyloromyotomy without mucosal perforation, immune-compromising conditions, infections, or trauma should be omitted. These findings support efforts to optimize antibiotic stewardship in pediatric surgical practice.

TYPE OF STUDY

Original Research Article LEVEL OF EVIDENCE: III.

Duration from start of antibiotic exposure to onset of Clostridioides difficile infection for different antibiotics in a non-outbreak setting

BACKGROUND

Antibiotic treatment is a well-known risk factor for Clostridioides difficile infection (CDI). The time from start of antibiotic exposure to onset of CDI for different antibiotics is sparsely studied. CDI with onset in the community is often treatable without in-hospital care while CDI patients treated in hospital need isolation, resulting in higher costs and infection control measures.

OBJECTIVES

To determine the time from start of antibiotic exposure to onset of healthcare facility-associated CDI for different antibiotics.

METHODS

Time between antibiotic exposure and disease onset was evaluated retrospectively with chart reading in a two-centre Swedish setting. A case was attributed to an antibiotic group if this represented more than 2/3 of total antibiotic exposure 30 days before onset of CDI.

RESULTS

Cephalosporins caused CDI faster (mean 7.6 days), and more often during ongoing antibiotic therapy (81% of the cases) than any other antibiotic group. All other common agents had between 2-3 times longer period between start of exposure to onset of CDI (quinolones more than 3 times).

CONCLUSIONS

The time gap between antibiotic exposure and onset of CDI is markedly different between different antibiotics. Decreased cephalosporin use could delay onset of healthcare facility-associated CDI and limit infections with onset within the hospital. This might decrease costs for inpatient care, need of infection control measures and shortage of beds in the hospital.

Clinical practice guideline for the prevention and management of peritoneal dialysis associated infections in children: 2024 update

Infection-related complications remain the most significant cause for morbidity and technique failure in infants, children and adolescents who receive maintenance peritoneal dialysis (PD). The 2024 update of the Clinical Practice Guideline for the Prevention and Management of Peritoneal Dialysis Associated Infection in Children builds upon previous such guidelines published in 2000 and 2012 and provides comprehensive treatment guidance as recommended by an international group of pediatric PD experts based upon a review of published literature and pediatric PD registry data. The workgroup prioritized updating key clinical issues contained in the 2012 guidelines, in addition to addressing additional questions developed using the PICO format. A variety of new guideline statements, highlighted by those pertaining to antibiotic therapy of peritonitis as a result of the evolution of antibiotic susceptibilities, antibiotic stewardship and clinical registry data, as well as new clinical benchmarks, are included. Recommendations for future research designed to fill important knowledge gaps are also provided.

Should All Patients Receive Extended Oral Antibiotic Prophylaxis? Defining Its Role in Patients Undergoing Primary and Aseptic Revision Total Joint Arthroplasty

BACKGROUND

Prior studies have demonstrated reduced periprosthetic joint infection (PJI) rates following extended oral antibiotics (EOAs) for high-risk patients undergoing primary total joint arthroplasty (TJA). This study compared 3-month PJI rates in all patients undergoing primary or aseptic revision TJA with or without EOA prophylaxis.

METHODS

In total, 2,982 consecutive primary (n = 2,677) and aseptic revision (n = 305) TJAs were performed by a single, fellowship-trained arthroplasty surgeon from 2016 to 2022 were retrospectively reviewed. Beginning January 2020, all patients received 7 days of 300 mg oral cefdinir twice daily immediately postoperatively. Rates of PJI at 3 months were compared between patients who received or did not receive EOA.

RESULTS

Rates of PJI at 3 months in patients undergoing primary and aseptic revision TJA were significantly lower in those receiving EOA prophylaxis compared to those who did not (0.41 versus 1.13%, respectively; P = .02). After primary TJA, lower PJI rates were observed with EOA prophylaxis utilization (0.23 versus 0.74%, P = .04; odds ratio [OR] 3.85). Following aseptic revision TJA, PJI rates trended toward a significant decrease with the EOA compared to without (1.88 versus 4.83%, respectively; P = .16; OR 2.71).

CONCLUSIONS

All patients undergoing primary or aseptic revision TJA who received EOA prophylaxis were 3.85 and 2.71 times less likely, respectively, to develop PJI at 3 months compared to those without EOA. Future studies are needed to determine if these results are maintained at postoperative time periods beyond 3 months following primary TJA.

LEVEL OF EVIDENCE

III, Retrospective review.

The Utility of Prophylactic Antibiotics for Laparoscopic Pyloromyotomy

INTRODUCTION

Laparoscopic pyloromyotomy (LP) for the treatment of infantile hypertrophic pyloric stenosis (IHPS) is a clean case with low expected rates of postoperative surgical site infection (SSI). Previous studies have shown a low risk of SSI following LP but also large variations in the utilization of prophylactic antibiotics. The goal of this study was to review the use of preoperative antibiotics for LP and to compare this with SSI incidence.

METHODS

We performed a retrospective single-center analysis of patients undergoing LP for infantile hypertrophic pyloric stenosis at a large quaternary children's hospital from January 2017 to June 2020. Subjects were <4 mo old. Exclusion criteria were those lost to follow-up within 30 d postoperatively and those who required open conversion intraoperatively. Statistical analysis was performed using Fisher's exact test, two-tailed independent t-tests, and descriptive statistics.

RESULTS

Two-hundred twenty-seven patients were included, mean population age was 5.7 wk, and 81.1% were male. Preoperative antibiotics were administered in 39% of patients. Only 1.3% (n = 3) of all patients developed an SSI within 30 d of their operation. Analysis between patients who received preoperative antibiotics and those who did not revealed no difference in age (5.72 wk versus 5.72 wk, t (225) = 0.38, P = 0.70), sex (41% of males versus 32% of females, P = 0.39), length of stay (t(225) = -0.94, P = 0.35), or postoperative SSI (1.1% versus 1.4%, P > 0.999). Large variability was noted in antibiotic utilization by surgeon.

CONCLUSIONS

In patients undergoing LP, there was no difference in SSI rates whether or not patients received preoperative antibiotics and, there is large variation in utilization. Measures are needed to decrease usage of prophylactic antibiotics before LP.

The Impact of Monthly Prophylactic Antibiotics Use in Patients with Recurrent Cellulitis: A 20-Year Population-Based Cohort Study in a Medical Center

Purpose

The vicious cycle of recurrent cellulitis ultimately results in a high risk of relapse, which facilitates the use of antibiotic prophylaxis with monthly intramuscular benzathine penicillin G (BPG) to prevent recurrence. However, several clinical situations hinder the guideline recommendations in daily practice. Therefore, intramuscular clindamycin has been used as an alternative in our institution for years. This study aims to elucidate the effectiveness of monthly intramuscular antibiotics in preventing further cellulitis recurrence and evaluate the applicability of intramuscular clindamycin as an alternative to BPG.

Patients and Methods

A retrospective cohort study was conducted at a medical center in Taiwan from January 2000 to October 2020. Adult patients with recurrent cellulitis were enrolled to receive monthly intramuscular antibiotic prophylaxis (including 1.2-2.4MU BPG or 300-600mg intramuscular clindamycin) or to be observed without prophylaxis. The decision to administer prophylaxis or observe was made at the discretion of the examining infectious disease specialists. Cox proportional-hazards regressions were performed to estimate hazard ratios (HR) and adjust for variables between groups. The Kaplan-Meier method was used to estimate survival curves.

Results

Enrollment in the study consisted of 426 patients, with 222 receiving BPG, 106 receiving intramuscular clindamycin, and 98 being observed without prophylaxis. Both types of antibiotics resulted in a significantly lower recurrence rate than observation alone (27.9% for BPG, 32.1% for intramuscular clindamycin, and 82.7% for observation, P < 0.001). After adjusting for multiple variables, antibiotic prophylaxis continued to significantly reduce the risk of cellulitis recurrence by 82% (HR 0.18, 95% CI 0.13 to 0.26), by 86% (HR 0.14, 95% CI 0.09 to 0.20) with BPG, and by 77% (HR 0.23, 95% CI 0.14 to 0.38) with intramuscular clindamycin.

Conclusion

Monthly intramuscular antibiotic prophylaxis was demonstrated to be effective in reducing cellulitis recurrence. Moreover, in the real-world practice, intramuscular clindamycin may serve as a reasonable alternative option to BPG.

Daptomycin for the treatment of acute bacterial meningitis: a narrative review

BACKGROUND

There is a growing interest in the utilization of daptomycin for the treatment of multi-drug resistant, Gram-positive infections. Pharmacokinetic studies suggest that daptomycin could penetrate into the cerebrospinal fluid, albeit to a small extent. The objective of this review was to evaluate the available clinical evidence for daptomycin use in acute bacterial meningitis of both pediatric and adult patients.

METHODS

Electronic databases were searched up to June 2022 for studies published on the topic. The inclusion criteria were met if the study reported the use of intravenous daptomycin (more than a single dose) for the treatment of diagnosed acute bacterial meningitis.

RESULTS

A total of 21 case reports were identified that met the inclusion criteria. These suggest that daptomycin could be safe and effective alternative in achieving clinical cure of meningitis. In these studies, daptomycin was used in the event of treatment failure, patient intolerance, or bacterial resistance to first-line agents.

CONCLUSIONS

Daptomycin has potential to be an alternative to standard care for meningitis caused by Gram-positive bacteria in the future; however, more robust research is required to establish an optimal dosing regimen, duration of therapy, and place in therapy for the management of meningitis.

Prehospital Administration of Cefazolin in Trauma Patients

OBJECTIVE

A lack of research has become a barrier to the common use of prehospital antibiotics. The objective of this study is to further the limited research of prehospital antibiotics through evaluating the clinical impact, safety, and reliability of prehospital cefazolin administration in trauma patients.

METHODS

We completed a retrospective evaluation of adult trauma patients who were transported by a single air and ground critical care transport program between January 1, 2014, and June 30 2017. Two hundred eighty-two patients received prehospital cefazolin for deep wounds or open fractures before their arrival at a single level 2 trauma center during the study period. Patient demographics, mechanism of injury, injury type, infection rate, and identification of allergic reactions to cefazolin were also collected.

RESULTS

Of 278 patients in the final analysis, 35.3% (n = 98) were diagnosed with an open fracture and 58.6% (n = 163) had a deep tissue injury. Eighty-two percent of prehospital open fracture diagnoses were confirmed in the emergency department. The overall infection rate was 6%; 31.3% of patients received a second dose of cefazolin in the emergency department during the study period. No patients receiving prehospital cefazolin had allergic or anaphylactic reactions. The overadministration rate was 5% (n = 14).

CONCLUSION

Prehospital providers reliably identified open fractures, and prehospital cefazolin administration was not associated with anaphylactic reactions. This study population's infection rate of open fractures caused by traumatic injury was found to be 6%, and there was a low inappropriate administration rate.

Single-center experience with perioperative antibiotic prophylaxis and surgical site infections in kidney transplant recipients

BACKGROUND

Infections in kidney transplant recipients are particularly challenging owing to the immunosuppressive treatment, usually long history of chronic illness, comorbidities and prior exposures to antibiotics. Among the most common complications early after surgery are surgical site infections. The aim of this study was to identify risk factors and evaluate epidemiological data regarding surgical site infections. Moreover, we were able to compare the current results with historical data from our institution when different perioperative antibiotic prophylaxis was practiced.

METHODS

We conducted a retrospective case-control study in a group of 254 deceased donor renal graft recipients transplanted in a single Central European institution. We evaluated epidemiological findings and resistance patterns of pathogens causing surgical site infections. We used multivariable logistic regression to determine risk factors for surgical site infections.

RESULTS

We revealed no differences in baseline characteristics between patients with and without surgical site infections. Ten surgical site infections (3.9%) were diagnosed (six superficial incisional, two deep incisional, and two organ/space). Eight species (19 strains) were identified, most of which were multi-drug resistant (63%). The most common was extended-spectrum β-lactamase producing Klebsiella pneumoniae (26%). We showed that statistically significant differences were present between reoperated and non-reoperated patients (adjusted odds ratio: 6.963, 95% confidence interval 1.523-31.842, P = .012).

CONCLUSIONS

Reoperation is an individual risk factor for surgical site infection after kidney transplantation. According to our experience, cefazolin-based prophylaxis can be safe and is associated with relatively low prevalence of surgical site infections.

Incidence of Clostridioides difficile in patients post loop ileostomy reversal in an Australian tertiary hospital: a retrospective study

INTRODUCTION

The purpose of a loop ileostomy is to temporarily divert faeces away from a distal anastomosis, to reduce the consequences of anastomotic leak. This ultimately requires a second procedure to restore bowel continuity, which confers risk of complications including the development of Clostridioides difficile infection (CDI). It is hypothesized that patients who undergo loop ileostomy reversal are at increased risk of CDI when compared with other patients undergoing elective colorectal surgical procedures, and that these patients also experience an increased length of stay (LOS).

METHODS

A retrospective cohort study was performed on all patients who underwent loop ileostomy reversal at the Gold Coast Hospital and Health Service between 1 January 2012 and 31 December 2019.

RESULTS

Two hundred and twenty-eight patients were identified. Eight tested positive for CDI on faecal PCR (3.51%), a higher incidence than that in patients who underwent an elective colorectal surgical procedure during the same period (0.83%) (RR = 4.23). Additionally, median LOS for ileostomy reversal patients was significantly increased in those who also had CDI when compared with those without CDI (11 versus 4 days; P = 0.0003).

CONCLUSION

The study confirmed that the incidence of CDI was higher in those who underwent ileostomy reversal when compared with an otherwise comparable hospital population (elective colorectal surgery patients). Additionally, those patients who underwent ileostomy reversal and had CDI experienced an increased LOS which translates to increased cost to the healthcare system. Further investigation into pre-operative screening and prophylactic antibiotics should be considered as a measure to mitigate this post-operative complication.

Prevention of Infection due to Clostridium (Clostridioides) difficile

Clostridium (Clostridioides) difficile infection (CDI) causes significant morbidity and mortality in the United States every year. Prevention of CDI is difficult because of spore durability and requires implementation of multipronged strategies. Two categories of prevention strategies are infection control and prevention and risk factor reduction. Hand hygiene, contact precautions, patient isolation, and environmental decontamination are cornerstones of infection control and prevention. Risk factor reduction should focus on antibiotic stewardship to reduce unnecessary antibiotic use. If CDI incidence remains higher than the institution's goal despite these measures, then special measures should be considered.

Postoperative Prophylactic Antibiotics in Spine Surgery: A Propensity-Matched Analysis

BACKGROUND

Surgical site infections are common and costly complications after spine surgery. Prophylactic antibiotics are the standard of care; however, the appropriate duration of antibiotics has yet to be adequately addressed. We sought to determine whether the duration of antibiotic administration (preoperatively only versus preoperatively and for 24 hours postoperatively) impacts postoperative infection rates.

METHODS

All patients undergoing inpatient spinal procedures at a single institution from 2011 to 2018 were evaluated for inclusion. A minimum of 1 year of follow-up was used to adequately capture postoperative infections. The 1:1 nearest-neighbor propensity score matching technique was used between patients who did and did not receive postoperative antibiotics, and multivariable logistic regression analysis was conducted to control for confounding.

RESULTS

A total of 4,454 patients were evaluated and, of those, 2,672 (60%) received 24 hours of postoperative antibiotics and 1,782 (40%) received no postoperative antibiotics. After propensity-matched analysis, there was no difference between patients who received postoperative antibiotics and those who did not in terms of the infection rate (1.8% compared with 1.5%). No significant decrease in the odds of postoperative infection was noted in association with the use of postoperative antibiotics (odds ratio = 1.17; 95% confidence interval, 0.620 to 2.23; p = 0.628). Additionally, there was no observed increase in the risk of Clostridium difficile infection or in the short-term rate of infection with multidrug-resistant organisms.

CONCLUSIONS

There was no difference in the rate of surgical site infections between patients who received 24 hours of postoperative antibiotics and those who did not. Additionally, we found no observable risks, such as more antibiotic-resistant infections and C. difficile infections, with prolonged antibiotic use.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association Between Antibiotic Use and Hospital-onset Clostridioides difficile Infection in US Acute Care Hospitals, 2006-2012: An Ecologic Analysis

BACKGROUND

Unnecessary antibiotic use (AU) contributes to increased rates of Clostridioides difficile infection (CDI). The impact of antibiotic restriction on hospital-onset CDI (HO-CDI) has not been assessed in a large group of US acute care hospitals (ACHs).

METHODS

We examined cross-sectional and temporal associations between rates of hospital-level AU and HO-CDI using data from 549 ACHs. HO-CDI was defined as a discharge with a secondary International Classification of Diseases, Ninth Revision, Clinical Modification code for CDI (008.45), and treatment with metronidazole or oral vancomycin > 3 days after admission. Analyses were performed using multivariable generalized estimating equation models adjusting for patient and hospital characteristics.

RESULTS

During 2006-2012, the unadjusted annual rates of HO-CDI and total AU were 7.3 per 10 000 patient-days (PD) (95% confidence interval [CI], 7.1-7.5) and 811 days of therapy (DOT)/1000 PD (95% CI, 803-820), respectively. In the cross-sectional analysis, for every 50 DOT/1000 PD increase in total AU, there was a 4.4% increase in HO-CDI. For every 10 DOT/1000 PD increase in use of third- and fourth-generation cephalosporins or carbapenems, there was a 2.1% and 2.9% increase in HO-CDI, respectively. In the time-series analysis, the 6 ACHs with a ≥30% decrease in total AU had a 33% decrease in HO-CDI (rate ratio, 0.67 [95% CI, .47-.96]); ACHs with a ≥20% decrease in fluoroquinolone or third- and fourth-generation cephalosporin use had a corresponding decrease in HO-CDI of 8% and 13%, respectively.

CONCLUSIONS

At an ecologic level, reductions in total AU, use of fluoroquinolones, and use of third- and fourth-generation cephalosporins were each associated with decreased HO-CDI rates.

Perioperative antibiotics for preventing post-surgical site infections in solid organ transplant recipients

BACKGROUND

Solid organ transplant recipients are at high risk for infections due to the complexity of surgical procedures combined with the impact of immunosuppression. No consensus exists on the role of antibiotics for surgical site infections in solid organ transplant recipients.

OBJECTIVES

To assess the benefits and harms of prophylactic antimicrobial agents for preventing surgical site infections in solid organ transplant recipients.

SEARCH METHODS

The Cochrane Kidney and Transplant Register of Studies was searched up to 21 April 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-RCTs in any language assessing prophylactic antibiotics in preventing surgical site infections in solid organ transplant recipients at any time point after transplantation.

DATA COLLECTION AND ANALYSIS

Two authors independently determined study eligibility, assessed quality, and extracted data. Primary outcomes were surgical site infections and antimicrobial resistance. Other outcomes included urinary tract infections, pneumonias and septicaemia, death (any cause), graft loss, graft rejection, graft function, adverse reactions to antimicrobial agents, and outcomes identified by the Standardised Outcomes of Nephrology Group (SONG), specifically graft health, cardiovascular disease, cancer and life participation. Summary effect estimates were obtained using a random-effects model and results were expressed as risk ratios (RR) and 95% confidence intervals (CI). The quality of the evidence was assessed using the risk of bias and the GRADE approach.

MAIN RESULTS

We identified eight eligible studies (718 randomised participants). Overall, five studies (248 randomised participants) compared antibiotics versus no antibiotics, and three studies (470 randomised participants) compared extended duration versus short duration antibiotics. Risk of bias was assessed as high for performance bias (eight studies), detection bias (eight studies) and attrition bias (two studies). It is uncertain whether antibiotics reduce the incidence of surgical site infections as the certainty of the evidence has been assessed as very low (RR 0.42, 95% CI 0.21 to 0.85; 5 studies, 226 participants; I² = 25%). The certainty of the evidence was very low for all other reported outcomes (death, graft loss, and other infections). It is uncertain whether extended duration antibiotics reduces the incidence of surgical site infections in either solid organ transplant recipients (RR 1.19, 95% CI 0.58 to 2.48; 2 studies, 302 participants; I² = 0%) or kidney-only transplant recipients (RR 0.50, 95% CI 0.05 to 5.48; 1 study, 205 participants) as the certainty of the evidence has been assessed as very low. The certainty of the evidence was very low for all other reported outcomes (death, graft loss, and other infections). None of the eight included studies evaluated antimicrobial agent adverse reactions, graft health, cardiovascular disease, cancer, life participation, biochemical and haematological parameters, intervention cost, hospitalisation length, or overall hospitalisation costs.

AUTHORS' CONCLUSIONS

Due to methodological limitations, risk of bias and significant heterogeneity, the current evidence for the use of prophylactic perioperative antibiotics in transplantation is of very low quality. Further high quality, adequately powered RCTs would help better inform clinical practice.

Focusing the Lens on the CAMERA Concepts: Early Combination β-Lactam and Vancomycin Therapy in Methicillin-Resistant Staphylococcus aureus Bacteremia

Methicillin-resistant Staphylococcus aureus (MRSA) has grown to become a major burden on health care systems. The cumulation of limited therapeutic options and worsened patient outcomes with persistent MRSA bacteremia has driven research in optimizing its initial management. The guidelines published by the Infectious Diseases Society of America currently recommend combination therapy for refractory MRSA bacteremia, but the utility of combining antibiotics from the start of therapy is under investigation. The alternative strategy of early use of β-lactam antibiotics in combination with vancomycin upon initial MRSA bacteremia detection has shown promise. While this concept has gained international attention, providers should give this strategy serious consideration prior to implementation. The objective of this review is to examine retrospective and prospective evidence for early combination with vancomycin and β-lactam antibiotics, as well as explore potential consequences of combination therapy.

Trends in the use of surgical antibiotic prophylaxis in general pediatric surgery: Are we missing the mark for both stewardship and infection prevention?

BACKGROUND

The purpose of this study was to assess compliance with antimicrobial spectrum guidelines in the use of surgical antibiotic prophylaxis (SAP) in pediatric surgery.

METHODS

A retrospective cohort study of children undergoing elective clean-contaminated and clean surgical procedures with foreign body implantation using the Pediatric Health Information System database (10/2015-6/2018) was performed. Compliance rates with consensus guidelines surrounding appropriate spectrum of SAP coverage were calculated for each procedure. Undertreatment was defined as the use of SAP with inappropriately narrow coverage (or omission altogether), while overtreatment was defined as inappropriately broad coverage.

RESULTS

Eight procedure groups including a total of 15,708 patients were included. Overall, 44% of cases received inappropriate prophylaxis, of which 58% were considered undertreatment and 42% overtreatment. Procedures with the highest rates of overtreatment included small bowel procedures (77%), colorectal procedures (29%), and hepatobiliary procedures (20%), while the highest rates of undertreatment were associated with placement of tunneled central venous catheters and ports (43%), hepatobiliary procedures (24%), and colorectal procedures (20%).

CONCLUSION

Noncompliance with the recommended spectrum of coverage for surgical antibiotic prophylaxis is common in pediatric surgery, with both over and undertreatment being common themes. Improved compliance is needed to optimize both antibiotic stewardship and infection prevention.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Implementation of a Plan-Do-Study-Act framework to reduce unindicated surgical antimicrobial prophylaxis

PURPOSE

The goal of this study was to use a Plan-Do-Study-Act (PDSA) framework to reduce utilization of unindicated surgical antibiotic prophylaxis (SAP) for clean cases without foreign body implantation.

METHODS

This was a pre-post intervention study conducted at a single children's hospital comparing 6 months of retrospective preintervention data to 10 months of prospectively collected postintervention data. Interventions to reduce unindicated SAP included faculty meetings to review guidelines and establish consensus around inclusion criteria, publicizing guidelines with regular email reminders, and conducting ongoing compliance audits to root cause noncompliance. Early unanticipated noncompliant cases were associated with rotating trainees who prescribed SAP routinely without attending knowledge. A second PDSA cycle then included education-based emails targeting residents with mandatory feedback loop closure.

RESULTS

Preintervention, 40.4% (107/265) of patients received unindicated SAP. Postintervention, the rate of unindicated SAP decreased to 15.4% (6/39) after the first month and 6.2% (20/323) after 10 months, reflecting an 85% reduction across periods (p < 0.01). There was no difference in the rate of surgical site infections between the pre and postintervention cohorts (0.36% vs. 0.67%, p = 1.00).

CONCLUSIONS

Unindicated surgical antibiotic prophylaxis was significantly reduced by implementing a Plan-Do-Study-Act intervention targeting both faculty and trainees.

LEVEL OF EVIDENCE

Prospective comparative treatment study, level II.

The Use of Preoperative Antibiotics in Elective Soft-Tissue Procedures in the Hand: A Critical Analysis Review

» The use of preoperative antibiotic prophylaxis is not supported for elective cases of patients undergoing soft-tissue hand procedures that are ≤2 hours in length.

» The use of preoperative antibiotic prophylaxis is not supported for patients with diabetes undergoing elective, soft-tissue hand surgical procedures.

» There is a paucity of literature evaluating the use of preoperative antibiotic prophylaxis in patients with rheumatoid arthritis, those with cardiac valves, and those taking corticosteroids; because of this, there is no evidence to vary from our general recommendations.

Statin Effects on Incidence, Treatment Success, and Mortality of Clostridium difficile Infections

PURPOSE

To review the effects of statin use in patients at risk for or diagnosed with Clostridium difficile infection (CDI) on CDI incidence, treatment success, and mortality.

METHODS

A literature search was performed through January 2019 using the following terms: statins, HMG-CoA inhibitors, Clostridium difficile, Clostridium difficile associated diarrhea, and Clostridium difficile infection. Additional references were identified from a review of literature citations. Studies evaluating statin effects on C difficile-related outcomes were included.

RESULTS

A total of 8 studies were identified for inclusion in this review. All studies were retrospective. Five studies reported the association between statin use and the development of CDI, suggesting that statins may decrease risk of CDI development in patients already on statin. In one study, there was an improved treatment response against CDI with the use of statin. Three retrospective studies evaluated statin use and mortality from CDI and only one study found significant mortality benefit in statin users.

CONCLUSIONS

Statin use may have a protective effect against the development of CDI and improve CDI treatment success; however, it is unclear if use confers a mortality benefit. Current data remain sparse and larger, prospective studies are needed to confirm current results and identify the specific population that may benefit the most from this intervention.

Surgical site infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.

2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients

In the last three decades, Clostridium difficile infection (CDI) has increased in incidence and severity in many countries worldwide. The increase in CDI incidence has been particularly apparent among surgical patients. Therefore, prevention of CDI and optimization of management in the surgical patient are paramount. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of CDI in surgical patients according to the most recent available literature. The update includes recent changes introduced in the management of this infection.

2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients

In the last three decades, Clostridium difficile infection (CDI) has increased in incidence and severity in many countries worldwide. The increase in CDI incidence has been particularly apparent among surgical patients. Therefore, prevention of CDI and optimization of management in the surgical patient are paramount. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of CDI in surgical patients according to the most recent available literature. The update includes recent changes introduced in the management of this infection.

Preoperative Antibiotics in Wrist Arthroscopy

PURPOSE

This study seeks to evaluate the need for preoperative antibiotics for wrist arthroscopy.

METHODS

A retrospective review of 576 consecutive wrist arthroscopies was performed over a 10-year period at a single ambulatory surgery center. The chart of each included patient was reviewed for postoperative infections following the National Nosocomial Infections Surveillance criteria for diagnosis.

RESULTS

Of the 576 wrist arthroscopies reviewed, 324 met the inclusion criteria. Preoperative antibiotics were administered in 209 cases (65%) and not administered in 115 cases (35%). There were 116 cases (36%) with concomitant open soft tissue procedures. We identified 2 infections (0.6% overall infection rate), both of which were in patients who had received preoperative antibiotics. Both of these patients underwent concomitant percutaneous pinning of carpal bones with Kirschner wires, which were buried beneath the skin.

CONCLUSIONS

Administering preoperative antibiotics for routine wrist arthroscopy does not appear to lower the surgical site infection rate. The rate of surgical site infection is so low in both cohorts that a meaningful difference cannot be determined between the 2 groups. This study adds to the current body of literature suggesting that it is acceptable practice to withhold preoperative antibiotics for surgeries that have a very low rate of infection.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Acute Kidney Injury After Prophylactic Cefuroxime and Gentamicin in Patients Undergoing Primary Hip and Knee Arthroplasty-A Propensity Score-Matched Study

BACKGROUND

Perioperative acute kidney injury (AKI) can be associated with lower limb arthroplasty and increases morbidity, length of stay, and mortality. AKI is more prevalent in some antibiotic regimes compared with others. The aim of the present study is to assess the impact of cefuroxime (CEF), with or without gentamicin (±G), on AKI rates.

METHODS

A prospective cohort study involving patients undergoing hip or knee arthroplasty was performed, between September 1, 2015 and November 30, 2016. Prophylactic intravenous antibiotics were administered according to local policy. AKI was graded according to the validated Acute Kidney Injury Network criteria based on the changes from baseline serum creatinine values. Propensity score matching was performed to identify risk factors. The local audit department approved the study. Appropriate statistical analyses were performed.

RESULTS

A total of 2560 met the inclusion criteria, with a female preponderance (1447/2560; 56.5%). The mean age was 67.5 ± 10.7 years, with males being significantly younger (65.9 ± 10.9 vs 68.7 ± 10.4 years). AKI developed in 32 cases (1.25%). There was no difference in AKI rates between CEF alone and CEF in combination with gentamicin (1.07% vs 1.36%; P = .524). Overall 31/32 cases were Acute Kidney Injury Network stage I. AKI did not affect the length of stay. Postoperative infection rate was 7/2560 (0.27%). There were no incidences of Clostridium difficile-associated diarrhea. Multivariate analysis demonstrated an increased AKI risk with the use of intravenous gentamicin.

CONCLUSION

C ± G yields low rates of infection and AKI compared with high-dose penicillin-based regimes. It is a safe and effective choice for lower limb arthroplasty.

Clostridium difficile colitis and zoonotic origins-a narrative review

Clostridium difficile is a major cause of hospital-associated diarrhoea, and in severe cases leads to pseudomembranous colitis and toxic megacolon. The frequency of C. difficile infection (CDI) has increased in recent decades, with 453 000 cases identified in 2011 in the USA. This is related to antibiotic-selection pressure, disruption of normal host intestinal microbiota and emergence of antibiotic-resistant C. difficile strains. The burden of community-acquired CDI has been increasingly appreciated, with disease identified in patients previously considered low-risk, such as young women or patients with no prior antibiotic exposure. C. difficile has been identified in livestock animals, meat products, seafood and salads. It has been postulated that the pool of C. difficile in the agricultural industry may contribute to human CDI. There is widespread environmental dispersal of C. difficile spores. Domestic households, turf lawns and public spaces are extensively contaminated, providing a potential reservoir for community-acquired CDI. In Australia, this is particularly associated with porcine-derived C. difficile UK PCR ribotype 014/020. In this article, the epidemiological differences between hospital- and community-acquired CDI are discussed, including some emerging evidence for community-acquired CDI being a possible zoonosis.

Systematic review of the cost-effectiveness of preoperative antibiotic prophylaxis in reducing surgical-site infection

BACKGROUND

Surgical-site infections (SSIs) increase the length of hospital admission and costs. SSI prevention guidelines include preoperative antibiotic prophylaxis. This review assessed the reporting quality and cost-effectiveness of preoperative antibiotics used to prevent SSI.

METHODS

PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Index of Economic Articles (EconLit), Database of Abstracts of Reviews of Effect (including the National Health Service Economic Evaluation Database) and Cochrane Central databases were searched systematically from 1970 to 2017 for articles that included costs, preoperative antibiotic prophylaxis and SSI. Included were RCTs and quasi-experimental studies conducted in Organisation for Economic Co-operation and Development countries with participants aged at least 18 years and published in English. Two reviewers assessed eligibility, with inter-rater reliability determined by Cohen's κ statistic. The Consolidated Health Economic Evaluation and Reporting Standards (CHEERS) and modified Drummond checklists were used to assess reporting and economic quality. Study outcomes and characteristics were extracted, and incremental cost-effectiveness ratios were calculated, with costs adjusted to euros (2016) (€1 = US $1·25; £1 sterling = €1·28).

RESULTS

Twelve studies published between 1988 and 2014 were included from 646 records identified; nine were RCTs, two were nested within RCTs and one was a retrospective chart review. Study quality was highest in the nested studies. Cephalosporins (first, second and third generation) were the most frequent prophylactic interventions. Eleven studies demonstrated clinically effective interventions; ten were cost-effective (the intervention was dominant); in one the intervention was dominated by the control; and in one the intervention was more effective and more expensive than the control.

CONCLUSION

Preoperative antibiotic prophylaxis does reduce SSI, costs to hospitals and health providers, but the reporting of economic methods in RCTs is not standardized. Routinely nesting economic methods in RCTs would improve economic evaluations and ensure appropriate selection of prophylactic antibiotics.

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.

Antibiotic treatment for Clostridium difficile-associated diarrhoea in adults

BACKGROUND

Clostridium difficile (C. difficile) is recognized as a frequent cause of antibiotic-associated diarrhoea and colitis. This review is an update of a previously published Cochrane review.

OBJECTIVES

The aim of this review is to investigate the efficacy and safety of antibiotic therapy for C. difficile-associated diarrhoea (CDAD), or C. difficile infection (CDI), being synonymous terms.

SEARCH METHODS

We searched MEDLINE, EMBASE, CENTRAL and the Cochrane IBD Group Specialized Trials Register from inception to 26 January 2017. We also searched clinicaltrials.gov and clinicaltrialsregister.eu for ongoing trials.

SELECTION CRITERIA

Only randomised controlled trials assessing antibiotic treatment for CDI were included in the review.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed abstracts and full text articles for inclusion and extracted data. The risk of bias was independently rated by two authors. For dichotomous outcomes, we calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI). We pooled data using a fixed-effect model, except where significant heterogeneity was detected, at which time a random-effects model was used. The following outcomes were sought: sustained symptomatic cure (defined as initial symptomatic response and no recurrence of CDI), sustained bacteriologic cure, adverse reactions to the intervention, death and cost.

MAIN RESULTS

Twenty-two studies (3215 participants) were included. The majority of studies enrolled patients with mild to moderate CDI who could tolerate oral antibiotics. Sixteen of the included studies excluded patients with severe CDI and few patients with severe CDI were included in the other six studies. Twelve different antibiotics were investigated: vancomycin, metronidazole, fusidic acid, nitazoxanide, teicoplanin, rifampin, rifaximin, bacitracin, cadazolid, LFF517, surotomycin and fidaxomicin. Most of the studies were active comparator studies comparing vancomycin with other antibiotics. One small study compared vancomycin to placebo. There were no other studies that compared antibiotic treatment to a placebo or a 'no treatment' control group. The risk of bias was rated as high for 17 of 22 included studies. Vancomycin was found to be more effective than metronidazole for achieving symptomatic cure. Seventy-two per cent (318/444) of metronidazole patients achieved symptomatic cure compared to 79% (339/428) of vancomycin patients (RR 0.90, 95% CI 0.84 to 0.97; moderate quality evidence). Fidaxomicin was found to be more effective than vancomycin for achieving symptomatic cure. Seventy-one per cent (407/572) of fidaxomicin patients achieved symptomatic cure compared to 61% (361/592) of vancomycin patients (RR 1.17, 95% CI 1.04 to 1.31; moderate quality evidence). Teicoplanin may be more effective than vancomycin for achieving a symptomatic cure. Eightly-seven per cent (48/55) of teicoplanin patients achieved symptomatic cure compared to 73% (40/55) of vancomycin patients (RR 1.21, 95% CI 1.00 to 1.46; very low quality evidence). For other comparisons including the one placebo-controlled study the quality of evidence was low or very low due to imprecision and in many cases high risk of bias because of attrition and lack of blinding. One hundred and forty deaths were reported in the studies, all of which were attributed by study authors to the co-morbidities of the participants that lead to acquiring CDI. Although many other adverse events were reported during therapy, these were attributed to the participants' co-morbidities. The only adverse events directly attributed to study medication were rare nausea and transient elevation of liver enzymes. Recent cost data (July 2016) for a 10 day course of treatment shows that metronidazole 500 mg is the least expensive antibiotic with a cost of USD 13 (Health Warehouse). Vancomycin 125 mg costs USD 1779 (Walgreens for 56 tablets) compared to fidaxomicin 200 mg at USD 3453.83 or more (Optimer Pharmaceuticals) and teicoplanin at approximately USD 83.67 (GBP 71.40, British National Formulary).

AUTHORS' CONCLUSIONS

No firm conclusions can be drawn regarding the efficacy of antibiotic treatment in severe CDI as most studies excluded patients with severe disease. The lack of any 'no treatment' control studies does not allow for any conclusions regarding the need for antibiotic treatment in patients with mild CDI beyond withdrawal of the initiating antibiotic. Nonetheless, moderate quality evidence suggests that vancomycin is superior to metronidazole and fidaxomicin is superior to vancomycin. The differences in effectiveness between these antibiotics were not too large and the advantage of metronidazole is its far lower cost compared to the other two antibiotics. The quality of evidence for teicoplanin is very low. Adequately powered studies are needed to determine if teicoplanin performs as well as the other antibiotics. A trial comparing the two cheapest antibiotics, metronidazole and teicoplanin, would be of interest.

Antibiotic prophylaxis in orthopaedic surgery: difficult decisions in an era of evolving antibiotic resistance

Prophylactic antibiotics can decrease the risk of wound infection and have been routinely employed in orthopaedic surgery for decades. Despite their widespread use, questions still surround the selection of antibiotics for prophylaxis, timing and duration of administration. The health economic costs associated with wound infections are significant, and the judicious but appropriate use of antibiotics can reduce this risk. This review examines the evidence behind commonly debated topics in antibiotic prophylaxis and highlights the uses and advantages of some commonly used antibiotics. Cite this article: Bone Joint J 2016;98-B:1014-19.

Clostridium difficile colonization and antibiotics response in PolyFermS continuous model mimicking elderly intestinal fermentation

Background

Clostridium difficile (CD), a spore-forming and toxin-producing bacterium, is the main cause for antibiotic-associated diarrhea in the elderly. Here we investigated CD colonization in novel in vitro fermentation models inoculated with immobilized elderly fecal microbiota and the effects of antibiotic treatments.

Methods

Two continuous intestinal PolyFermS models inoculated with different immobilized elder microbiota were used to investigate selected factors of colonization of CD in proximal (PC, model 1) and transverse-distal (TDC, model 1 and 2) colon conditions. Colonization of two CD strains of different PCR ribotypes, inoculated as vegetative cells (ribotype 001, model 1) or spores (ribotypes 001 and 012, model 2), was tested. Treatments with two antibiotics, ceftriaxone (daily 150 mg L⁻¹) known to induce CD infection in vivo or metronidazole (twice daily 333 mg L⁻¹) commonly used to treat CD, were investigated in TDC conditions (model 2) for their effects on gut microbiota composition (qPCR, 16S pyrosequencing) and activity (HPLC), CD spore germination and colonization, and cytotoxin titer (Vero cell assay).

Results

CD remained undetected after inoculating vegetative cells in PC reactors of model 1, but was shown to colonize TDC reactors of both models, reaching copy numbers of up to log₁₀ 8 mL⁻¹ effluent with stable production of toxin correlating with CD cell numbers. Ceftriaxone treatment in TDC reactors showed only small effects on microbiota composition and activity and did not promote CD colonization compared to antibiotic-free control reactor. In contrast, treatment with metronidazole after colonization of CD induced large modifications in the microbiota and decreased CD numbers below the detection limit of the specific qPCR. However, a fast CD recurrence was measured only 2 days after cessation of metronidazole treatment.

Conclusions

Using our in vitro fermentation models, we demonstrated that stable CD colonization in TDC reactors can be induced by inoculating CD vegetative cells or spores without the application of ceftriaxone. Treatment with metronidazole temporarily reduced the counts of CD, in agreement with CD infection recurrence in vivo. Our data demonstrate that CD colonized an undisturbed microbiota in vitro, in contrast to in vivo observations, thus suggesting an important contribution of host-related factors in the protection against CD infection.

Electronic supplementary material

The online version of this article (doi:10.1186/s13099-016-0144-y) contains supplementary material, which is available to authorized users.

Prevention of Infection Due to Clostridium difficile

Clostridium difficile is one of the foremost nosocomial pathogens. Preventing infection is particularly challenging. Effective prevention efforts typically require a multifaceted bundled approach. A variety of infection control procedures may be advantageous, including strict hand decontamination with soap and water, contact precautions, and using chlorine-containing decontamination agents. Additionally, risk factor reduction can help reduce the burden of disease. The risk factor modification is principally accomplished though antibiotic stewardship programs. Unfortunately, most of the current evidence for prevention is in acute care settings. This review focuses on preventative approaches to reduce the incidence of Clostridium difficile infection in healthcare settings.

Clostridium difficile infection following systemic antibiotic administration in randomised controlled trials: a systematic review and meta-analysis

Antibiotics have been the most important risk factor for Clostridium difficile infection (CDI). However, only data from non-randomised studies have been reviewed. We sought to evaluate the risk for development of CDI associated with the major antibiotic classes by analysing data from randomised controlled trials (RCTs). The PubMed, Cochrane and Scopus databases were searched and the references of selected RCTs were also hand-searched. Eligible studies should have compared only one antibiotic versus another administered systemically. Inclusion of studies comparing combinations of antibiotics was allowed only if the second antibiotic was the same or from the same class or if it was administered in a subset of the enrolled patients who were equally distributed in the two arms. Only a minority of the selected RCTs (79/1332; 5.9%) reported CDI episodes. Carbapenems were associated with more CDI episodes than fluoroquinolones [risk ratio (RR) = 2.44, 95% confidence interval (CI) 1.32-4.49] and cephalosporins (RR = 2.24, 95% CI 1.46-3.42), but not penicillins (RR = 2.53, 95% CI 0.87-7.41). Cephalosporins were associated with more CDIs than penicillins (RR = 2.36, 95% CI 1.32-4.23) and fluoroquinolones (RR = 2.84, 95% CI 1.60-5.06). There was no difference in CDI frequency between fluoroquinolones and penicillins (RR = 1.34, 95% CI 0.55-3.25). Finally, clindamycin was associated with more CDI episodes than cephalosporins and penicillins (RR = 3.92, 95% CI 1.15-13.43). In conclusion, data from RCTs showed that clindamycin and carbapenems were associated with more CDIs than other antibiotics.

Asymptomatic Clostridium difficile colonization: epidemiology and clinical implications

BACKGROUND

The epidemiology of Clostridium difficile infection (CDI) has changed over the past decades with the emergence of highly virulent strains. The role of asymptomatic C. difficile colonization as part of the clinical spectrum of CDI is complex because many risk factors are common to both disease and asymptomatic states. In this article, we review the role of asymptomatic C. difficile colonization in the progression to symptomatic CDI, describe the epidemiology of asymptomatic C. difficile colonization, assess the effectiveness of screening and intensive infection control practices for patients at risk of asymptomatic C. difficile colonization, and discuss the implications for clinical practice.

METHODS

A narrative review was performed in PubMed for articles published from January 1980 to February 2015 using search terms 'Clostridium difficile' and 'colonization' or 'colonisation' or 'carriage'.

RESULTS

There is no clear definition for asymptomatic CDI and the terms carriage and colonization are often used interchangeably. The prevalence of asymptomatic C. difficile colonization varies depending on a number of host, pathogen, and environmental factors; current estimates of asymptomatic colonization may be underestimated as stool culture is not practical in a clinical setting.

CONCLUSIONS

Asymptomatic C. difficile colonization presents challenging concepts in the overall picture of this disease and its management. Individuals who are colonized by the organism may acquire protection from progression to disease, however they also have the potential to contribute to transmission in healthcare settings.

Impact of maternal intrapartum antibiotics, method of birth and breastfeeding on gut microbiota during the first year of life: a prospective cohort study

OBJECTIVE

Dysbiosis of the infant gut microbiota may have long-term health consequences. This study aimed to determine the impact of maternal intrapartum antibiotic prophylaxis (IAP) on infant gut microbiota, and to explore whether breastfeeding modifies these effects.

DESIGN

Prospective pregnancy cohort of Canadian infants born in 2010-2012: the Canadian Healthy Infant Longitudinal Development (CHILD) Study.

SETTING

General community.

SAMPLE

Representative sub-sample of 198 healthy term infants from the CHILD Study.

METHODS

Maternal IAP exposures and birth method were documented from hospital records and breastfeeding was reported by mothers. Infant gut microbiota was characterised by Illumina 16S rRNA sequencing of faecal samples at 3 and 12 months.

MAIN OUTCOME MEASURES

Infant gut microbiota profiles.

RESULTS

In this cohort, 21% of mothers received IAP for Group B Streptococcus prophylaxis or pre-labour rupture of membranes; another 23% received IAP for elective or emergency caesarean section (CS). Infant gut microbiota community structures at 3 months differed significantly with all IAP exposures, and differences persisted to 12 months for infants delivered by emergency CS. Taxon-specific composition also differed, with the genera Bacteroides and Parabacteroides under-represented, and Enterococcus and Clostridium over-represented at 3 months following maternal IAP. Microbiota differences were especially evident following IAP with emergency CS, with some changes (increased Clostridiales and decreased Bacteroidaceae) persisting to 12 months, particularly among non-breastfed infants.

CONCLUSIONS

Intrapartum antibiotics in caesarean and vaginal delivery are associated with infant gut microbiota dysbiosis, and breastfeeding modifies some of these effects. Further research is warranted to explore the health consequences of these associations.

TWEETABLE ABSTRACT

Maternal #antibiotics during childbirth alter the infant gut #microbiome.

WSES guidelines for management of Clostridium difficile infection in surgical patients

In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.

Clostridium difficile colitis: review of the therapeutic approach

Clostridium difficile infection (CDI) is the leading cause of antibiotic-associated and nosocomial infectious diarrhea. Presenting as clostridium difficile colitis, it is a significant cause of morbidity and mortality. Metronidazole is regarded as the agent of choice for CDl therapy and also for the first recurrence in most patients with mild to moderate CDI. Vancomycin is recommended as an initial therapy for patients with severe CDI. With recent Food and Drug Administration-approval fidaxomicin is available for clinical use and is as effective as vancomycin with lower relapse rates. Rifaximin and fecal bacteriotherapy are alternative approaches in patients with severe or refractory CDI, before surgical intervention. Antibiotic research is ongoing to add potential new drugs such as teicoplanin, ramoplanin, fusidic acid, nitazoxanide, rifampin, bacitracin to our armamentarium. Role of toxin-binding agents is still questionable. Monoclonal antibody and intravenous immunoglobulin are still investigational therapies that could be promising options. The ongoing challenges in the treatment of CDI include management of recurrence and presence of resistance strains such as NAP1/BI/027, but early recognition of surgical candidates can potentially decrease mortality in CDI.

Effects of an Educational Module in Rationalizing Surgical Prophylaxis

Assessment of current antibiotic prescribing patterns is an important step towards appropriate use of antimicrobial agents. This study was planned to know the surgical prophylaxis practices and the influence of educational intervention. In this educational interventional study, only clean and clean-contaminated surgeries were included. Preinterventional study was done by collecting data regarding the use of surgical prophylaxis in the Department of Surgery. After analyzing the preinterventional data, educational intervention was done. A pretest questionnaire was given to all the surgeons to assess knowledge and practice of surgical prophylaxis in our institute. The questionnaire was designed to collect information regarding the use of prophylactic antibiotic, its duration, time of administration, and prevention of surgical site infections (SSI). In our study, third-generation cephalosporin was used in maximum cases in preinterventional analysis and prophylaxis was continued for 3-5 days. Surgeon's decision in selecting a prophylactic agent was based on information taken from departmental colleagues or drug companies. Two or more doses of antibiotic were used even when duration of surgery did not exceed more than two and half hours. Definite improvement was seen after the education where single antibiotic was used as prophylactic drug and the first dose of antibiotic was administered 30 to 60 min before incision. This shows that educational intervention makes a change in antibiotic prescribing habit. Hence, there is an urgent need for adoption of specific guidelines to ensure standardization of surgical antibiotic prophylaxis practices in hospitals.

Antibiotic and Diagnostic Discordance Between ED Physicians and Hospitalists for Pediatric Respiratory Illness

BACKGROUND AND OBJECTIVE

Imperfect diagnostic tools make it difficult to know the extent to which a bacterial process is contributing to respiratory illness, complicating the decision to prescribe antibiotics. We sought to quantify diagnostic and antibiotic prescribing disagreements between emergency department (ED) and pediatric hospitalist physicians for children admitted with respiratory illness.

METHODS

Manual chart review was used to identify testing, diagnostic, and antibiotic prescribing decisions for consecutive children admitted for respiratory illness in a winter (starting February 20, 2012) and a summer (starting August 20, 2012) season to a tertiary, freestanding children's hospital. Respiratory illness diagnoses were grouped into 3 categories: bacterial, viral, and asthma.

RESULTS

A total of 181 children admitted for respiratory illness were studied. Diagnostic discordance was significant for all 3 types of respiratory illness but greatest for bacterial (P<.001). Antibiotic prescribing discordance was significant (P<.001), with pediatric hospitalists changing therapy for 93% of patients prescribed antibiotics in the ED, including stopping antibiotics altogether for 62% of patients.

CONCLUSIONS

Significant diagnostic and antibiotic discordance between ED and pediatric hospitalist physicians exists for children admitted to the hospital for respiratory illness.

Diagnosis and treatment of Clostridium difficile in adults: a systematic review

IMPORTANCE

Since 2000, the incidence and severity of Clostridium difficile infection (CDI) have increased.

OBJECTIVE

To review current evidence regarding best practices for the diagnosis and treatment of CDI in adults (age ≥ 18 years).

EVIDENCE REVIEW

Ovid MEDLINE and Cochrane databases were searched using keywords relevant to the diagnosis and treatment of CDI in adults. Articles published between January 1978 and October 31, 2014, were selected for inclusion based on targeted keyword searches, manual review of bibliographies, and whether the article was a guideline, systematic review, or meta-analysis published within the past 10 years. Of 4682 articles initially identified, 196 were selected for full review. Of these, the most pertinent 116 articles were included. Clinical trials, large observational studies, and more recently published articles were prioritized in the selection process.

FINDINGS

Laboratory testing cannot distinguish between asymptomatic colonization and symptomatic infection with C difficile. Diagnostic approaches are complex due to the availability of multiple testing strategies. Multistep algorithms using polymerase chain reaction (PCR) for the toxin gene(s) or single-step PCR on liquid stool samples have the best test performance characteristics (for multistep: sensitivity was 0.68-1.00 and specificity was 0.92-1.00; and for single step: sensitivity was 0.86-0.92 and specificity was 0.94-0.97). Vancomycin and metronidazole are first-line therapies for most patients, although treatment failures have been associated with metronidazole in severe or complicated cases of CDI. Recent data demonstrate clinical success rates of 66.3% for metronidazole vs 78.5% for vancomycin for severe CDI. Newer therapies show promising results, including fidaxomicin (similar clinical cure rates to vancomycin, with lower recurrence rates for fidaxomicin, 15.4% vs vancomycin, 25.3%; P = .005) and fecal microbiota transplantation (response rates of 83%-94% for recurrent CDI).

CONCLUSIONS AND RELEVANCE

Diagnostic testing for CDI should be performed only in symptomatic patients. Treatment strategies should be based on disease severity, history of prior CDI, and the individual patient's risk of recurrence. Vancomycin is the treatment of choice for severe or complicated CDI, with or without adjunctive therapies. Metronidazole is appropriate for mild disease. Fidaxomicin is a therapeutic option for patients with recurrent CDI or a high risk of recurrence. Fecal microbiota transplantation is associated with symptom resolution of recurrent CDI but its role in primary and severe CDI is not established.

Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)

Since publication of the Society for Healthcare Epidemiology of America position paper onClostridium difficileinfection in 1995, significant changes have occurred in the epidemiology and treatment of this infection.C. difficileremains the most important cause of healthcare-associated diarrhea and is increasingly important as a community pathogen. A more virulent strain ofC. difficilehas been identified and has been responsible for more-severe cases of disease worldwide. Data reporting the decreased effectiveness of metronidazole in the treatment of severe disease have been published. Despite the increasing quantity of data available, areas of controversy still exist. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, and infection control and environmental management.

The potential use of cholestyramine to reduce the risk of developing Clostridium difficile-associated diarrhoea in patients receiving long-term intravenous ceftriaxone

Intravenous pharmacotherapy with the third-generation cephalosporin ceftriaxone is unfortunately associated with a relatively high incidence of Clostridium difficile-associated diarrhoea. Cholestyramine (colestyramine) is an anion-binding resin which can bind luminal C.difficile toxin A (TcdA) and toxin B (TcdB) and which may be beneficial in the treatment of recurrent antibiotic-associated pseudomembranous colitis. We therefore hypothesised that concomitant oral cholestyramine might reduce the risk of C.difficile-associated diarrhoea in patients receiving long-term intravenous ceftriaxone. A pilot study was carried out in which it was found that only three out of 46 (6.5%) such patients being treated with 2 g ceftriaxone daily for Lyme borreliosis, who also received 4 g cholestyramine daily, developed C.difficile-associated diarrhoea. This is smaller than a published report of the incidence of this complication in six out of 26 (23.1%) patients following 1-3 days' treatment with 1 g intravenous ceftriaxone, but without oral cholestyramine (p=0.06). We therefore recommend that a larger, double-blind placebo-controlled trial be carried out to test this hypothesis.

Risk of Clostridium difficile infection in hospitalized patients receiving metronidazole for a non-C difficile infection

BACKGROUND & AIMS

Antibiotics often are given to prevent infections but also constitute a risk factor for Clostridium difficile infection (CDI). Metronidazole is an effective treatment for CDI. We investigated whether prophylactic administration of metronidazole to patients before they receive other antibiotics reduces the risk of CDI.

METHODS

We performed a retrospective cohort analysis of data collected from 12,026 high-risk patients admitted to Cleveland Clinic Foundation Hospitals from 2008 through 2012. High-risk patients were defined as age 55 or older who received a broad-spectrum antibiotic (piperacillin-tazobactam or ciprofloxacin) and a gastric acid suppressant (a proton pump inhibitor or a histamine-2 receptor blocker) during their hospitalization. Development of CDI was compared between patients who received metronidazole for non-CDI indications before broad-spectrum antibiotics (n = 811) and those who did not (n = 11,215). Logistic regression was used to control for patient demographics and comorbidities.

RESULTS

The rate of CDI was 1.4% (n = 11) among the patients who received metronidazole for non-CDI indications and 6.5% (n = 728) among those who did not. This was observed to be an 80% reduction in CDI among patients who received metronidazole (odds ratio, 0.21; 95% confidence interval, 0.11-0.38; P < .001), adjusted for age, sex, and comorbidities.

CONCLUSIONS

Based on a retrospective analysis, metronidazole might be used to prevent CDI in certain high-risk patients. Prospective controlled trials are necessary before making further recommendations.

Surgical Management of Severe Colitis in the Intensive Care Unit

Severe colitis, an umbrella encompassing several entities, is one of the most common acute gastrointestinal disorders resulting in critical illness. Clostridium difficile infection is responsible for the majority of nosocomial diarrhea with fulminant C difficile colitis (CDC) carrying a high mortality. Optimal outcomes can be achieved by early identification and treatment of fulminant CDC, with appropriate surgical intervention when indicated. Ischemic colitis, on the other hand, is uncommon with a range of etiological factors including abdominal aortic surgery, inotropic drugs, rheumatoid diseases, or often no obvious triggering factor. Most cases resolve with nonsurgical management; however, prompt recognition of full-thickness necrosis and gangrene is crucial for good patient outcomes. Fulminant colitis is a severe disease secondary to progressive ulcerative colitis with systemic deterioration. Surgical intervention is indicated for hemorrhage, perforation, or peritonitis and failure of medical therapy to control the disease. Although, failure of medical management is the most common indication, it can be difficult to define objectively and requires a collaborative multidisciplinary approach. This article proposes some simple management algorithms for these clinical entities, with a focus on critically ill patients.

Comparison between oral antibiotics and probiotics as bowel preparation for elective colon cancer surgery to prevent infection: prospective randomized trial

BACKGROUND

We have already reported that, for patients undergoing elective colon cancer operations, perioperative infection can be prevented by a single intravenous dose of an antibiotic given immediately beforehand if mechanical bowel preparation and the administration of oral antibiotics are implemented. Synbiotics has been reported to reduce the rate of infection in patients after pancreatic cancer operations. The effectiveness of oral antibiotics and probiotics in preventing postoperative infection in elective colon cancer procedures was examined in a randomized controlled trial.

METHODS

Three hundred ten patients with colon cancer randomly were assigned to one of three groups. All patients underwent mechanical bowel preparation and received a single intravenous dose of flomoxef immediately before operation. Probiotics were administered in Group A; oral antibiotics were administered in Group B; and neither probiotics nor oral antibiotics were administered in Group C. Stool samples were collected 9 and 2 days before and 7 and 14 days after the procedure. Clostridium difficile toxin and the number of bacteria in the intestine were determined.

RESULTS

The rates of incisional surgical-site infection were 18.0%, 6.1%, and 17.9% in Groups A, B, and C, and the rates of leakage were 12.0%, 1.0%, and 7.4% in Groups A, B, and C, respectively, indicating that both rates were lesser in Group B than in Groups A and C (P = .014 and P = .004, respectively). The detection rates of C. difficile toxin were not changed among the three groups.

CONCLUSION

We recommend oral antibiotics, rather than probiotics, as bowel preparation for elective colon cancer procedures to prevent surgical-site infections.