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Knisely A, Iniesta MD, Marten CA, Chisholm G, Schmeler KM, Taylor JS. Metronidazole and cefazolin vs cefazolin alone for surgical site infection prophylaxis in gynecologic surgery at a comprehensive cancer center. Am J Obstet Gynecol 2024:S0002-9378(24)00507-6. [PMID: 38599478 DOI: 10.1016/j.ajog.2024.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Surgical site infection is one of the most common complications of gynecologic cancer surgery. Current guidelines recommend the administration of cefazolin preoperatively to reduce surgical site infection rates for patients undergoing clean-contaminated surgeries such as hysterectomy. OBJECTIVE To evaluate the impact of a quality improvement project adding metronidazole to cefazolin for antibiotic prophylaxis on surgical site infection rate for women undergoing gynecologic surgery at a comprehensive cancer center. STUDY DESIGN This retrospective, single-center cohort study included patients who underwent surgery in the gynecologic oncology department from May 2017 to June 2023. Patients with penicillin allergies and those undergoing concomitant bowel resections and/or joint cases were excluded. The preintervention group patients had surgery from May 2017 to April 2022, and the postintervention group patients had surgery from April 2022 to June 2023. The primary outcome was a 30-day surgical site infection rate. Sensitivity analyses were performed to compare surgical site infection rates on the basis of actual antibiotics received and for those who had a hysterectomy. Factors independently associated with surgical site infection were identified using a multivariable logistic regression model adjusting for confounding variables. RESULTS Of 3343 patients, 2572 (76.9%) and 771 (23.1%) were in the pre-post intervention groups, respectively. Most patients (74.7%) had a hysterectomy performed. Thirty-four percent of cases were for nononcologic (benign) indications. Preintervention patients were more likely to receive appropriate preoperative antibiotics (95.6% vs 90.7%; P<.001). The overall surgical site infection rate before the intervention was 4.7% compared with 2.6% after (P=.010). The surgical site infection rate for all patients who underwent hysterectomy was 4.9% (preintervention) vs 2.8% (postintervention) (P=.036); a similar trend was seen for benign cases (4.4% vs 2.4%; P=.159). On multivariable analysis, the odds ratio for surgical site infection was 0.49 (95% confidence interval, 0.38-0.63) for the postintervention compared with the preintervention group (P<.001). In a sensitivity analysis (n=3087), the surgical site infection rate was 4.5% for those who received cefazolin alone compared with 2.3% for those who received cefazolin plus metronidazole, with significantly decreased odds of surgical site infection for the cefazolin plus metronidazole group (adjusted odds ratio, 0.40 [95% confidence interval, 0.30-0.53]; P<.001). Among only those who had a hysterectomy performed, the odds of surgical site infection were significantly reduced for those in the postintervention group (adjusted odds ratio, 0.63 [95% confidence interval, 0.47-0.86]; P=.003). CONCLUSION The addition of metronidazole to cefazolin before gynecologic surgery decreased the surgical site infection rate by half, even after accounting for other known predictors of surgical site infection and differences in practice patterns over time. Providers should consider this combination regimen in women undergoing gynecologic surgery, especially for cases involving hysterectomy.
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Affiliation(s)
- Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claire A Marten
- Division of Pharmacy, Department of Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gary Chisholm
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Novy E, Liu X, Hernandez-Mitre MP, Belveyre T, Scala-Bertola J, A Roberts J, L Parker S. Population pharmacokinetics of prophylactic cefoxitin in elective bariatric surgery patients: A prospective monocentric study. Anaesth Crit Care Pain Med 2024:101376. [PMID: 38494157 DOI: 10.1016/j.accpm.2024.101376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/19/2024] [Accepted: 03/12/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND This study describes the population pharmacokinetics of cefoxitin in obese patients undergoing elective bariatric surgery and evaluates different dosing regimens for achievement of pre-defined target exposures. METHODS Serial blood samples were collected during surgery with relevant clinical data. Total serum cefoxitin concentrations were measured by chromatographic assay and analysed using a population PK approach with Pmetrics®. The cefoxitin unbound fraction (fu) was estimated. Dosing simulations were performed to ascertain the probability of target attainment (PTA) to achieve cefoxitin fu above minimum inhibitory concentrations (MIC) from surgical incision to wound closure. Fractional target attainment (FTA) was calculated against MIC distributions of common pathogens. RESULTS A total of 123 obese patients (median BMI 44.3 kg/m2) were included with 381 cefoxitin concentration values. Cefoxitin was best described by a one-compartment model, with a mean clearance and volume of distribution of 10.9 ± 6.1 L/h and 23.4 ± 10.5 L, respectively. In surgery <2 h, a 2 and a 4 g doses were sufficient for an MIC up to 4 and 8 mg/L (fu 50%), respectively. In prolonged surgery (2 to 4 h), only continuous infusion enabled optimal PTA for an MIC up to 16 mg/L. Optimal FTAs were obtained against Staphylococcus aureus and Escherichia Coli only when simulating with 50% cefoxitin protein binding (intermittent regimen) and regardless of the protein binding for the continuous infusion. CONCLUSION Intermittent dosing regimens resulted in optimal FTAs against susceptible MIC distributions of S. aureus and E. coli when simulating with 50% cefoxitin protein binding. Continuous infusion of cefoxitin may improve FTA regardless of protein binding. STUDY REGISTRATION Registration on ClinicalTrials.gov, NCT03306290.
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Affiliation(s)
- Emmanuel Novy
- Department of Anaesthesiology Critical Care and perioperative medicine, Nancy University Hospital, University of Lorraine, Vandoeuvre-Lès-Nancy, 54500, France; UR 7300, SIMPA, Université de Lorraine, 54000, Nancy, France; UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, 4029, Australia.
| | - Xin Liu
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, 4029, Australia
| | | | - Thibaut Belveyre
- Department of Anaesthesiology Critical Care and perioperative medicine, Nancy University Hospital, University of Lorraine, Vandoeuvre-Lès-Nancy, 54500, France
| | - Julien Scala-Bertola
- Department of Clinical Pharmacology and Toxicology, Nancy University Hospital, Vandoeuvre-Lès-Nancy, 54500, France; CNRS, IMoPA, Université de Lorraine, 54000, Nancy, France
| | - Jason A Roberts
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, 4029, Australia; Division of Anaesthesiology Critical Care Emergency & Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, 30029, France; Herston Infectious Disease Institute (HeiDI), Metro North Health, Brisbane, Australia
| | - Suzanne L Parker
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, 4029, Australia
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Premachandra A, Moine P. Antibiotics in anesthesia and critical care. Ann Transl Med 2024; 12:6. [PMID: 38304898 PMCID: PMC10777233 DOI: 10.21037/atm-22-5585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 11/06/2023] [Indexed: 02/03/2024]
Abstract
Sepsis is life-threatening organ dysfunction due to a dysregulated host response to an underlying acute infection. Sepsis is a major worldwide healthcare problem. An annual estimated 48.9 million incident cases of sepsis is reported, with 11 million (20%) sepsis-related deaths. Administration of appropriate antimicrobials is one of the most effective therapeutic interventions to reduce mortality. The severity of illness informs the urgency of antimicrobial administration. Nevertheless, even used properly, they cause adverse effects and contribute to the development of antibiotic resistance. Both inadequate and unnecessarily broad empiric antibiotics are associated with higher mortality and also select for antibiotic-resistant germs. In this narrative review, we will first discuss important factors and potential confounders which may influence the occurrence of surgical site infection (SSI) and which should be considered in the provision of perioperative antibiotic prophylaxis (PAP). Then, we will summarize recent advances and perspectives to optimize antibiotic therapy in the intensive care unit (ICU). Finally, the major role of the microbiota and the impact of antimicrobials on it will be discussed. While expert recommendations help guide daily practice in the operating theatre and ICU, a thorough knowledge of pharmacokinetic/pharmacodynamic (PK/PD) rules is critical to optimize the management of complex patients and minimize the emergence of multidrug-resistant organisms.
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Affiliation(s)
- Antoine Premachandra
- Department of Intensive Care, Hôpital Raymond Poincaré, Groupe Hospitalo-Universitaire GHU AP-HP, University Versailles Saint Quentin-University Paris-Saclay, Garches, France
| | - Pierre Moine
- Department of Intensive Care, Hôpital Raymond Poincaré, Groupe Hospitalo-Universitaire GHU AP-HP, University Versailles Saint Quentin-University Paris-Saclay, Garches, France
- Laboratory of Infection & Inflammation - U1173, University of Versailles Saint-Quentin-en-Yvelines (UVSQ) - University Paris-Saclay - Institut National de la Santé et de la Recherche Médicale (INSERM), Garches, France
- Fédération Hospitalo-Universitaire FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for Sepsis), Garches, France
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Zelenitsky SA. Effective Antimicrobial Prophylaxis in Surgery: The Relevance and Role of Pharmacokinetics-Pharmacodynamics. Antibiotics (Basel) 2023; 12:1738. [PMID: 38136772 PMCID: PMC10741006 DOI: 10.3390/antibiotics12121738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
Appropriate surgical antimicrobial prophylaxis (SAP) is an important measure in preventing surgical site infections (SSIs). Although antimicrobial pharmacokinetics-pharmacodynamics (PKPD) is integral to optimizing antibiotic dosing for the treatment of infections, there is less research on preventing infections postsurgery. Whereas clinical studies of SAP dose, preincision timing, and redosing are informative, it is difficult to isolate their effect on SSI outcomes. Antimicrobial PKPD aims to explain the complex relationship between antibiotic exposure during surgery and the subsequent development of SSI. It accounts for the many factors that influence the PKs and antibiotic concentrations in patients and considers the susceptibilities of bacteria most likely to contaminate the surgical site. This narrative review examines the relevance and role of PKPD in providing effective SAP. The dose-response relationship i.e., association between lower dose and SSI in cefazolin prophylaxis is discussed. A comprehensive review of the evidence for an antibiotic concentration-response (SSI) relationship in SAP is also presented. Finally, PKPD considerations for improving SAP are explored with a focus on cefazolin prophylaxis in adults and outstanding questions regarding its dose, preincision timing, and redosing during surgery.
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Affiliation(s)
- Sheryl A. Zelenitsky
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0T5, Canada;
- Department of Pharmacy, St. Boniface Hospital, Winnipeg, MB R2H 2A6, Canada
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Giamarellou H, Galani L, Karavasilis T, Ioannidis K, Karaiskos I. Antimicrobial Stewardship in the Hospital Setting: A Narrative Review. Antibiotics (Basel) 2023; 12:1557. [PMID: 37887258 PMCID: PMC10604258 DOI: 10.3390/antibiotics12101557] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
The increasing global threat of antibiotic resistance, which has resulted in countless fatalities due to untreatable infections, underscores the urgent need for a strategic action plan. The acknowledgment that humanity is perilously approaching the "End of the Miracle Drugs" due to the unjustifiable overuse and misuse of antibiotics has prompted a critical reassessment of their usage. In response, numerous relevant medical societies have initiated a concerted effort to combat resistance by implementing antibiotic stewardship programs within healthcare institutions, grounded in evidence-based guidelines and designed to guide antibiotic utilization. Crucial to this initiative is the establishment of multidisciplinary teams within each hospital, led by a dedicated Infectious Diseases physician. This team includes clinical pharmacists, clinical microbiologists, hospital epidemiologists, infection control experts, and specialized nurses who receive intensive training in the field. These teams have evidence-supported strategies aiming to mitigate resistance, such as conducting prospective audits and providing feedback, including the innovative 'Handshake Stewardship' approach, implementing formulary restrictions and preauthorization protocols, disseminating educational materials, promoting antibiotic de-escalation practices, employing rapid diagnostic techniques, and enhancing infection prevention and control measures. While initial outcomes have demonstrated success in reducing resistance rates, ongoing research is imperative to explore novel stewardship interventions.
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Affiliation(s)
- Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Lamprini Galani
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Theodoros Karavasilis
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Konstantinos Ioannidis
- Clinical Pharmacists, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece;
| | - Ilias Karaiskos
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
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Mendoza MA, Ranganath N, Garcia BB, Stevens RW, Lahr B, O’Horo J, Stulak J, Shah A. Left Ventricular Assist Device: Review of Antimicrobial Prophylaxis Strategies and Incidence of Infections at a Tertiary Care Center 12-Year Experience. Open Forum Infect Dis 2023; 10:ofad465. [PMID: 37732167 PMCID: PMC10508979 DOI: 10.1093/ofid/ofad465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/06/2023] [Indexed: 09/22/2023] Open
Abstract
Background Left ventricular assist devices (LVAD) have an associated infection rate of 13%-80% postimplant. An optimal strategy for surgical infection prophylaxis (SIP) at the time of implantation has not been well defined. We aimed to evaluate the different LVAD implantation antibiotic prophylaxis regimens as well as the incidence of LVAD infection at our institution. Methods We performed a single-center, retrospective study of patients who underwent LVAD implantation between February 2007 and June 2019. The primary outcome was the incidence of LVAD infection (LVADI), within 3 months and 1 year of placement, between patients who received expanded or narrow-spectrum regimens for SIP. We assessed outcomes using Kaplan-Meier, time-to-first event. We used a noninferiority analysis, which was established if the narrow-spectrum event rate was no more than 5% greater than the expanded-spectrum event rate. Results We included 399 patients, 305 (76.4%) patients received narrow-spectrum SIP, whereas the remaining 94 (23.6%) patients received the expanded-spectrum regimen. Statistical noninferiority of the narrow spectrum to the multiple drug regimen was demonstrated at both time points, and statistical superiority of the narrow-spectrum group across 12-month follow up was further evident (P = .037). Conclusions We report evidence supporting noninferiority, or even superiority, of the narrow-spectrum over expanded-spectrum antimicrobial prophylaxis strategy with respect to LVADI. These findings support data-driven antimicrobial prophylaxis strategies.
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Affiliation(s)
- Maria Alejandra Mendoza
- Division of Public Health, Infectious Diseases, and Occupational Medicine News, Mayo Clinic, Rochester, Minnesota, USA
| | - Nischal Ranganath
- Division of Public Health, Infectious Diseases, and Occupational Medicine News, Mayo Clinic, Rochester, Minnesota, USA
| | - Bismarck Bisono Garcia
- Division of Public Health, Infectious Diseases, and Occupational Medicine News, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan W Stevens
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian Lahr
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - John O’Horo
- Division of Public Health, Infectious Diseases, and Occupational Medicine News, Mayo Clinic, Rochester, Minnesota, USA
| | - John Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aditya Shah
- Division of Public Health, Infectious Diseases, and Occupational Medicine News, Mayo Clinic, Rochester, Minnesota, USA
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7
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Cabral SM, Harris AD, Cosgrove SE, Magder LS, Tamma PD, Goodman KE. Adherence to Antimicrobial Prophylaxis Guidelines for Elective Surgeries Across 825 US Hospitals, 2019-2020. Clin Infect Dis 2023; 76:2106-2115. [PMID: 36774539 DOI: 10.1093/cid/ciad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND There are limited US data assessing adherence to surgical antimicrobial prophylaxis guidelines, particularly across a large, nationwide sample. Moreover, commonly prescribed inappropriate antimicrobial prophylaxis regimens remain unknown, hindering improvement initiatives. METHODS We conducted a retrospective cohort study of adults who underwent elective craniotomy, hip replacement, knee replacement, spinal procedure, or hernia repair in 2019-2020 at hospitals in the PINC AI (Premier) Healthcare Database. We evaluated adherence of prophylaxis regimens, with respect to antimicrobial agents endorsed in the American Society of Health-System Pharmacist guidelines, accounting for patient antibiotic allergy and methicillin-resistant Staphylococcus aureus colonization status. We used multivariable logistic regression with random effects by hospital to evaluate associations between patient, procedural, and hospital characteristics and guideline adherence. RESULTS Across 825 hospitals and 521 091 inpatient elective surgeries, 308 760 (59%) were adherent to prophylaxis guidelines. In adjusted analysis, adherence varied significantly by US Census division (adjusted OR [aOR] range: .61-1.61) and was significantly lower in 2020 compared with 2019 (aOR: .92; 95% CI: .91-.94; P < .001). The most common reason for nonadherence was unnecessary vancomycin use. In a post hoc analysis, controlling for patient age, comorbidities, other nephrotoxic agent use, and patient and procedure characteristics, patients receiving cefazolin plus vancomycin had 19% higher odds of acute kidney injury (AKI) compared with patients receiving cefazolin alone (aOR: 1.19; 95% CI: 1.11-1.27; P < .001). CONCLUSIONS Adherence to antimicrobial prophylaxis guidelines remains suboptimal, largely driven by unnecessary vancomycin use, which may increase the risk of AKI. Adherence decreased in the first year of the COVID-19 pandemic.
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Affiliation(s)
- Stephanie M Cabral
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Katherine E Goodman
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, Maryland, USA
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Mittal N, Mittal R, Goel N, Parmar A, Bahl A, Kaur S, Gudibanda KR, Dudhraj V, Singh SK. WHO-Point Prevalence Survey of Antibiotic Use Among Inpatients at a Core National Antimicrobial Consumption Network Site in North India: Findings and Implications. Microb Drug Resist 2023; 29:1-9. [PMID: 36656989 DOI: 10.1089/mdr.2022.0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Data on Point Prevalence Surveys (PPSs) in India are limited yet. We report findings of a PPS conducted in a core "National Antimicrobial Consumption Network site" under National Centre for Disease Control - WHO project "Point prevalence survey of antimicrobial consumption at healthcare facilities." A cross-sectional survey was conducted as per the "WHO methodology for PPS on antibiotic use in hospitals" in a tertiary care hospital in India in December 2021. Data were collected using predesigned and pretested questionnaire in separate hospital, ward, and patient forms. Eight hundred two inpatients (excluding ICUs) were covered out of whom 299 (37.3%) were on antibiotics with 11.7% receiving 3 or more antibiotics. Surgical prophylaxis (SP) (42.5%) and community acquired infections (32.8%) were the most common indications for antibiotic use. Of the patients, 92.5% received SP for more than 24 hrs. Most commonly prescribed antibiotics were penicillins with beta-lactamase inhibitors (22.3%). Of the total antibiotic prescriptions, 81.5% were from WHO essential medicines list and 12% from "not recommended" WHO AWaRe classification. Of the antibiotic prescriptions, 84.6% were parenteral. Few prescriptions complied with standard treatment guidelines (1.9%), documented indication for antibiotic use (11.6%), and stop/review date (4.4%) in notes. Double anaerobic cover accounted for 6.8% of the total prescriptions. Some identified areas for improvement were: formulation of hospital antibiotic guidelines, promoting culture of sending cultures, improvement in surgical antibiotic prophylaxis, decreasing use of antibiotic combinations and double anaerobic cover, fostering IV to oral switch of antibiotics, and ensuring effective communication among health care workers by documenting adequate information in medical notes.
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Affiliation(s)
- Niti Mittal
- Department of Pharmacology and Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
| | - Rakesh Mittal
- Department of Pharmacology and Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
| | - Nidhi Goel
- Department of Microbiology, Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
| | - Aparna Parmar
- Department of Microbiology, Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
| | - Arti Bahl
- National Center for Disease Control (NCDC), New Delhi, India
| | - Suneet Kaur
- National Center for Disease Control (NCDC), New Delhi, India
| | | | - Vibhor Dudhraj
- National Center for Disease Control (NCDC), New Delhi, India
| | - Sujeet K Singh
- National Center for Disease Control (NCDC), New Delhi, India
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Housman ST, McWhorter PB, Barie PS, Nicolau DP. Ertapenem Concentrations in Obese Patients Undergoing Surgery. Surg Infect (Larchmt) 2022; 23:545-549. [PMID: 35638999 DOI: 10.1089/sur.2022.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Antimicrobial prophylaxis is a cornerstone to preventing surgical site infections (SSIs). Ertapenem, a carbapenem antibiotic, is commonly used for surgical prophylaxis for many different procedures, including patients undergoing colorectal and other gastrointestinal surgeries. Obesity complicates surgical intervention and increases the risk for SSIs. This study aims to describe the pharmacokinetics of ertapenem for surgical prophylaxis using a population pharmacokinetic model. Patients and Methods: Ten patients were recruited and given a single dose of ertapenem 1 g intravenous over 30 minutes. Plasma samples were obtained at multiple time points over 24 hours and assayed via validated high-performance liquid chromatography (HPLC). Pharmacokinetic analyses were conducted using a population pharmacokinetic analysis to generate pharmacokinetic parameters used in the subsequent 5,000 patient Monte Carlo simulation. The probability of target attainment (PTA) for free drug concentrations remaining above the minimum inhibitory concentration (MIC) for ≥40% was used. Results: The mean maximum plasma concentration and area under the concentration time curve (AUC0-∞) was 40.7 ± 16.5 and 148.8 ± 28.0, respectively, with a half-life of the terminal portion to be 4.3 ± 0.8 hours. Monte Carlo simulations observed PTAs above 90% for MICs ≤0.25 and ≤0.125 mcg/mL in surgeries up to three and four hours, respectively. Sufficiently high PTAs were not attainable for MICs of ≥0.5 mcg/mL. Conclusions: Ertapenem given as 1 g single dose may be an appropriate candidate for surgical prophylaxis in obese patients undergoing surgeries of four hours or less.
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Affiliation(s)
- Seth T Housman
- Western New England University College of Pharmacy and Health Sciences, Springfield, Massachusetts, USA
| | | | - Philip S Barie
- New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA.,Division of Infectious Diseases, Hartford Hospital, Hartford, Connecticut, USA
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Castaman G, Borchiellini A, Coppola A, Cultrera D, Marino R, Federici AB, Giuffrida AC, Marchesini E, Molinari AC, Maria SS, Zanon E. Use of the von Willebrand factor concentrate with low factor VIII content to manage patients with inherited von Willebrand disease requiring surgical or secondary long-term prophylaxis: An expert opinion paper from an Italian panel. Eur J Haematol 2022; 109:121-128. [PMID: 35531770 DOI: 10.1111/ejh.13785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The present review aims to summarize the state-of-the-art von Willebrand disease (VWD) treatment focusing on specific clinical settings (obstetrics, surgery, long-term prophylaxis and comorbidities) as well as on the use of a Von Willebrand factor (VWF) concentrate with low FVIII content. METHODS Literature research and case reports. RESULTS AND CONCLUSIONS Considering that patients affected by VWD have an intact ability to synthesize FVIII, in order to avoid excessive levels of FVIII, a highly purified plasma VWF concentrate with low FVIII content could be particularly useful in those patients and clinical circumstances at high thrombotic risk as well as for long-term prophylaxis. When deciding the optimal therapeutic strategy, physicians should take into account both the patient's history and the differences among available concentrates according to the clinical situations requiring treatment.
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Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Alessandra Borchiellini
- RRC Thrombosis & Haemophilia Centre, AOU Città della Salute e della Scienza - Molinette Hospital, Turin, Italy
| | - Antonio Coppola
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Dorina Cultrera
- Department of Haematology, Haemophilia Regional Reference Centre, University Hospital of Catania, Catania, Italy
| | - Renato Marino
- Haemophilia and Thrombosis Centre, Policlinico Giovanni XXIII, Bari, Italy
| | - Augusto B Federici
- Division of Haematology and Transfusion Medicine, L. Sacco University Hospital and Department of Oncology and Haematology Oncology, University of Milan, Milan, Italy
| | | | - Emanuela Marchesini
- Department of Vascular and Emergency Medicine, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Angelo Claudio Molinari
- Regional Reference Centre for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Siboni Simona Maria
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Milan, Italy
| | - Ezio Zanon
- Haemophilia Center, General Medicine, Department of Medicine, University of Padua Medical School, Padua, Italy
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Baráth B, Jász DK, Horváth T, Baráth B, Maróti G, Strifler G, Varga G, Sándor L, Perényi D, Tallósy S, Donka T, Jávor P, Boros M, Hartmann P. Mitochondrial Side Effects of Surgical Prophylactic Antibiotics Ceftriaxone and Rifaximin Lead to Bowel Mucosal Damage. Int J Mol Sci 2022; 23:5064. [PMID: 35563455 DOI: 10.3390/ijms23095064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/28/2022] [Accepted: 04/30/2022] [Indexed: 02/04/2023] Open
Abstract
Despite their clinical effectiveness, a growing body of evidence has shown that many classes of antibiotics lead to mitochondrial dysfunction. Ceftriaxone and Rifaximin are first choice perioperative antibiotics in gastrointestinal surgery targeting fundamental processes of intestinal bacteria; however, may also have negative consequences for the host cells. In this study, we investigated their direct effect on mitochondrial functions in vitro, together with their impact on ileum, colon and liver tissue. Additionally, their impact on the gastrointestinal microbiome was studied in vivo, in a rat model. Rifaximin significantly impaired the oxidative phosphorylation capacity (OxPhos) and leak respiration in the ileal mucosa, in line with increased oxidative tissue damage and histological changes following treatment. Ceftriaxone prophylaxis led to similar changes in the colon mucosa. The composition and diversity of bacterial communities differed extensively in response to antibiotic pre-treatment. However, the relative abundances of the toxin producing species were not increased. We have confirmed the harmful effects of prophylactic doses of Rifaximin and Ceftriaxone on the intestinal mucosa and that these effects were related to the mitochondrial dysfunction. These experiments raise awareness of mitochondrial side effects of these antibiotics that may be of clinical importance when evaluating their adverse effects on bowel mucosa.
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12
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Lim CY, Alonso A, Koh YY, Roydhouse S, McCormack L, Deans R, Nesbitt-Hawes E, Rao A, Causer L, Abbott JA. A Double-Blinded, Randomised, Placebo-Controlled Trial of Antibiotic Prophylaxis in Elective Non-Hysterectomy Laparoscopic Surgery for Benign Gynaecological Conditions: A Pilot Study. J Minim Invasive Gynecol 2022; 29:992-997. [PMID: 35513301 DOI: 10.1016/j.jmig.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE To determine the feasibility of a double-blinded randomised, placebo-controlled study in determining the efficacy of antibiotic prophylaxis in preventing postoperative infections (POI) in elective non-hysterectomy laparoscopic procedures for benign gynaecological conditions. DESIGN Double-blinded, randomised, placebo-controlled trial. SETTING University-affiliated tertiary referral hospital in Sydney, Australia. PATIENTS Women over the age of 18 undergoing elective non-hysterectomy laparoscopic procedures for benign gynaecological conditions were eligible for the study and approached. INTERVENTIONS Prior to surgery, participants were randomised to receive either 2g cephazolin or placebo (10ml normal saline) administered by the anaesthetist. Participants and other research staff were blinded to group allocation. MEASUREMENTS AND MAIN RESULTS The primary outcome was study feasibility measured by recruitment rates, compliance rates of drug administration, compliance rates of delivery, maintenance of double blinding and follow-up rates. Secondary outcomes included rate of postoperative infections, length of hospitalisation, re-admission to hospital, unscheduled presentations to healthcare facilities and antibiotic-related reactions. Between February 2019 and March 2021, 170 patients were approached with 117 (68.8%) participants recruited and randomised. The study had a high compliance rate of trial drug delivery (95.7%) and a high follow-up rate (99.1%). CONCLUSION This pilot study has demonstrated feasibility of a large-scale study with a recruitment rate of 68% of patients approached and excellent trial drug delivery and follow-up rates. As anticipated, it is underpowered for identifying clinically significant findings for postoperative infection rates. A large-scale study is appropriate and essential to determine the health-related risks of antibiotic prophylaxis with an emphasis on antimicrobial stewardship. The sample size for a large-scale study is 1678 participants based on infection rates in this pilot study.
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Affiliation(s)
- Claire Yinn Lim
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Anaïs Alonso
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Yi Ying Koh
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Stephanie Roydhouse
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Lalla McCormack
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Rebecca Deans
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Erin Nesbitt-Hawes
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Archana Rao
- Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Louise Causer
- Kirby Institute, UNSW Sydney, New South Wales, Australia
| | - Jason A Abbott
- School of Women's and Children's Health, UNSW Sydney, New South Wales, Australia; The Gynaecological Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia.
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13
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Ting JY, Autmizguine J, Dunn MS, Choudhury J, Blackburn J, Gupta-Bhatnagar S, Assen K, Emberley J, Khan S, Leung J, Lin GJ, Lu-Cleary D, Morin F, Richter LL, Viel-Thériault I, Roberts A, Lee KS, Skarsgard ED, Robinson J, Shah PS. Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective. Front Pediatr 2022; 10:894005. [PMID: 35874568 PMCID: PMC9304938 DOI: 10.3389/fped.2022.894005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.
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Affiliation(s)
- Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Autmizguine
- Division of Infectious Diseases, Department of Pediatrics, Université de Montreal, Montreal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, QC, Canada
| | - Michael S Dunn
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Julie Choudhury
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Julie Blackburn
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montreal, Montreal, QC, Canada
| | - Shikha Gupta-Bhatnagar
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Katrin Assen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Emberley
- Division of Neonatology, Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Sarah Khan
- Department of Microbiology, McMaster University, Hamilton, ON, Canada
| | - Jessica Leung
- Department of Pediatrics, University of Massachusetts, Worcester, MA, United States
| | - Grace J Lin
- School of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Frances Morin
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay L Richter
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Ashley Roberts
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kyong-Soon Lee
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joan Robinson
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Prakesh S Shah
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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14
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Lasko MJ, Serrano OK, Kois AK, Nicolau DP, Kuti JL. Effect of Blood Product Resuscitation on the Pharmacokinetics of Ampicillin-Sulbactam during Orthotopic Liver Transplantation. Surg Infect (Larchmt) 2021; 23:119-126. [PMID: 34818052 DOI: 10.1089/sur.2021.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Ampicillin-sulbactam is a piperacillin-tazobactam-sparing alternative antibiotic administered as surgical prophylaxis during orthotopic liver transplant (OLT), but limited data are available describing its pharmacokinetics and impact of blood product resuscitation. The purpose of this study was to determine the intra-operative pharmacokinetics of ampicillin-sulbactam in patients during OLT and evaluate the effects of blood resuscitation on exposure. Patients and Methods: This was a pharmacokinetic study in 10 OLT patients receiving ampicillin-sulbactam surgical prophylaxis. A 5,000-patient Monte Carlo simulation was conducted to identify optimal ampicillin-sulbactam regimens. Linear regression assessed association between blood product administration and ampicillin exposures. Results: Ampicillin and sulbactam concentrations best fitted two-compartment models. Mean ampicillin pharmacokinetic parameters were central compartment volume (Vc): 6.9 ± 2.0 L, clearance (CL): 26.6 ± 18.4 L/h, and inter-compartmental rate constants (k12 and k21): 4.8 ± 2.6 and 2.3 ± 1.4 h-1. Sulbactam pharmacokinetic parameters were Vc: 8.1 ± 2.7 L, CL: 26.1 ± 7.4 L/h, k12 and k21: 4.9 ± 1.0 and 2.8 ± 1.1 h-1. Participants received between 500 and 23,642 mL of total blood product. No statistical relations were observed between blood product administration and exposures (R2 0.00-0.26). Ampicillin-sulbactam 2/1 g every two hours and 2/1 g bolus followed by 6/3 g continuous infusion provided acceptable probability of target attainment up to minimum inhibitory concentrations (MICs) of 16 and 32 mcg/mL, respectively. Conclusions: High and frequent ampicillin-sulbactam doses are required to maintain 100% fT > MIC at relevant MICs during OLT and no impact of blood product resuscitation was observed on ampicillin exposure. These are the first data available to guide ampicillin-sulbactam dosing in patients undergoing OLT.
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Affiliation(s)
- Maxwell J Lasko
- Center for Anti-Infective Research and Development, Hartford Hospital, Harford, Connecticut, USA
| | - Oscar K Serrano
- Transplant and Comprehensive Liver Center, Hartford Hospital, Harford, Connecticut, USA.,University of Connecticut School of Medicine, Department of Surgery, Farmington, Connecticut, USA
| | - Abigail K Kois
- Center for Anti-Infective Research and Development, Hartford Hospital, Harford, Connecticut, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Harford, Connecticut, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Harford, Connecticut, USA
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15
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Bertram CM, Postelnick M, Mancini CM, Fu X, Zhang Y, Schulz LT, Bhowmick T, Lee F, Blumenthal KG. Association of β-Lactam Allergy Documentation and Prophylactic Antibiotic Use in Surgery: A National Cross-Sectional Study of Hospitalized Patients. Clin Infect Dis 2021; 72:e872-e875. [PMID: 33242095 DOI: 10.1093/cid/ciaa1762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Indexed: 11/14/2022] Open
Abstract
Alternative antibiotics for surgical prophylaxis are associated with increased adverse events and surgical site infection compared to cefazolin. In a sample of perioperative inpatients from 100 hospitals in the United States, cefazolin was 9-fold less likely to be used in patients with a documented β-lactam allergy whereas clindamycin was 45-fold more likely.
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Affiliation(s)
- Christie M Bertram
- Northwestern Memorial Hospital, Department of Pharmacy, Chicago, Illinois, USA.,Department of Pharmacy Practice, College of Pharmacy, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Michael Postelnick
- Northwestern Memorial Hospital, Department of Pharmacy, Chicago, Illinois, USA
| | - Christian M Mancini
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yuqing Zhang
- The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Clinical Epidemiology Research and Training, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lucas T Schulz
- Department of Pharmacy, University of Wisconsin Health, Madison, Wisconsin, USA
| | - Tanaya Bhowmick
- Division of Allergy, Immunology, and Infectious Diseases, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Francesca Lee
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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16
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Collins CD, Scheidel C, Anam K, Polega S, Malani AN, Hayward A, Leo HL, Shankar T, Morrin C, Brockhaus K. Impact of an Antibiotic Side-Chain-Based Cross-reactivity Chart Combined With Enhanced Allergy Assessment Processes for Surgical Prophylaxis Antimicrobials in Patients With β-Lactam Allergies. Clin Infect Dis 2021; 72:1404-1412. [PMID: 32155264 DOI: 10.1093/cid/ciaa232] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND β-Lactam antibiotics are first-line therapy for perioperative prophylaxis; however, patient-reported allergies often lead to increased prescribing of alternative antibiotics that may increase the incidence of surgical site infections. The R-group side chain of the β-lactam ring is responsible for allergic cross-reactivity and experts recommend the use of β-lactams that are structurally dissimilar. METHODS An internally developed, antibiotic side-chain-based cross-reactivity chart was developed and implemented alongside enhanced allergy assessment processes. This single-center, quasi-experimental study analyzed antibiotic prescribing in all adult patients with a documented β-lactam allergy undergoing an inpatient surgical procedure between quartile (Q) 1 (2012)-Q3 (2014) (historical group) and Q3 (2016)-Q3 (2018) (intervention group). Propensity-weighted scoring analyses compared categorical and continuous outcomes. Interrupted time-series analysis further analyzed key outcomes. RESULTS A total of 1119 and 1089 patients were included in the historical and intervention cohorts, respectively. There was a significant difference in patients receiving a β-lactam alternative antibiotic between cohorts (84.9% vs 15.1%; P < .001). There was a decrease in 30-day readmissions in the intervention cohort (7.9% vs 6.3%; P = .035); however, there was no difference in the incidence of SSIs in patients readmitted (14.8% vs 13%; P = .765). No significant differences were observed in allergic reactions (0.5% vs 0.3%; P = .323), surgical site infections, in-hospital and 30-day mortality, healthcare facility-onset Clostridiodes difficile infection, acute kidney injury, or hospital costs. CONCLUSIONS Implementation of an antibiotic cross-reactivity chart combined with enhanced allergy assessment processes significantly improved the prescribing of β-lactam antibiotics for surgical prophylaxis.
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Affiliation(s)
- Curtis D Collins
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Caleb Scheidel
- Methods Consultants of Ann Arbor, Ypsilanti, Michigan, USA
| | - Kishore Anam
- Michigan Data Analytics, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Shikha Polega
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Division of Infectious Diseases, Department of Internal Medicine, St Joseph Mercy Health System, Ann Arbor, Michigan, USA.,Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Alexandra Hayward
- Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Harvey L Leo
- Allergy and Immunology Associates of Ann Arbor, PC, Ann Arbor, Michigan, USA
| | - Tara Shankar
- Allergy and Immunology Associates of Ann Arbor, PC, Ann Arbor, Michigan, USA
| | - Cheryl Morrin
- Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Kara Brockhaus
- Department of Pharmacy Services, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
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17
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Heffernan A, Alawie J, Wallis SC, Naicker S, Adiraju S, Roberts JA, Sime FB. Pharmacodynamic Evaluation of a Single Dose versus a 24-Hour Course of Multiple Doses of Cefazolin for Surgical Prophylaxis. Antibiotics (Basel) 2021; 10:602. [PMID: 34069492 PMCID: PMC8161008 DOI: 10.3390/antibiotics10050602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/15/2021] [Accepted: 05/16/2021] [Indexed: 11/16/2022] Open
Abstract
The optimal perioperative duration for the administration of cefazolin and other prophylactic antibiotics remains unclear. This study aimed to describe the pharmacodynamics of cefazolin for a single 2 g dose versus a 24 h course of a 2 g single dose plus a 1 g eight-hourly regimen against methicillin-susceptible Staphylococcus aureus. Static concentration time-kill assay and a dynamic in vitro hollow-fibre infection model simulating humanised plasma and interstitial fluid exposures of cefazolin were used to characterise the pharmacodynamics of prophylactic cefazolin regimens against methicillin-sensitive Staphylococcus aureus clinical isolates. The initial inoculum was 1 × 105 CFU/mL to mimic a high skin flora inoculum. The static time-kill study showed that increasing the cefazolin concentration above 1 mg/L (the MIC) did not increase the rate or the extent of bacterial killing. In the dynamic hollow-fibre model, both dosing regimens achieved similar bacterial killing (~3-log CFU/mL within 24 h). A single 2 g dose may be adequate when low bacterial burdens (~104 CFU/mL) are anticipated in an immunocompetent patient with normal pharmacokinetics.
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Affiliation(s)
- Aaron Heffernan
- School of Pharmacy, The University of Queensland, Woolloongabba, Brisbane, QLD 4103, Australia; (A.H.); (J.A.)
- School of Medicine, Griffith University, Southport, Gold Cost, QLD 4222, Australia
| | - Jowana Alawie
- School of Pharmacy, The University of Queensland, Woolloongabba, Brisbane, QLD 4103, Australia; (A.H.); (J.A.)
| | - Steven C Wallis
- University of Queensland Centre for Clinical Research, Faculty of Medicine, University of Queensland, Herston, Brisbane, QLD 4029, Australia; (S.C.W.); (S.N.); (S.A.); (J.A.R.)
| | - Saiyuri Naicker
- University of Queensland Centre for Clinical Research, Faculty of Medicine, University of Queensland, Herston, Brisbane, QLD 4029, Australia; (S.C.W.); (S.N.); (S.A.); (J.A.R.)
| | - Santosh Adiraju
- University of Queensland Centre for Clinical Research, Faculty of Medicine, University of Queensland, Herston, Brisbane, QLD 4029, Australia; (S.C.W.); (S.N.); (S.A.); (J.A.R.)
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, University of Queensland, Herston, Brisbane, QLD 4029, Australia; (S.C.W.); (S.N.); (S.A.); (J.A.R.)
- Department of Intensive Care Medicine and Pharmacy Department, Royal Brisbane and Women’s Hospital, Herston, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30900 Nîmes, France
| | - Fekade Bruck Sime
- School of Pharmacy, The University of Queensland, Woolloongabba, Brisbane, QLD 4103, Australia; (A.H.); (J.A.)
- University of Queensland Centre for Clinical Research, Faculty of Medicine, University of Queensland, Herston, Brisbane, QLD 4029, Australia; (S.C.W.); (S.N.); (S.A.); (J.A.R.)
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18
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Skosana PP, Schellack N, Godman B, Kurdi A, Bennie M, Kruger D, Meyer JC. A point prevalence survey of antimicrobial utilisation patterns and quality indices amongst hospitals in South Africa; findings and implications. Expert Rev Anti Infect Ther 2021; 19:1353-1366. [PMID: 33724147 DOI: 10.1080/14787210.2021.1898946] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objectives: Antimicrobial use is growing, driven mainly by rising demands in developing countries. Knowing how antimicrobials are prescribed is important. Consequently, we undertook a point prevalence survey (PPS) quantifying antimicrobial consumption among 18 public sector hospitals across South Africa.Method: A purpose-built web-based application was used to collect PPS data.Results: Out of 4407 adult patients surveyed, 33.6% were treated with an antimicrobial. The most frequently prescribed groups were a combination of penicillins including β-lactamase inhibitors. Amoxicillin combined with an enzyme inhibitor accounted for 21.4% total DDDs. In the medical and surgical wards, Access antimicrobials (54.1%) were mostly used, while in the ICU, Watch antimicrobials (51.5%) were mostly used. Compliance with the South African Standard Treatment Guidelines and Essential Medicines List was 90.2%; however, concerns with extended use of antimicrobials for surgical prophylaxis (73.2% of patients).Conclusion: The web-based PPS tool was easy to use and successful in capturing PPS data since the results were comparable to other PPS studies across Africa. High use of amoxicillin combined with an enzyme inhibitor, possibly because it was among the broad-spectrum antimicrobials in the Access group. The findings will assist with future targets to improve antimicrobial prescribing among public sector hospitals in South Africa.
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Affiliation(s)
- P P Skosana
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Gauteng, South Africa
| | - N Schellack
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Gauteng, South Africa
| | - B Godman
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Gauteng, South Africa.,Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.,Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - A Kurdi
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.,Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
| | - M Bennie
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - D Kruger
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Gauteng, South Africa
| | - J C Meyer
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Gauteng, South Africa
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19
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Calò F, Onorato L, Macera M, Di Caprio G, Monari C, Russo A, Galdieri A, Giordano A, Cuccaro P, Coppola N. Impact of an Education-Based Antimicrobial Stewardship Program on the Appropriateness of Antibiotic Prescribing: Results of a Multicenter Observational Study. Antibiotics (Basel) 2021; 10:antibiotics10030314. [PMID: 33803069 PMCID: PMC8002962 DOI: 10.3390/antibiotics10030314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/07/2021] [Accepted: 03/16/2021] [Indexed: 12/16/2022] Open
Abstract
To evaluate the effect that an education-based Antimicrobial stewardship program (ASP) implemented in two hospitals in southern Italy had on the quality and appropriateness of antibiotic prescription. We conducted a multicenter observational study in two hospitals in the Campania region. Only some departments of both hospitals were already participating in the ASP. We collected data on all patients admitted on the day of evaluation in antibiotic therapy or prophylaxis through a case report form. The primary outcome was to investigate the difference in the appropriateness of the antibiotic prescriptive practice in the departments that had joined the ASP and in those that had not participated in the project (non-ASP). The total number of patients assessed was 486. Of these, 78 (16.05%) were in antibiotic prophylaxis and 130 (26.7%) in antibiotic therapy. The prescriptive appropriateness was better in the units that had joined ASP than in those that had not, with respectively 65.8% versus 22.7% (p < 0.01). Patients in the non-ASP units more frequently received unnecessary antibiotics (44.9% versus 0%, p = 0.03) and, as surgical prophylaxis, the use of antibiotics not recommended by the guidelines (44.2% versus 0%, p = 0.036). Multivariable analysis of the factors associated with prescriptive appropriateness identified ASP units (p = 0.02) and bloodstream or cardiovascular infections (p = 0.03) as independent predictors of better prescriptive appropriateness. The findings of the present study reinforce the importance of adopting an educational ASP to improve the quality of antimicrobial prescription in clinical practice.
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Affiliation(s)
- Federica Calò
- Department of Mental Health and Public Medicine–Infectious Diseases Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (F.C.); (L.O.); (M.M.); (C.M.); (A.R.)
| | - Lorenzo Onorato
- Department of Mental Health and Public Medicine–Infectious Diseases Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (F.C.); (L.O.); (M.M.); (C.M.); (A.R.)
- Infectious Diseases Unit, AORN Sant’Anna and San Sebastiano, 81100 Caserta, Italy;
| | - Margherita Macera
- Department of Mental Health and Public Medicine–Infectious Diseases Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (F.C.); (L.O.); (M.M.); (C.M.); (A.R.)
| | - Giovanni Di Caprio
- Infectious Diseases Unit, AORN Sant’Anna and San Sebastiano, 81100 Caserta, Italy;
| | - Caterina Monari
- Department of Mental Health and Public Medicine–Infectious Diseases Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (F.C.); (L.O.); (M.M.); (C.M.); (A.R.)
| | - Antonio Russo
- Department of Mental Health and Public Medicine–Infectious Diseases Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (F.C.); (L.O.); (M.M.); (C.M.); (A.R.)
| | - Anna Galdieri
- Direzione Sanitaria, AOU Vanvitelli, 80138 Naples, Italy;
| | | | - Patrizia Cuccaro
- Direzione Sanitaria, AORN Sant’Anna and San Sebastiano, 81100 Caserta, Italy;
| | - Nicola Coppola
- Department of Mental Health and Public Medicine–Infectious Diseases Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (F.C.); (L.O.); (M.M.); (C.M.); (A.R.)
- Correspondence: ; Tel.: +39-081-5666223; Fax: +39-081-5666013
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20
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Schmitz ML, Rubino CM, Onufrak NJ, Martinez DV, Licursi D, Karpf A, Cetnarowski W. Pharmacokinetics and Optimal Dose Selection of Cefazolin for Surgical Prophylaxis of Pediatric Patients. J Clin Pharmacol 2020; 61:666-676. [PMID: 33202066 PMCID: PMC8049034 DOI: 10.1002/jcph.1785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/07/2020] [Indexed: 11/25/2022]
Abstract
Cefazolin is an antibiotic frequently used for perioperative prophylaxis. Data from healthy adults and pediatric surgery patients were pooled to refine a previously developed population pharmacokinetic (PK) model and to determine the optimal body weight cutoff for selecting fixed doses of either 1 or 2 g cefazolin to produce exposures in pediatric surgery patients similar to a single 2‐g dose in adults. Regardless of dose used, cefazolin was well tolerated in pediatric patients. A total of 1102 plasma samples from 62 patients from 3 studies were available to assess the previous model. The pooled data set allowed for simplification of the model such that allometrically scaled clearance and volume parameters were found to provide a robust fit while removing unnecessary covariate relationships. Monte Carlo simulations using the final cefazolin population PK model suggested an optimal weight cutoff of 50 kg, in contrast to the previously suggested 60 kg for a single 2‐g dose. Patients at or above this 50‐kg cutoff would receive a 2‐g dose of cefazolin, and those below 50 kg but ≥25 kg would receive a 1‐g dose of cefazolin.
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Affiliation(s)
| | - Christopher M Rubino
- Institute for Clinical Pharmacodynamics, Inc., Schenectady, New York, USA.,University at Buffalo, Buffalo, New York, USA
| | - Nikolas J Onufrak
- Institute for Clinical Pharmacodynamics, Inc., Schenectady, New York, USA.,Boehringer Ingelheim, Ridgefield, Connecticut, USA
| | | | | | - Angela Karpf
- B. Braun Medical Inc., Allentown, Pennsylvania, USA
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21
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Machowska A, Landstedt K, Stålsby Lundborg C, Sharma M. Antibiotic Prescribing to Patients with Infectious and Non-Infectious Indications Admitted to Obstetrics and Gynaecology Departments in Two Tertiary Care Hospitals in Central India. Antibiotics (Basel) 2020; 9:E464. [PMID: 32751558 PMCID: PMC7459830 DOI: 10.3390/antibiotics9080464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Patients admitted to obstetrics and gynaecology (OBGY) departments are at high risk of infections and subsequent antibiotic prescribing, which may contribute to antibiotic resistance (ABR). Although antibiotic surveillance is one of the cornerstones to combat ABR, it is rarely performed in low- and middle-income countries. Aim: To describe and compare antibiotic prescription patterns among the inpatients in OBGY departments of two tertiary care hospitals, one teaching (TH) and one nonteaching (NTH), in Central India. Methods: Data on patients' demographics, diagnoses and prescribed antibiotics were collected prospectively for three years. Patients were divided into two categories- infectious and non-infectious diagnosis and were further divided into three groups: surgical, nonsurgical and possible-surgical indications. The data was coded based on the Anatomical Therapeutic Chemical classification system, and the International Classification of Disease system version-10 and Defined Daily Doses (DDDs) were calculated per 1000 patients. Results: In total, 5558 patients were included in the study, of those, 81% in the TH and 85% in the NTH received antibiotics (p < 0.001). Antibiotics were prescribed frequently to the inpatients in the nonsurgical group without any documented bacterial infection (TH-71%; NTH-75%). Prescribing of broad-spectrum, fixed-dose combinations (FDCs) of antibiotics was more common in both categories in the NTH than in the TH. Overall, higher DDD/1000 patients were prescribed in the TH in both categories. Conclusions: Antibiotics were frequently prescribed to the patients with no documented infectious indications. Misprescribing of the broad-spectrum FDCs of antibiotics and unindicated prescribing of antibiotics point towards threat of ABR and needs urgent action. Antibiotics prescribed to the inpatients having nonbacterial infection indications is another point of concern that requires action. Investigation of underlying reasons for prescribing antibiotics for unindicated diagnoses and the development and implementation of antibiotic stewardship programs are recommended measures to improve antibiotic prescribing practice.
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Affiliation(s)
- Anna Machowska
- Department of Global Public Health, Health Systems and Policy, Karolinska Institutet, Tomtebodavägen 18A, 17177 Stockholm, Sweden; (A.M.); (K.L.); (C.S.L.)
| | - Kristoffer Landstedt
- Department of Global Public Health, Health Systems and Policy, Karolinska Institutet, Tomtebodavägen 18A, 17177 Stockholm, Sweden; (A.M.); (K.L.); (C.S.L.)
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Health Systems and Policy, Karolinska Institutet, Tomtebodavägen 18A, 17177 Stockholm, Sweden; (A.M.); (K.L.); (C.S.L.)
| | - Megha Sharma
- Department of Global Public Health, Health Systems and Policy, Karolinska Institutet, Tomtebodavägen 18A, 17177 Stockholm, Sweden; (A.M.); (K.L.); (C.S.L.)
- Department of Pharmacology, Ruxmaniben Deepchand Gardi Medical College, Ujjain 456006, India
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22
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Pough K, Bhakta R, Maples H, Honeycutt M, Vijayan V. Evaluation of Pediatric Surgical Site Infections Associated with Colorectal Surgeries at an Academic Children's Hospital. Healthcare (Basel) 2020; 8:healthcare8020091. [PMID: 32283686 PMCID: PMC7348892 DOI: 10.3390/healthcare8020091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/04/2020] [Accepted: 04/05/2020] [Indexed: 01/22/2023] Open
Abstract
Appropriate use of antibiotic prophylaxis (AP) is a key measure for the prevention of surgical site infections (SSI) in colorectal surgeries; however, despite the presence of national and international guidelines, compliance with AP recommendations remains low. The purpose of this study is to evaluate compliance with recommendations for the use of AP in children undergoing colorectal surgeries and to evaluate the effectiveness of antibiotics in the prevention of SSI. We collected demographic and clinical characteristics of patients who underwent colorectal surgeries, as well as microbiological and antimicrobial susceptibility data for patients who developed SSI. AP data were collected and compared with national guidelines. Antibiotic dosing and duration were most frequently in concordance with national guidelines, while antibiotic timing and selection had the lowest rates of compliance. Twelve of the 192 colorectal procedures evaluated resulted in SSI. Only 2 of the 12 children with SSI received appropriate AP for all four categories evaluated. Eight cases that resulted in SSI were due to organisms not covered by the recommended AP. We identified multiple areas for the improvement of AP in children undergoing colorectal surgery. A multidisciplinary approach to development of standardized protocols, educational interventions, and EHR-based algorithms may facilitate or improve appropriate AP use.
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Affiliation(s)
- Kimberly Pough
- Department of Pharmacy Practice, Arkansas Children’s Hospital, Little Rock, AR 72202, USA;
- Department of Pharmacy Practice, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA
- Correspondence:
| | - Rima Bhakta
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Holly Maples
- Department of Pharmacy Practice, Arkansas Children’s Hospital, Little Rock, AR 72202, USA;
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Michele Honeycutt
- Department of Infection Prevention and Hospital Epidemiology, Arkansas Children’s Hospital, Little Rock, AR 72202, USA;
| | - Vini Vijayan
- Division of Infectious Diseases, Department of Pediatrics, Valley Children’s Hospital, Madera, CA 93636, USA;
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23
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Lissitchkov T, Madan B, Djambas Khayat C, Zozulya N, Ross C, Karimi M, Kavakli K, De Angulo GR, Almomen A, Subramanian K, D'Souza F, Viswabandya A, Hoorfar H, Schwartz BA, Solomon C, Knaub S, Peyvandi F. Fibrinogen concentrate for treatment of bleeding and surgical prophylaxis in congenital fibrinogen deficiency patients. J Thromb Haemost 2020; 18:815-824. [PMID: 31885190 PMCID: PMC7187153 DOI: 10.1111/jth.14727] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/19/2019] [Accepted: 12/26/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Congenital fibrinogen deficiency is an ultra-rare disorder in which patients can experience severe and/or frequent bleeding episodes (BEs). Here, we present the largest prospective study to date on the treatment of this disorder. METHODS Hemostatic efficacy of human fibrinogen concentrate (HFC; FIBRYGA® , Octapharma AG) for treatment of bleeding or surgical prophylaxis was assessed by investigators and adjudicated by an independent data monitoring and endpoint adjudication committee (IDMEAC) according to a four-point scale, using objective criteria. Thromboelastometry maximum clot firmness (MCF) was also determined. RESULTS Twenty-five afibrinogenemia patients were treated with HFC: 24 for on-demand treatment of 89 BEs, and nine as prophylaxis for 12 surgeries. For BEs, treatment success (rating of excellent or good) evaluated by investigators was 96.6% (90% confidence interval [CI], 0.92-0.99; two missing ratings, classified as failures) and by the IDMEAC was 98.9% (90% CI, 0.95-0.999). Mean ± standard deviation (SD) increase in MCF was 5.8 ± 2.5 mm one hour after the first HFC infusion (mean ± SD dose, 61.88 ± 11.73 mg/kg). For the 12 surgeries (median [range] HFC dose/surgery, 85.80 mg/kg [34.09-225.36]), intraoperative and postoperative treatment success were both rated 100% (90% CI, 0.82-1.00) by investigators and the IDMEAC. Three adverse events were possibly treatment related, including a moderate case of thrombosis. There were no deaths, no severe allergic or hypersensitivity reactions, and no clinical evidence of neutralizing antifibrinogen antibodies. CONCLUSIONS Human fibrinogen concentrate was efficacious for on-demand treatment of bleeding and as surgical prophylaxis, with a favorable safety profile, in patients with congenital afibrinogenemia.
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Affiliation(s)
- Toshko Lissitchkov
- Department of Hemorrhagic Diathesis and AnemiaSpecialized Hospital for Active Treatment (SHAT) “Joan Pavel”SofiaBulgaria
| | - Bella Madan
- Centre for Haemostasis & ThrombosisGuy's & St Thomas' NHS Foundation TrustLondonUK
| | | | - Nadezhda Zozulya
- Federal State‐Funded Institution “National Research Center for Hematology” of the Ministry of Healthcare of the Russian FederationMoscowRussia
| | - Cecil Ross
- Department of HematologySt. John's Medical College & HospitalBangaloreIndia
| | | | | | | | - Abdulkareem Almomen
- Centre of Excellence in Thrombosis & HemostasisCollege of Medicine and King Khalid University HospitalKing Saud UniversityRiyadhSaudi Arabia
| | | | - Fulton D'Souza
- Department of HematologySt. John's Medical College & HospitalBangaloreIndia
| | | | | | | | | | - Sigurd Knaub
- Research & Development DepartmentOctapharmaLachenSwitzerland
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
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24
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Li M, Mazzeffi MA, Gammie JS, Banoub M, Pazhani Y, Herr D, Madathil R, Pousatis S, Bathula A. Characterization of Postoperative Infection Risk in Cardiac Surgery Patients With Delayed Sternal Closure. J Cardiothorac Vasc Anesth 2020; 34:1238-1243. [PMID: 32127277 DOI: 10.1053/j.jvca.2020.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the incidence of postoperative infection in cardiac surgery patients who had delayed sternal closure (DSC) with those who had primary sternal closure (PSC) and evaluate the effectiveness of antibiotic prophylaxis in DSC patients. DESIGN Retrospective, observational cohort study with propensity score matching. SETTING Single academic medical center. PARTICIPANTS Cardiothoracic surgery patients, excluding transplantation patients, from a single academic medical center who had DSC or PSC between November 2015 and November 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 2,685 patients who had cardiac surgery with cardiopulmonary bypass, 99 had DSC. Fifty-nine DSC patients met study inclusion criteria, and the final propensity score matched cohort included 57 patients with DSC and 57 patients with PSC. Propensity score matching reduced bias but was unable to balance all covariates. The most common indication for DSC was coagulopathy in 32 of the 57 patients. All patients in the PSC group received routine antibiotic prophylaxis for 48 hours after surgery. Patients in the DSC group received prolonged broadened prophylaxis until 48 hours after sternal closure. Despite prolonged broadened antibiotic prophylaxis, the DSC group had a higher rate of postoperative infection (31.6% v 3.5%; p < 0.005), mainly pneumonia (19.3% v 1.8%; p < 0.005), in the first 30 days after surgery. There was no difference in the incidence of sepsis (5.3% v 0%; p = 0.24), superficial skin and soft tissue infection (1.8% v 1.8%; p = 1), or mediastinitis/deep tissue infection (5.3% v 0%; p = 0.24) in patients with DSC. Seventy-seven percent of causative organisms for infection were Gram-negative bacteria in the matched cohort. CONCLUSION The incidence of postoperative infection, particularly pneumonia, is high in cardiothoracic surgery patients with DSC, even with prolonged broadened antibiotic prophylaxis, but the rate of mediastinitis/deep tissue infection did not appear to be greater with DSC. Additional research is needed into optimal antibiotic prophylaxis in this high-risk group of patients.
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Affiliation(s)
- Matthew Li
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD.
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - James S Gammie
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Mary Banoub
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | | | - Daniel Herr
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Ronson Madathil
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Sheelagh Pousatis
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Allison Bathula
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
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25
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Sganga G, Pea F, Aloj D, Corcione S, Pierangeli M, Stefani S, Rossolini GM, Menichetti F. Acute wound infections management: the 'Don'ts' from a multidisciplinary expert panel. Expert Rev Anti Infect Ther 2020; 18:231-240. [PMID: 32022606 DOI: 10.1080/14787210.2020.1726740] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction: The management of acute wounds may be affected by malpractices leading to poor outcome, prolonged hospital stay and inappropriate use of antibiotic therapy.Areas covered: Acute wound infections are represented by surgical site and post-traumatic infections. The aim of this expert opinion is to identify a list of inadvisable actions and to provide a guide for an optimal management of acute wound infections. A literature search using Pubmed/MEDLINE database was performed. Articles pertaining to areas covered published until December 2019 were selected. We identified the most common malpractices in this setting and, using the Choosing Wisely methodology, we proposed a list of "Don'ts" for an easy use in clinical practice.Expert opinion: Malpractices may occur from the surgical prophylaxis to the discharge of patient. A prolonged surgical prophylaxis, the underestimation of signs and symptoms, the omission of source control, the inappropriate collection of wound swab, the improper use of clinical microbiology and pharmacology, the lack of hygiene measures and the delay of discharge are all factors that may lead to unfavorable outcome. A multidisciplinary approach is needed to optimally manage these patients. The "Don'ts" refer to all professional figures involved in the management of patients with acute wound infections.
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Affiliation(s)
- Gabriele Sganga
- Emergency Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Federico Pea
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Clinical Pharmacology, Santa Maria Della Misericordia University Hospital, Azienda Sanitaria, Universitaria Integrata Di Udine, Udine, Italy
| | - Domenico Aloj
- Department of Traumatology, Hospital of Vercelli, Vercelli, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Marina Pierangeli
- S.O.D. Clinica di Chirurgia Plastica e Ricostruttiva, Ospedale Riuniti of Ancona, Ancona, Italy
| | - Stefania Stefani
- Department of Biomedical and Biotechnological Sciences, Section of Microbiology, University of Catania, Catania, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Microbiology and Virology, Florence Careggi University Hospital, Florence, Italy
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Abstract
Background: Infections caused by Staphylococcus aureus continue to plague surgical patients, whether as surgical site infections or other nosocomial infections that complicate surgical care. The only meaningful methods available to decrease the risk of developing such infections are topical skin antisepsis (pre-operative skin preparation) and peri-operative antibiotic prophylaxis, neither of which offer a panacea. Alternatives to the latter are sought so as to minimize antibiotic selection pressure as a factor in the increasing problem of antimicrobial drug resistance. This review considers the possibility that immunization against S. aureus may offer a viable alternative for prophylaxis. Methods: Review and synthesis of pertinent English-language medical literature. Results: Vaccination against viral pathogens has been in successful clinical use for more than two centuries and was instrumental in the eradication of smallpox and the near-elimination of diseases such as poliomyelitis. Vaccinations against a limited number of bacterial pathogens (e.g., Bordetella pertussis, Clostridium tetanii, Corynebacterium diphtheriae, Haemophilus influenzae type b, Neisseria meningiditis, Streptococcus pneumoniae) have also been introduced with success, whereas others against bacteria are in development (C. difficile, Pseudomonas aeruginosa, S. aureus). Vaccination against S. aureus infection is in current veterinary use (e.g., to prevent mastitis among dairy cattle) but has not been successful to date in human beings despite multiple attempts, although development continues. Conclusions: Because of its complex microbiology, including multiple virulence factors and the ability to evade host immune surveillance, S. aureus presents numerous antigenic targets for vaccine development. Failure of two prior single-antigen vaccines in clinical trials has led to the consensus that future vaccine candidates must be directed against multiple antigens. Two distinct four-antigen vaccines are in clinical trials, but efficacy is yet to be determined.
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Affiliation(s)
- Philip S Barie
- 1 Department of Surgery, Weill Cornell Medicine , New York, New York
- 2 Department of Medicine, Weill Cornell Medicine , New York, New York
| | - Mayur Narayan
- 1 Department of Surgery, Weill Cornell Medicine , New York, New York
| | - Robert G Sawyer
- 3 Department of Surgery, Western Michigan University , Kalamazoo, Michigan
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Kumar-M P, Shafiq N, Kumar P, Gupta A, Malhotra S, M N, Gautam V, Ray P, Gupta R, Gupta V, Deen Yadav T, Verma GR, Singh R, Singh G. Antimicrobial susceptibility patterns of organisms causing secondary abdominal infections in patients with perforated abdominal viscus. Ther Adv Infect Dis 2019; 6:2049936119865796. [PMID: 31391942 PMCID: PMC6669836 DOI: 10.1177/2049936119865796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/03/2019] [Indexed: 11/22/2022] Open
Abstract
Background: Secondary peritonitis, following intestinal perforation, constitutes a significant proportion of cases admitted as a surgical emergency and has a mortality rate of 6–21% worldwide. As a part of an antimicrobial stewardship program, we noted considerable variation among the choice of empirical regimens among such cases. Hence, we conducted a prospective study to generate the evidence for a rational empiric regimen for patients with secondary peritonitis following intestinal perforation. Methods: The study included a complete follow up of 77 cases of secondary peritonitis admitted during a 12 month period. The intraoperative fluid (peritoneal) sample of the patient was sent for culture and sensitivity pattern analysis. Results: The sites of perforation as seen in decreasing order were lower gastrointestinal (GI) (50.6%), upper GI (36.4%), and unclassified (13%). The most common organism found in the intraoperative fluid was Escherichia coli (47.9%) followed by Klebsiella pneumoniae (12.5%). amikacin, cefoperazone-sulbactam, piperacillin-tazobactam and imipenem were sensitive in 22 (out of 23 tested), 5 (out of 9), 13 (out of 13) and 22 (out of 22) isolates of E. coli and 3 (out of 6), 1 (out of 3), 4 (out of 6), 4 (out of 6) isolates of K. pneumoniae, respectively. The most common empirical antibiotic was cefoperazone-sulbactam (38.7%) followed by piperacillin-tazobactam (29.3%). Conclusion: Based on our prospective study, piperacillin-tazobactam or imipenem should be used empirically in patients presenting with complicated intra-abdominal infections secondary to perforated viscus, especially if they have sepsis or septic shock.
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Affiliation(s)
- Praveen Kumar-M
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nusrat Shafiq
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Room No. 4017, Research Block B, Chandigarh 160012, India
| | - Pradeep Kumar
- Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashish Gupta
- Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Samir Malhotra
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Naveen M
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vikas Gautam
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pallab Ray
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Gupta
- Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vikas Gupta
- Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Thakur Deen Yadav
- Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - G R Verma
- Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajinder Singh
- Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Gurpreet Singh
- Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Abstract
OBJECTIVE To review the evidence and provide recommendations on antibiotic prophylaxis for obstetrical procedures. OUTCOMES Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in obstetrical procedures. EVIDENCE Published literature was retrieved through searches of Medline and The Cochrane Library on the topic of antibiotic prophylaxis in obstetrical procedures. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and articles published from January 1978 to June2009 were incorporated in the guideline. Current guidelines published by the American College of Obstetrics and Gynecology were also incorporated. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS Implementation of this guideline should reduce the cost and harm resulting from the administration of antibiotics when they are not required and the harm resulting from failure to administer antibiotics when they would be beneficial. SUMMARY STATEMENTS RECOMMENDATIONS.
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29
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Ho AL, Cannon JGD, Mohole J, Pendharkar AV, Sussman ES, Li G, Edwards MSB, Cheshier SH, Grant GA. Topical vancomycin surgical prophylaxis in pediatric open craniotomies: an institutional experience. J Neurosurg Pediatr 2018; 22:710-715. [PMID: 30141749 DOI: 10.3171/2018.5.peds17719] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 05/30/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVETopical antimicrobial compounds are safe and can reduce cost and complications associated with surgical site infections (SSIs). Topical vancomycin has been an effective tool for reducing SSIs following routine neurosurgical procedures in the spine and following adult craniotomies. However, widespread adoption within the pediatric neurosurgical community has not yet occurred, and there are no studies to report on the safety and efficacy of this intervention. The authors present the first institution-wide study of topical vancomycin following open craniotomy in the pediatric population.METHODSIn this retrospective study the authors reviewed all open craniotomies performed over a period from 05/2014 to 12/2016 for topical vancomycin use, SSIs, and clinical variables associated with SSI. Topical vancomycin was utilized as an infection prophylaxis and was applied as a liquid solution following replacement of a bone flap or after dural closure when no bone flap was reapplied.RESULTSOverall, 466 consecutive open craniotomies were completed between 05/2014 and 12/2016, of which 43% utilized topical vancomycin. There was a 1.5% SSI rate in the nontopical cohort versus 0% in the topical vancomycin cohort (p = 0.045). The number needed to treat was 66. There were no significant differences in risk factors for SSI between cohorts. There were no complications associated with topical vancomycin use.CONCLUSIONSRoutine topical vancomycin administration during closure of open craniotomies can be a safe and effective tool for reducing SSIs in the pediatric neurosurgical population.
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Affiliation(s)
- Allen L Ho
- 1Department of Neurosurgery, Stanford University School of Medicine; and
| | - John G D Cannon
- 1Department of Neurosurgery, Stanford University School of Medicine; and
| | - Jyodi Mohole
- 1Department of Neurosurgery, Stanford University School of Medicine; and
| | - Arjun V Pendharkar
- 1Department of Neurosurgery, Stanford University School of Medicine; and
| | - Eric S Sussman
- 1Department of Neurosurgery, Stanford University School of Medicine; and
| | - Gordon Li
- 1Department of Neurosurgery, Stanford University School of Medicine; and
| | - Michael S B Edwards
- 1Department of Neurosurgery, Stanford University School of Medicine; and.,2Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital Stanford, Stanford, California
| | - Samuel H Cheshier
- 1Department of Neurosurgery, Stanford University School of Medicine; and.,2Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital Stanford, Stanford, California
| | - Gerald A Grant
- 1Department of Neurosurgery, Stanford University School of Medicine; and.,2Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital Stanford, Stanford, California
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Padilla E, Oms L, Espejo E, Gómez L, Pagespetit L, Boada N, Bella F, Pérez J. Rifampin Resistance in Staphylococci after Rifaximin Intake for Surgical Prophylaxis in Elective Colorectal Surgery. Antimicrob Agents Chemother 2018; 62:e01353-18. [PMID: 30249689 DOI: 10.1128/AAC.01353-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/12/2018] [Indexed: 12/20/2022] Open
Abstract
The aim of our study was to determine whether rifampin resistance emerges in human skin staphylococci after oral intake of rifaximin for surgical prophylaxis. Rifampin-resistant staphylococci appeared on the skin of 32 out of 74 patients (43.2%) two weeks after prophylactic treatment with rifaximin. In all cases, the resistant strains were coagulase-negative staphylococci. The resistance completely reverted after three months. This study shows the emergence of transient resistance to rifampin after rifaximin intake.
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Zelenitsky SA, Calic D, Arora RC, Grocott HP, Lakowski TM, Lillico R, Ariano RE. Antimicrobial Prophylaxis for Patients Undergoing Cardiac Surgery: Intraoperative Cefazolin Concentrations and Sternal Wound Infections. Antimicrob Agents Chemother 2018; 62:e01360-18. [PMID: 30150469 DOI: 10.1128/AAC.01360-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 08/20/2018] [Indexed: 11/20/2022] Open
Abstract
This study characterizes the pharmacodynamics of antimicrobial prophylaxis and sternal wound infections following cardiac surgery. Duration of surgery and cefazolin plasma concentration during wound closure were independently associated with surgical site infection at 30 days. Furthermore, a duration of surgery of >346 min and a total cefazolin closure concentration of <104 mg/liter were significant thresholds for an increased risk of infection. This study provides new data that informs dosing strategies for effective antimicrobial prophylaxis (AP) in patients undergoing cardiac surgery with cardiopulmonary bypass.
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Abstract
RATIONALE Anaphylaxis is a very rare event in pregnancy, triggering maternal hypotension leading to intrapartum hypoxic-ischemic encephalopathy in infant. Furthermore, cesarean sections are performed at a high rate in anaphylactic pregnant women. PATIENT CONCERNS A 34-year-old pregnant woman presented with maternal anaphylaxis following prophylactic antibiotic injection for cesarean section. Within a few minutes after initiation of intradermal skin test with cefotetan, the pregnant woman developed generalized itchy rash, chest tightness, and dyspnea. DIAGNOSES Several minutes after the injection of antibiotics, a diffuse urticarial rash was detected over her face and trunk followed by complaints of chest tightness and dyspnea. She was diagnosed with hypotension and hypoxia. Further, fetal heart tones showed bradycardia. A presumptive diagnosis of anaphylactic reaction induced by cefotetan was made for surgical prophylaxis. INTERVENTIONS The patient was managed for anaphylaxis, via administration of epinephrine, glucocorticoid, and antihistamine. Emergency cesarean section performed under general anesthesia resulted in a favorable perinatal outcome for the fetus. OUTCOMES Maternal and fetal outcomes were good after prompt treatment for anaphylaxis and emergency cesarean section. LESSONS This is the first reported case of anaphylaxis following cefotetan administration in pregnancy. Cefotetan, a second-generation cephalosporin, is a commonly prescribed antibiotic used to treat a wide range of bacterial infections. The case demonstrated life-threatening anaphylactic reaction during pregnancy. Even a skin test using antibiotics alone triggered anaphylaxis.
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Affiliation(s)
| | - Aeli Ryu
- Departments of Obstetrics and Gynaecology
| | - Jiwon Min
- Departments of Obstetrics and Gynaecology
| | - Nan Seol Kim
- Anesthesiology and Pain Medicine, Soonchunhyang University College of Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Danan E, Smith J, Kruer RM, Avdic E, Lipsett P, Curless MS, Jarrell AS. Use and Effectiveness of Peri-Operative Cefotetan versus Cefazolin Plus Metronidazole for Prevention of Surgical Site Infection in Abdominal Surgery Patients. Surg Infect (Larchmt) 2018; 19:388-396. [PMID: 29688837 DOI: 10.1089/sur.2018.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Current practice guidelines for antimicrobial prophylaxis in surgery recommend a cephamycin or cefazolin plus metronidazole for various abdominal surgeries. In February 2016, cephamycin drug shortages resulted in a change in The Johns Hopkins Hospital's (JHH) recommendation for peri-operative antibiotic prophylaxis in abdominal surgeries from cefotetan to cefazolin plus metronidazole. The primary objective of this study was to quantify the percentage of abdominal surgeries adherent to JHH peri-operative antibiotic prophylaxis guidelines. A sub-group analysis investigated whether prophylaxis with cefazolin plus metronidazole was associated with a lower rate of surgical site infections (SSIs) versus cefotetan. PATIENTS AND METHODS This retrospective cohort study included adult inpatients who underwent an abdominal surgery at JHH in September 2015 (Study Period I: cefotetan) or February to March 2016 (Study Period II: cefazolin plus metronidazole). RESULTS Two hundred abdominal surgery cases were included in the primary analysis. A subset of 156 surgical cases were included in the sub-group analysis. The overall adherence rate to JHH guidelines was 75% in Study Period I versus 17% in Study Period II (p < 0.001). The largest difference in adherence was attributed to pre-operative administration time (87% vs. 23%, p < 0.001), primarily because of the longer infusion time required for metronidazole. Surgical site infections occurred in 14% (12/83) of surgeries with cefotetan versus 8.2% (6/73) with cefazolin plus metronidazole for prophylaxis (p = 0.19). CONCLUSIONS Adherence to an institution-specific peri-operative antibiotic prophylaxis guideline for abdominal surgeries was limited primarily by the longer infusion time required for pre-operative metronidazole. A higher percentage of SSIs occurred among abdominal surgeries with cefotetan versus cefazolin plus metronidazole for prophylaxis.
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Affiliation(s)
- Eleanor Danan
- 1 Department of Pharmacy, The Johns Hopkins Hospital , Baltimore, Maryland
| | - Janessa Smith
- 2 Department of Pharmacy, Orlando Regional Medical Center , Orlando, Florida
| | - Rachel M Kruer
- 1 Department of Pharmacy, The Johns Hopkins Hospital , Baltimore, Maryland
| | - Edina Avdic
- 1 Department of Pharmacy, The Johns Hopkins Hospital , Baltimore, Maryland.,3 Antimicrobial Stewardship Program, The Johns Hopkins Hospital , Baltimore, Maryland
| | - Pamela Lipsett
- 4 Departments of Surgery, Anesthesiology, Critical Care Medicine , and Nursing, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland
| | - Melanie S Curless
- 5 Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital , Baltimore, Maryland
| | - Andrew S Jarrell
- 1 Department of Pharmacy, The Johns Hopkins Hospital , Baltimore, Maryland
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Skoog G, Struwe J, Cars O, Hanberger H, Odenholt I, Prag M, Skärlund K, Ulleryd P, Erntell M. Repeated nationwide point-prevalence surveys of antimicrobial use in Swedish hospitals: data for actions 2003-2010. ACTA ACUST UNITED AC 2017; 21:30264. [PMID: 27367646 DOI: 10.2807/1560-7917.es.2016.21.25.30264] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 06/23/2016] [Indexed: 11/20/2022]
Abstract
This study sought to analyse antimicrobial pressure, indications for treatment, and compliance with treatment recommendations and to identify possible problem areas where inappropriate use could be improved through interventions by the network of the local Swedish Strategic Programme Against Antibiotic Resistance (Strama) groups. Five point-prevalence surveys were performed in between 49 and 72 participating hospitals from 2003 to 2010. Treatments were recorded for 19 predefined diagnosis groups and whether they were for community-acquired infection, hospital-acquired infection, or prophylaxis. Approximately one-third of inpatients were treated with antimicrobials. Compliance with guidelines for treatment of community-acquired pneumonia with narrow-spectrum penicillin was 17.0% during baseline 2003-2004, and significantly improved to 24.2% in 2010. Corresponding figures for quinolone use in uncomplicated cystitis in women were 28.5% in 2003-2004, and significantly improved, decreasing to 15.3% in 2010. The length of surgical prophylaxis improved significantly when data for a single dose and 1 day were combined, from 56.3% in 2003-2004 to 66.6% in 2010. Improved compliance was possibly the effect of active local feedback, repeated surveys, and increasing awareness of antimicrobial resistance. Strama groups are important for successful local implementation of antimicrobial stewardship programs in Sweden.
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Srisung W, Teerakanok J, Tantrachoti P, Karukote A, Nugent K. Surgical prophylaxis with gentamicin and acute kidney injury: a systematic review and meta-analysis. Ann Transl Med 2017; 5:100. [PMID: 28361065 DOI: 10.21037/atm.2017.03.06] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Gentamicin has been increasingly used instead of cephalosporins for surgical prophylaxis in an attempt to reduce the rate of "Clostridium difficile" infection. There are limited data regarding nephrotoxicity related to gentamicin in these patients. METHODS We have conducted a systematic review and meta-analysis to evaluate the risk of acute kidney injury (AKI) in gentamicin-containing surgical prophylactic regimens, compared to regimens without gentamicin, in several types of surgery. Electronic searches were performed using PubMed and Embase, including terms for "AKI, gentamicin, and surgical prophylaxis" with and without MeSH/EMTREE functions. Statistical analysis was then performed using a random-effect model; risk ratios (RR), risk differences (RD) and heterogeneity (I2) were calculated. Funnel plot was used for assessment of publication bias. RESULTS Eleven studies with fifteen cohorts with 18,354 patients were included in the analysis. Subgroup analysis was performed according to surgery type. We have found that antibiotic prophylaxis with gentamicin containing regimen has significant risk for developing postoperative AKI in orthopedic surgery (RR 2.99; 95% CI: 1.84, 4.88). The results were inconclusive in other types of surgery. Funnel plot indicates potential publication bias. CONCLUSIONS Gentamicin-induced AKI is significant in patients undergoing orthopedic surgery. Physicians should consider risks and benefits of using this regimen in individual patients.
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Affiliation(s)
- Weeraporn Srisung
- Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, NY, USA
| | - Jirapat Teerakanok
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Pakpoom Tantrachoti
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Agrawal M, Sharma PK, Dhaneria SP. Clinical Practice Audit of Perioperative Antimicrobial Prophylaxis in a Tertiary Care Hospital: Do Routine Academic Activities Improve Adherence to Practice Guidelines? Rev Recent Clin Trials 2016; 12:59-64. [PMID: 27670801 DOI: 10.2174/1574887111666160926103104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 09/03/2016] [Accepted: 09/06/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Antimicrobial prophylaxis should be used in circumstances where efficacy has been demonstrated and benefits outweigh the risk. Each hospital must have an antibiotic policy that is implementable and fully adhered to. METHODS A prospective observational study was conducted in 209 patients, admitted to wards of various surgical departments including surgery, obstetrics & gynaecology (O&G), otorhinolaryngology (ENT) and orthopaedics. Relevant antimicrobial use data of each patient was collected in a customized Case Record Form (CRF) from day one until patient was discharged. RESULTS Majority of the patients were young adults between 19-39 years of age. Preoperative antibiotics were given in 151 and postoperative antibiotics were prescribed in all. Third generation cephalosporins was the most frequently prescribed group. The selection of antibiotics by different departments varied greatly and many prescribed (n=85) two antibiotics for preoperative prophylaxis. Average duration of surgical prophylaxis was 6.25 days. In 90 patients, preoperative antibiotic was administered before 3 hours. CONCLUSION Despite routine interactive academic activities, pattern of antibiotic used was not as per guidelines suggested by competent authorities. Interventions are warranted to promote the development, dissemination and adoption of evidence based antibiotic policy. The policy should be simple, clear, noncontroversial, clinically relevant and implementable. The constant monitoring with periodic audit to ensure adherence is warranted.
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Affiliation(s)
| | - Pramod K Sharma
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Wagner JL, Kenney RM, Vazquez JA, Ghanem TA, Davis SL. Surgical prophylaxis with gram-negative activity for reduction of surgical site infections after microvascular reconstruction for head and neck cancer. Head Neck 2016; 38:1449-54. [PMID: 27458902 DOI: 10.1002/hed.24178] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 02/12/2015] [Accepted: 06/11/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The purpose of this study was to determine the incidence of and risk factors for surgical site infections in microvascular reconstruction for patients with head and neck cancer. METHODS One hundred seventeen patients with head and neck cancer undergoing microvascular reconstruction received postoperative surgical infection prophylaxis and were followed for 30 days. Surgical infection prophylaxis was categorized by empiric spectrum of activity. Risk factors for surgical site infection development and cumulative incidence of surgical site infections were characterized. RESULTS Thirty-seven patients developed surgical site infection (cumulative surgical site infection incidence of 31.6%). Risk factors identified in logistic regression include alcohol use (odds ratio [OR] = 2.704; 95% confidence interval [CI] = 1.029-7.106), increased surgical duration (OR = 1.403; 95% CI = 1.185-1.661), American Society of Anesthesiologists (ASA) class IV (OR = 3.075; 95% CI = 1.000-9.459), and lack of postoperative gram-negative coverage (OR = 15.139; 95% CI = 3.083-74.347). CONCLUSION Alcohol use, longer surgical duration, and lack of gram-negative postoperative prophylactic coverage are modifiable risk factors for surgical site infection development. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1454, 2016.
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Affiliation(s)
- Jamie L Wagner
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, USA.,Pharmacy Administration, Henry Ford Hospital, Detroit, Michigan.,Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan
| | - Rachel M Kenney
- Pharmacy Administration, Henry Ford Hospital, Detroit, Michigan
| | - Jose A Vazquez
- Department of Infectious Diseases, Georgia Regents University, Augusta, Georgia
| | - Tamer A Ghanem
- Pharmacy Administration, Henry Ford Hospital, Detroit, Michigan
| | - Susan L Davis
- Pharmacy Administration, Henry Ford Hospital, Detroit, Michigan. .,Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan.
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Young OM, Shaik IH, Twedt R, Binstock A, Althouse AD, Venkataramanan R, Simhan HN, Wiesenfeld HC, Caritis SN. Pharmacokinetics of cefazolin prophylaxis in obese gravidae at time of cesarean delivery. Am J Obstet Gynecol 2015; 213:541.e1-7. [PMID: 26103528 DOI: 10.1016/j.ajog.2015.06.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 05/15/2015] [Accepted: 06/15/2015] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The objective of the study was to compare the pharmacokinetics of 2 g and 3 g doses of cefazolin when used for perioperative prophylaxis in obese gravidae undergoing cesarean delivery. STUDY DESIGN We performed a double-blinded, randomized controlled trial from August 2013 to April 2014. Twenty-six obese women were randomized to receive either 2 or 3 g intravenous cefazolin within 30 minutes of a skin incision. Serial maternal plasma samples were obtained at specific time points up to 8 hours after drug administration. Umbilical cord blood was obtained after placental delivery. Maternal adipose samples were obtained prior to fascial entry, after closure of the hysterotomy, and subsequent to fascial closure. Pharmacokinetic parameters were determined via noncompartmental analysis. RESULTS The median area under the plasma concentration vs time curve was significantly greater in the 3 g group than in the 2 g group (27204 μg/mL per minute vs 14058 μg/mL per minute; P = .001). Maternal plasma concentrations had an impact by body mass index. For every 1 kg/m(2) increase in body mass index at the time of the cesarean delivery, there was an associated 13.77 μg/mL lower plasma concentration of cefazolin across all time points (P = .01). By the completion of cesarean delivery, cefazolin concentrations in maternal adipose were consistently above the minimal inhibitory concentration for both Gram-positive and Gram-negative bacteria with both the 2 g and 3 g doses. The median umbilical cord blood concentrations were significantly higher in the 3 g vs the 2 g group (34.5 μg/mL and 21.4 μg/mL; P = .003). CONCLUSION Cefazolin concentrations in maternal adipose both at time of hysterotomy closure and fascial closure were above the minimal inhibitory concentration for both Gram-positive and Gram-negative bacteria when either 2 g or 3 g cefazolin was administered as perioperative surgical prophylaxis. Maternal cefazolin concentrations in plasma and maternal adipose tissue are related to both dose and body mass index.
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Talaat M, Saied T, Kandeel A, Abo El-Ata GA, El-Kholy A, Hafez S, Osman A, Abdel Razik M, Ismail G, El-Masry S, Galal R, Yehia M, Amer A, Calfee DP. A Point Prevalence Survey of Antibiotic Use in 18 Hospitals in Egypt. Antibiotics (Basel) 2014; 3:450-60. [PMID: 27025755 PMCID: PMC4790372 DOI: 10.3390/antibiotics3030450] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 07/22/2014] [Accepted: 09/01/2014] [Indexed: 02/03/2023] Open
Abstract
Inappropriate antibiotic use leads to increased risk of antibiotic resistance and other adverse outcomes. The objectives of the study were to determine the prevalence and characteristics of antibiotic use in Egyptian hospitals to identify opportunities for quality improvement. A point prevalence survey was conducted in 18 hospitals in March 2011. A total of 3408 patients were included and 59% received at least one antibiotic, with the most significant use among persons <12 years and intensive care unit patients (p < 0.05). Third generation cephalosporin were the most commonly prescribed antibiotics (28.7% of prescriptions). Reasons for antibiotic use included treatment of community-(27%) and healthcare-associated infections (11%) and surgical (39%) and medical (23%) prophylaxis. Among surgical prophylaxis recipients, only 28% of evaluable cases received the first dose within two hours before incision and only 25% of cases received surgical prophylaxis for <24 h. The prevalence of antibiotic use in Egyptian hospitals was high with obvious targets for antimicrobial stewardship activities including provision of antibiotic prescription guidelines and optimization of surgical and medical prophylaxis practices.
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Affiliation(s)
- Maha Talaat
- Global Disease Detection and Response Center, US Naval Medical Research Unit, No.3, Cairo 11517, Egypt; E-Mail:
| | - Tamer Saied
- Global Disease Detection and Response Center, US Naval Medical Research Unit, No.3, Cairo 11517, Egypt; E-Mail:
- Author to whom correspondence should be addressed; E-Mail: or ; Tel.: +2-02-2348-0294; Fax: +2-02-2342-2540
| | - Amr Kandeel
- Ministry of Health and Population, Cairo 11516, Egypt; E-Mails: (A.K.); (R.G.)
| | - Gehad A. Abo El-Ata
- Cairo University Hospitals, Giza 11562, Egypt; E-Mails: (G.A.A.E.-A.); (A.E.-K.)
| | - Amani El-Kholy
- Cairo University Hospitals, Giza 11562, Egypt; E-Mails: (G.A.A.E.-A.); (A.E.-K.)
| | - Soad Hafez
- Alexandria University Hospitals, Alexandria 21111, Egypt; E-Mails: (S.H.); (A.A.)
| | - Ashraf Osman
- Minya University Hospitals, Minya 61519, Egypt; E-Mails: (A.O.); (M.A.R.)
| | | | - Ghada Ismail
- Ain Shams University Hospitals, Cairo 11591, Egypt; E-Mails: (G.I.); (S.E.-M.)
| | - Sherine El-Masry
- Ain Shams University Hospitals, Cairo 11591, Egypt; E-Mails: (G.I.); (S.E.-M.)
| | - Rami Galal
- Ministry of Health and Population, Cairo 11516, Egypt; E-Mails: (A.K.); (R.G.)
| | - Mohamad Yehia
- Azhar University Hospitals, Cairo 11517, Egypt; E-Mail:
| | - Amira Amer
- Alexandria University Hospitals, Alexandria 21111, Egypt; E-Mails: (S.H.); (A.A.)
| | - David P. Calfee
- Weil Cornell Medical College, New York, NY 4885, USA; E-Mail:
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Malcolm W, Nathwani D, Davey P, Cromwell T, Patton A, Reilly J, Cairns S, Bennie M. From intermittent antibiotic point prevalence surveys to quality improvement: experience in Scottish hospitals. Antimicrob Resist Infect Control 2013; 2:3. [PMID: 23320479 PMCID: PMC3573889 DOI: 10.1186/2047-2994-2-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 01/06/2013] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED BACKGROUND In 2008, the Scottish Antimicrobial Prescribing Group (SAPG) was established to coordinate a national antimicrobial stewardship programme. In 2009 SAPG led participation in a European point prevalence survey (PPS) of hospital antibiotic use. We describe how SAPG used this baseline PPS as the foundation for implementation of measures for improvement in antibiotic prescribing. METHODS In 2009 data for the baseline PPS were collected in accordance with the European Surveillance of Antimicrobial Consumption [ESAC] protocol. This informed the development of two quality prescribing indicators: compliance with antibiotic policy in acute admission units and duration of surgical prophylaxis. From December 2009 clinicians collected these data on a monthly basis. The prescribing indicators were reviewed and further modified in March 2011. Data for the follow up PPS in September 2011 were collected as part of a national PPS of healthcare associated infection and antimicrobial use developed using ECDC protocols. RESULTS In the baseline PPS data were collected in 22 (56%) acute hospitals. The frequency of recording the reason for treatment in medical notes was similar in Scotland (75.9%) and Europe (75.7%). Compliance with policy (81.0%) was also similar to Europe (82.5%) but duration of surgical prophylaxis <24hr (68.6%), was higher than in Europe (48.1%, OR: 0.41, p<0.001). Following the development and implementation of the prescribing indicators monthly measurement and data feedback in admission units illustrated improvement in indication documented of ≥90% and compliance with antibiotic prescribing policy increasing from 76% to 90%. The initial prescribing indicator in surgical prophylaxis was less successful in providing consistent national data as there was local discretion on which procedures to include. Following a review and a focus on colorectal surgery the mean proportion receiving single dose prophylaxis exceeded the target of 95% and the mean proportion compliant with policy was 83%. In the follow up PPS of 2011 indication documented (86.8%) and policy compliant (82.8%) were higher than in baseline PPS. CONCLUSIONS The baseline PPS identified priorities for quality improvement. SAPG has demonstrated that implementation of regularly reviewed national prescribing indicators, acceptable to clinicians, implemented through regular systematic measurement can drive improvement in quality of antibiotic use in key clinical areas. However, our data also show that the ESAC PPS method may underestimate the proportion of surgical prophylaxis with duration <24hr.
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Affiliation(s)
- William Malcolm
- NHS National Services Scotland, Health Protection Scotland, Meridian Court, 5 Cadogan Street, Glasgow, Scotland, G2 6QE, UK
| | - Dilip Nathwani
- Ninewells Hospital & Medical School, Dundee, Scotland, DD19SY, UK
| | - Peter Davey
- Population Health Sciences Division, Medical Research Institute, Dundee, Scotland, DD2 4BF, UK
| | - Tracey Cromwell
- NHS National Services Scotland, Information Services Division, Gyle Square 1 South Gyle Crescent, Edinburgh, Scotland, EH12 9EB, UK
| | - Andrea Patton
- Healthcare Improvement Scotland, Gyle Square 1 South Gyle Crescent, Edinburgh, Scotland, EH12 9EB, UK
| | - Jacqueline Reilly
- NHS National Services Scotland, Health Protection Scotland, Meridian Court, 5 Cadogan Street, Glasgow, Scotland, G2 6QE, UK
| | - Shona Cairns
- NHS National Services Scotland, Health Protection Scotland, Meridian Court, 5 Cadogan Street, Glasgow, Scotland, G2 6QE, UK
| | - Marion Bennie
- NHS National Services Scotland, Information Services Division, Gyle Square 1 South Gyle Crescent, Edinburgh, Scotland, EH12 9EB, UK
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Taylor Street, Glasgow, Scotland, G4 ONR, UK
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Abstract
OBJECTIVE To review the evidence and provide recommendations on antibiotic prophylaxis for obstetrical procedures. OUTCOMES Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in obstetrical procedures. EVIDENCE Published literature was retrieved through searches of Medline and The Cochrane Library on the topic of antibiotic prophylaxis in obstetrical procedures. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and articles published from January 1978 to June 2009 were incorporated in the guideline. Current guidelines published by the American College of Obstetrics and Gynecology were also incorporated. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS Implementation of this guideline should reduce the cost and harm resulting from the administration of antibiotics when they are not required and the harm resulting from failure to administer antibiotics when they would be beneficial. SUMMARY STATEMENTS: 1. Available evidence does not support the use of prophylactic antibiotics to reduce infectious morbidity following operative vaginal delivery. (II-1) 2. There is insufficient evidence to argue for or against the use of prophylactic antibiotics to reduce infectious morbidity for manual removal of the placenta. (III) 3. There is insufficient evidence to argue for or against the use of prophylactic antibiotics at the time of postpartum dilatation and curettage for retained products of conception. (III) 4. Available evidence does not support the use of prophylactic antibiotics to reduce infectious morbidity following elective or emergency cerclage. (II-3) RECOMMENDATIONS: 1. All women undergoing elective or emergency Caesarean section should receive antibiotic prophylaxis. (I-A) 2. The choice of antibiotic for Caesarean section should be a single dose of a first-generation cephalosporin. If the patient has a penicillin allergy, clindamycin or erythromycin can be used. (I-A) 3. The timing of prophylactic antibiotics for Caesarean section should be 15 to 60 minutes prior to skin incision. No additional doses are recommended. (I-A) 4. If an open abdominal procedure is lengthy (>3 hours) or estimated blood loss is greater than 1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the initial dose. (III-L) 5. Prophylactic antibiotics may be considered for the reduction of infectious morbidity associated with repair of third and fourth degree perineal injury. (I-B) 6. In patients with morbid obesity (BMI>35), doubling the antibiotic dose may be considered. (III-B) 7. Antibiotics should not be administered solely to prevent endocarditis for patients who undergo an obstetrical procedure of any kind. (III-E).
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Abstract
Despite improvement in infection control measures and surgical practice, surgical site infections (SSIs) remain a major cause of morbidity and mortality. In colorectal surgery, perioperative administration of a suitable antimicrobial regimen that covers both anaerobic and aerobic bacteria is universally accepted. In a prospective, double-blind, randomized study ertapenem was recently found to be more effective than cefotetan, a parenteral cephalosporin so broadly used as to be considered as gold standard in the prevention of SSIs following colorectal surgery. In this adequate and well controlled study, the superiority of ertapenem over cefotetan was clearly demonstrated from the clinical and bacteriological points of view. However, data that directly compares ertapenem with other antimicrobial regimen effective in preventing SSIs following colorectal surgery are lacking; furthermore, the possible risk of promotion of carbapenem resistance associated with widespread use of ertapenem prophylaxis as well as the ertapenem effects on the intestinal gut flora are of concern. Further comparative studies of ertapenem versus other widely used prophylactic regimens for colorectal surgery in patients submitted to mechanical bowel preparation versus no preparation as well as further research on adverse events of antibiotic prophylaxis, including emergence of resistance and Clostridium difficile infection, seem warranted.
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Affiliation(s)
- Fausto de Lalla
- Libero Docente of Infectious Diseases, University of Milano, Milano, Italy
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