Management of Penicillin Allergy in the Perioperative Setting

The selection of perioperative antibiotic prophylaxis is challenging in patients with a history of penicillin allergy; as such, we present a literature review exploring current best practices and the associated supporting evidence, as well as areas for future research. Guidelines recommend the use of alternative agents in patients with an IgE-mediated hypersensitivity reaction, but those alternative agents are associated with worse outcomes, including an increased risk of surgical site infection, and higher cost. More recent data suggest that the risk of cross-reactivity between penicillins and cephalosporins, particularly cefazolin, is extremely low, and that cefazolin can be used safely in most penicillin-allergic patients. Studies have therefore explored how best to implement first-line cefazolin use in patients with a penicillin allergy label. A variety of interventions, including preoperative allergy de-labeling with incorporation of penicillin skin testing, use of patient risk-stratification questionnaires, and utilization of clinician algorithms to guide antibiotic selection intraoperatively, have all been shown to significantly increase cefazolin utilization without a corresponding increase in adverse events. Further studies are needed to clarify the most effective interventions and implementation strategies, as well as to evaluate whether patients with severe delayed hypersensitivity reactions to penicillin should continue to be excluded from receipt of other beta-lactams.

Perioperative antibiotic prophylaxis in skin surgery - Position paper of the Antibiotic Stewardship working group of the German Society for Dermatologic Surgery (DGDC), Part 1: Procedure- and patient-related risk factors

The aim of perioperative antibiotic prophylaxis (PAP) is to prevent the occurrence of surgical site infections (SSIs) or other infectious complications (especially bacterial endocarditis or septic arthritis). PAP is effective in surgeries where overall infection rates are high even without considering patient-related risk factors (such as orthopedic surgery or fracture repair). Surgery on airways, gastrointestinal, genital, or urinary tract is also considered to be associated with a risk of infection and may require PAP. Overall, SSIs in skin surgery are relatively rare and vary between 1% and 11% depending on the localization, complexity of the wound closure and patient cohort. Therefore, the general surgical recommendations regarding PAP only partially reflect the needs of dermatologic surgery. In contrast to the USA, where recommendations on the use of PAP in skin surgery already exist, there are currently no guidelines for the use of PAP specifically designed for dermatologic surgery in Germany. In the absence of an evidence-based recommendation, the use of PAP is guided by the experience of the surgeons and leads to a heterogeneous use of antimicrobial substances. In this work, we summarize the current scientific literature on the use of PAP and make a recommendation depending on procedure- and patient-related risk factors.

Perioperative Antibiotikaprophylaxe in der Dermatochirurgie - Positionspapier der Arbeitsgruppe Antibiotic Stewardship der Deutschen Gesellschaft für Dermatochirurgie (DGDC), Teil 1: Eingriffs- und patientenbezogene Risikofaktoren

Die perioperative Antibiotikaprophylaxe (PAP) hat das Ziel, postoperative Wundinfektionen und Infektionskomplikationen (insbesondere bakterielle Endokarditis oder septische Arthritis) bei chirurgischen Eingriffen zu vermeiden. Die PAP hat sich besonders bei Eingriffen bewährt, bei denen die Infektionsraten auch ohne Berücksichtigung der patientenbezogenen Risikofaktoren insgesamt hoch sind (wie für orthopädische Eingriffe oder die Versorgung von Frakturen). Auch Operationen mit Eröffnung der Atemwege, des Verdauungs‐, Genital‐ oder Harntrakts gelten als mit Infektionsrisiko behaftet und können eine PAP erfordern. In der Dermatochirurgie sind Infektionskomplikationen insgesamt verhältnismäßig selten und variieren in Abhängigkeit von der Lokalisation, Komplexität des Eingriffes und der Patientenkohorte zwischen 1% und 11%. Daher spiegeln die allgemeinchirurgischen Empfehlungen bezüglich der PAP die Bedürfnisse der Dermatochirurgie nur begrenzt wider. Im Gegensatz zu den USA, wo eine entsprechende Empfehlung vorliegt, existiert in Deutschland zurzeit keine speziell für dermatochirurgische Eingriffe konzipierte Leitlinie zur Anwendung von PAP. In Abwesenheit evidenzbasierter Empfehlungen wird die PAP durch die Erfahrung der einzelnen Operateure geprägt, was zu einer heterogenen Anwendung antimikrobieller Substanzen führt. In der vorliegenden Arbeit wird die aktuelle wissenschaftliche Literatur zu dem Thema zusammengefasst und die daraus resultierende Empfehlung zur Anwendung der PAP in Abhängigkeit von eingriffs‐ und patientenbezogenen Risikofaktoren formuliert.

The Duration of Postoperative Antibiotics in Autologous Breast Reconstruction: A Systematic Review and Meta-Analysis

Although prophylactic antibiotic use following autologous breast reconstruction post-mastectomy is a common practice, there is no consensus in the literature regarding its duration. Antibiotic stewardship is important to minimise multi-resistant organisms as well as mitigate the associated side effects. Currently, there are no published guidelines regarding the duration of prophylactic antibiotics in autologous breast reconstruction surgery following mastectomy. The authors searched the online literature regarding the administration of antibiotics for autologous breast reconstruction surgery post-mastectomy. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. The primary outcome measure was the incidence of surgical site infections (SSIs). Three studies met the inclusion criteria and included a total of 1,400 patients. Overall, 101 (7.2%) SSIs were observed. There was no significant difference in the rate of SSIs when comparing the use of antibiotics for less than or longer than 24 hours postoperatively (odds ratio = 1.434, p = 0.124). There is no significant difference between SSIs with the use of antibiotics for longer than 24 hours when compared to less than 24 hours. Further studies in the form of randomised controlled trials are required to assess the effects of prophylactic antibiotic duration in autologous breast reconstruction following mastectomy.

Perioperative Antibiotic Prophylaxis in Pediatric Cardiac Surgery-Simple Is Better

Pediatric cardiac surgery requires perioperative antibiotic prophylaxis (PAP) to reduce the risk of surgical site infections. However, the complexity of these procedures and the metabolic immaturity of children impede the establishment of PAP regimens that are both efficacious and in line with antimicrobial stewardship (AMS). In this study, we compared two PAP regimens: cefazolin with gentamicin (in a retrospective group) and cefazolin only (prospectively) in children undergoing elective cardiac surgery. In the prospective group, additional elements of AMS were introduced, i.e., restricted access to cefazolin and more diligent use of empirical antibiotics proceeded by consultation with an AMS team. The rate of surgical site infections (SSI), the scope of PAP deviations, and the postoperative use of antibiotics other than PAP within 30 days after surgery were analyzed. There were no significant differences in the rate of SSIs between the groups (3.9% vs. 1.2% in the prospective and retrospective groups, respectively (p = 0.35)). However, in the prospective group, the PAP violation was significantly reduced compared with the retrospective group (full compliance with the PAP regimen was 45.5% vs. 4.8%, p < 0.001, respectively). In addition, a reduction of postoperative antibiotic use was observed in the prospective group (0.991 vs. 1.932 defined daily doses, respectively).

Analysis of the Validity of Perioperative Antibiotic Prophylaxis in Maxillofacial Surgery

Perioperative antibiotic prophylaxis is the standard in surgical departments. The type of operation, the duration of the procedure, the degree of microbiological purity of the operating field and the current clinical condition of the patient determine its administration. The aim of this study was to validate the antibiotic prophylaxis used in a Maxillofacial Surgery Department for a group of trauma and non-trauma patients. To that end, an observational prospective cohort study was carried out. The study was conducted on a group of 83 patients of the Department of Cranio-Maxillo-Facial Surgery who were divided into a group of trauma patients (n = 43) and one of non-trauma patients (n = 40). In both groups, the classic microbiological tests were carried out, and the results were analyzed in relation to: the study group, age, sex, duration of surgery, type of surgical access. Most bacterial strains were isolated at the initial stage of the operation. Gram (+) cocci were isolated more often in the trauma group and Gram (-) rods in the non-trauma group. Significantly more often, strains of fungi were noted in the initial stage of the procedure in the trauma group. We conclude that the use of perioperative antibiotic prophylaxis in the Maxillofacial Surgery Departments is justified.

Patient-dependent risk factors for wound infection after skin surgery: A systematic review and meta-analysis

Postoperative wound infection in dermatologic surgery causes impaired wound healing, poor cosmetic outcome and increased morbidity. Patients with a high‐risk profile may benefit from perioperative antibiotic prophylaxis. The objective of this systematic review was to identify risk factors for surgical site infection after dermatologic surgery. In this article, we report findings on patient‐dependent risk factors. The literature search included MEDLINE, EMBASE, CENTRAL and trial registers. We performed meta‐analysis, if studies reported sufficient data to calculate risk ratios with 95% confidence intervals. Study quality was assessed according to the Newcastle‐Ottawa‐Scale. Seventeen observational studies that analysed 31213 surgical wounds were eligible for inclusion. Fourteen studies qualified for meta‐analysis. Nine studies showed good, three fair and five poor methodological quality. The reported incidence of surgical site infection ranged from 0.96% to 8.70%. Meta‐analysis yielded that male gender and immunosuppression were significantly associated with higher infection rates. There was a tendency towards a higher infection risk for patients with diabetes, without statistical significance. Meta‐analysis did not show different infection rates after excision of squamous cell carcinoma or basal cell carcinoma, but studies were substantially heterogenous. There was no significant association between risk for wound infection and smoking, age over 60 years, oral anti‐aggregation or anti‐coagulation or excision of malignant melanoma. In conclusion, the risk for surgical site infection in dermatologic surgery is low. Infection rates were increased significantly in male as well as immunosuppressed patients and non‐significantly in diabetics.

Barriers and Facilitators in Perioperative Antibiotic Prophylaxis: A Mixed-Methods Study in a Small Island Setting

Few studies have addressed antibiotic guideline adherence in small island settings, such as Aruba. This study aimed to evaluate the appropriateness of perioperative antibiotic prophylaxis (PAP) and identify barriers for PAP guideline adherence. A mixed-methods study was carried out at the operating theatre (OT) in the Dr. Horacio E. Oduber Hospital (HOH) in Aruba. First, a prospective audit was performed on the appropriateness of guideline-derived quality indicators (QIs). Then, interviews based on the Flottorp framework were conducted to identify barriers for guideline adherence. Finally, a survey was distributed to verify the outcomes of the interviews. The appropriateness of QIs was measured: correct indication (50.6%); antimicrobial agent (30.8%); dose (94.4%); timing (55.0%); route of administration (100%); duration (89.5%); and redosing (95.7%). The overall appropriateness was 34.9%. The main barriers discovered were poor knowledge about PAP and the guidelines and professional interactions regarding PAP, specifically poor communication and lack of clarity about responsibilities regarding PAP. This study was the first to evaluate the appropriateness and to identify barriers for PAP guideline adherence in a small island hospital. The overall appropriateness of PAP was poor with just 34.9%. Future interventions should be focused on communication, education and awareness of the possibility to consult an ID physician or microbiologist.

The Influence of Perioperative Antibiotic Prophylaxis on Wound Infection and on the Colonization of Wound Drains in Patients After Correction of Craniosynostosis

Objective: Evidence for the duration of perioperative antibiotic prophylaxis (PAP) after the correction of craniosynostosis in children is scarce. We evaluated the necessary duration of PAP to ensure a minimal rate of postoperative wound infections. Methods: In this monocentric, retrospective, and prospective pilot study, two PAP protocols were compared. From August 2017 to May 2018, treatment group 1 (TG 1) was treated using the standard PAP protocol with at least three doses of antibiotics. Between May 2018 and March 2019, a shortened PAP with a single-shot administration was given to treatment group 2 (TG 2a and b). Endpoints of this study were wound infection rate, colonization rate of wound drains, and the course of treatment reflected by clinical and laboratory data. Results: A cohort of 187 children underwent craniosynostosis correction: 167 were treated according to protocols--95 patients with at least three doses (TG 1) and 72 patients with a single-shot of cefuroxime (TG 2a). Baseline characteristics were similar for both groups. We could not detect significant differences, neither for wound infection rates (TG 1: 1.1%, TG 2a: 0.0%, p = 0.38) nor for colonization rates of wound drains (TG 1: 4.8%, TG 2a: 10.5%, p = 0.27). Conclusions: Single-shot PAP had no adverse effects on the wound infection rate or the colonization rate of the wound drains compared with prolonged perioperative antibiotic prophylaxis. As a result, single-shot preoperative PAP is now applied to the majority craniosynostosis patients undergoing surgical correction in our unit.

Perioperative Antibiotic Prophylaxis: Knowledge and Attitudes among Resident Physicians in Italy

The aim of this study is to evaluate knowledge and attitudes on the perioperative antibiotic prophylaxis (PAP) among surgery and anesthesiology resident physicians in Italy. A Web-based national survey of Italian surgery and anesthesiology resident physicians was conducted between March 2018 and January 2019. Participants completed a questionnaire and three case vignettes for each specialty. Of the 1282 resident physicians selected, 466 completed the online questionnaire for a response rate of 36.3%. More than half of the sample were female (52.9%), and the mean age was 30 years. A total of 36.3% of the participants had an adequate knowledge score about PAP. Multiple logistic regression analysis showed that resident physicians in general surgery compared to those in anesthesiology, those who agreed that PAP must be performed within 60 min before surgical incision, and those who were aware regarding the availability about the availability of national guidelines on PAP, were significantly more likely to have adequate knowledge about PAP. Moreover, 14% of participants were very concerned that patients may contract surgical site infections during hospitalization. These findings should be useful to promote educational intervention specifically targeted for surgery and anesthesiology resident physicians organizing training course on PAP, to improve the correct antibiotic use and to prevent healthcare-associated infections.

Inadequate Perioperative Prophylaxis and Postsurgical Complications After Graft Implantation Are Important Risk Factors for Subsequent Vascular Graft Infections: Prospective Results From the Vascular Graft Infection Cohort Study

BACKGROUND

Reconstructive vascular surgery has become increasingly common. Vascular graft infections (VGIs) are serious complications, leading to increased morbidity and mortality. Previously described risk factors for VGIs include groin incisions, wound infections, and comorbidities. We aimed to identify modifiable predictors for VGIs as targets for infection prevention strategies.

METHODS

Participants of the prospective Vascular Graft Infection Cohort (VASGRA) with surgery between 2013 and 2017 were included. The observation time was calculated from surgery until a confirmed VGI or the last follow-up. Variables were assessed by infection status, using non-parametric tests. Univariable and multivariable Cox proportional hazard regression models, adjusted for demographic factors, were applied to assess risk factors for a VGI.

RESULTS

A total of 438 predominantly male (83.1%) patients with a median age of 71 years (interquartile range [IQR] 63 - 76) contributed to 554 person years of follow-up. Thereof, 39 (8.9%) developed a VGI, amounting to an incidence rate of 7.0/100 person years. We found incisional surgical site infections (adjusted hazard ratio [aHR] 10.09, 95% CI 2.88 - 35.34); hemorrhage (aHR 4.92, 1.28-18.94); renal insufficiency (aHR 4.85, 1.20 - 19.61); inadequate perioperative prophylaxis in patients with an established antibiotic treatment, compared to the additional application of perioperative prophylaxis (aHR 2.87, 95% CI 1.17 - 7.05); and procedure time increases of 1-hour intervals (aHR 1.22, 95% CI 1.08 - 1.39) to be risk factors for VGIs.

CONCLUSIONS

We identified procedure time; inadequate perioperative prophylaxis, especially among patients with an established antibiotic treatment; and several postsurgical infectious and non-infectious complications as modifiable, predictive factors for VGIs and, therefore, as keys to improved surveillance programs and prevention strategies.

CLINICAL TRIALS REGISTRATION

NCT01821664.

An observational study of perioperative antibiotic-prophylaxis use at a major quaternary care and referral hospital in Saudi Arabia

Context

The use of perioperative antimicrobial prophylaxis has been consistently considered an effective means of reducing the risk of surgical site infections. However, inappropriate use of surgical antibiotic prophylaxis is associated with complications such as reduced treatment efficacy, development of antibiotic resistance, and increased health-care costs.

Aims

The aim of this study is to investigate the adherence to international/national guidelines regarding the use of surgical antibiotic prophylaxis in the perioperative period.

Settings and Design

King Faisal Specialist Hospital and Research Centre (KFSH&RC) a 1589-bed tertiary/quaternary care and referral hospital based in Riyadh, Saudi Arabia.

Subjects and Methods

A retrospective observational study, in which antibiotic prophylaxis parameters were assessed against recommendations provided by international/national guidelines in elective/emergency procedures performed at the general operating suite. Data was obtained from the medical records starting of 174 cases over a period of 2 weeks in May 2016.

Results

Preoperative antibiotic prophylaxis (PAP) was prescribed for 118 (78.7%) patients, 72 (61%) of which were "recommended," whereas 46 (39%) were "not recommended." Of the 72 patients for whom the antibiotics were "recommended" and given, 19 (26.4%) received "inadequate" choice of antibiotics, 50 (69.4%) received a sub-therapeutic dose, 14 (19.4%) had "improper" timing of the first dose, 11 (15.3%) were given an "inappropriate" second intraoperative dose, and 43 (59.7%) had an unnecessarily extended duration of prophylaxis. The overall compliance to guidelines was achieved in only 23 (15.3%) patients.

Conclusions

A significant gap between current KFSH & RC practice and international/national guidelines regarding surgical antibiotic prophylaxis usage has been demonstrated which calls for immediate action to ensure effective guideline adoption and implementation.

Perioperative Antibiotic Prophylaxis Has No Effect on Time to Positivity and Proportion of Positive Samples: a Cohort Study of 64 Cutibacterium acnes Bone and Joint Infections

If a bone or joint infection is suspected, perioperative antibiotic prophylaxis is frequently withheld until intraoperative microbiological sampling has been performed. This practice builds upon the hypothesis that perioperative antibiotics could render culture results negative and thus impede tailored antibiotic treatment of infections. We aimed to assess the influence of antibiotic prophylaxis within 30 to 60 min before surgery on time to positivity of microbiological samples and on proportion of positive samples in Cutibacterium acnes bone and joint infections. Patients with at least one sample positive for C. acnes between January 2005 and December 2015 were included and classified as having an "infection" if at least 2 samples were positive; otherwise they were considered to have a sample "contamination." Kaplan-Meier curves were used to illustrate time to culture positivity. We found 64 cases with a C. acnes infection and 46 classified as having a C. acnes contamination. Application of perioperative prophylaxis significantly differed between the infection and contamination groups (72.8% versus 55.8%; P < 0.001). Within the infection group, we found no difference in time to positivity between those who had or had not received a perioperative prophylaxis (7.07 days; 95% confidence interval [CI], 6.4 to 7.7, versus 7.11 days; 95% CI, 6.8 to 7.5; P = 0.3). Also, there was no association between the proportion of sample positivity and the application of perioperative prophylaxis (71.6% versus 65.9%; P = 0.39). Since perioperative prophylaxis did not negatively influence the microbiological yield in C. acnes infections, antibiotic prophylaxis can be routinely given to avoid surgical site infections.

Prevention options for ventriculoperitoneal shunt infections: a retrospective analysis during a five-year period

Shunt infection is the most common and dreaded complication in patients with hydrocephalus. For the purpose of reducing the high morbidity and mortality, how to prevent is a vital step. A retrospective analysis of 384 CSF cerebrospinal fluid (CSF) shunt procedures was undertaken from 2006 to 2010 in our neurosurgery department. Infection diagnosis was established by subjecting the CSF to biochemical and microbiological parameters. The patients' demographic and clinical characteristics, various treatment procedures and outcome were evaluated. The infection rate of ventriculoperitoneal (VP) shunt was 12.5% in 2006, which dropped to 2% and stabilized at lower level from 2008. The most common causes of hydrocephalus were traumatic injury and brain tumor. Fever and consciousness disturbance were the major clinical symptoms. Gram-negative rods episodes was the most frequently isolated microorganisms accounting for 58%, followed by S. aureus , S. epidermidis and Staphylococcus haemolyticus. With the removal of shunt and intravenous antibiotics therapy, 82% of the patients survived. Majority of the isolates were sensitive to the carbopenem antibiotics and vancomycin. The mean length of hospital stay was 47 days. Prompt shunt removal and perioperative antibiotic prophylaxis seems to be essential for the survival of patients with VP shunt infection.