[Surgical antibiotic prophylaxis's usage review in a mother-child university hospital]. / Revue de l'utilisation de l'antibioprophylaxie en chirurgie pédiatrique dans un centre hospitalier universitaire mère­enfant.

OBJECTIVES: The main objective was to evaluate the surgical antibiotic prophylaxis's compliance rate. The secondary objectives were to evaluate the tools designed to help the surgical antibiotic prophylaxis's prescription, and evaluate the surgical site infection rate. METHODS: This retrospective study was done in a university hospital on a random selection of 125 pediatric patients having undergone a surgery (cardiac, general, neurological, ENT, orthopedic or plastic). Compliance to the current recommendations has been assessed. RESULTS: Out of the 125 studied patients (2 exclusions), the indication was compliant at 87% (107/123). The perioperative document included an intention to use antibiotic prophylaxis in 24% of cases (29/123). The compliance for the presence of the standard order set for antibiotic prophylaxis was only 15% (19/123). The compliance for the preoperative administration varied: antibiotic choice (94%, 63/67), dose (91%, 61/67), route (99%, 66/67), timing (30%, 20/67). The compliances for intra- and postoperative administrations were respectively 75% (57/76) and 89% (68/76). The surgical site infection rate was 4% (5/123). CONCLUSIONS: The use of a standard order set for antibiotic prophylaxis and the timing of the preoperative administration were sub-optimal. A better dissemination and use of the administrative tools and the implementation of a coordination system with the members of anesthesia services would improve these important aspects of the surgical antibiotic prophylaxis. The establishment of a digital perioperative document is planned.

Relevance of antibiotic prophylaxis in the management of surgical emergency open hand trauma.

Surgical site infection after emergency hand surgery can cause considerable morbidity and, in the most severe forms, even toxic shock syndrome. Postoperative antibiotic prophylaxis aims to reduce the number of surgical site infections. However, excessive use of antibiotics induces side-effects for patients and antibiotic resistance for society. Contrary to other orthopedic sites, there is no consensus on postoperative antibiotic prophylaxis in open hand trauma beyond analogic reasoning with no proven scientific validity. Our hypothesis was that absence of postoperative antibiotic prophylaxis after open hand trauma surgery does not affect the rate of surgical site infections. A prospective cohort study included 405 patients, operated on in the emergency hand trauma unit without intra- or post-operative antibiotic prophylaxis. Patients were followed up in consultation at 7, 14 and 30 days. Surgical site infection was defined by need for surgery for detersion and flattening, followed by curative antibiotic therapy. The surgical site infection rate was 2.22%. Four patients were lost to follow-up and counted as surgical site infection as originally planned in the worst-case analysis. There were five surgical revisions followed by antibiotic therapy. These results do not differ from those reported in the literature, and thus confirm our hypothesis that postoperative antibiotic prophylaxis is not indicated in open hand trauma management.

[Infections in interventional electrophysiology]. / Infections en rythmologie interventionnelle.

The implantation of pacemakers and defibrillators carries the highest risk of infection in interventional electrophysiology. The use of implantable cardiac devices is continually increasing with almost 2 million devices implanted worldwide each year. The recipients' profile may also be associated with an increased risk of infection. Several measures can be implemented to reduce the risk of device-related infection. Systematic antibiotic prophylaxis has proven to be beneficial provided that prescription modalities are respected, especially with respect to the selection of the appropriate molecule and timing of administration prior to the procedure. Despite all the precautions taken during surgery (asepsis, prophylactic antibiotic therapy….) the estimated rate of peri-procedural infection is around 2%. Device related infections are associated with a high rate of morbidity and mortality as well as substantial healthcare costs. Staphylococcus aureus (SA) and epidermidis (SE) are the pathogenic agents involved in most cases. Prevention is crucial given the difficulties in treating such infections because of the near-systematic need to remove the device and antibiotic resistance. Leadless pacemakers and subcutaneous defibrillators are potential alternatives to implantable endocardial devices, albeit with certain limitations. A group of experts has recently issued consensus paper on the prevention, diagnosis and treatment of infections associated with endocardial implantable cardiac devices.

Postoperative empyema following chronic subdural hematoma surgery: Clinically based medicine.

INTRODUCTION: Subdural empyema (SDE) is a rare complication of chronic subdural hematoma (CSDH) surgery. We introduced antibiotic prophylaxis (AP) for this procedure in 2014 following a morbidity-mortality conference (MMC) in our department. We report the results of retrospective data analysis to assess the effect of systematic AP and to identify risk factors for SDE. MATERIAL AND METHODS: Two hundred eight patients were recruited between January 2013 and December 2015; 5 were excluded for incomplete data: 107 without and 96 with AP (n=203). SDE was confirmed by clinical examination, imaging and bacteriological analysis. Comparisons between AP-(no cefuroxime) and AP+ (cefuroxime) groups were made with Chi2 test and Student's t-test. RESULTS: One empyema was found in each group, indicating that AP had no effect (P=1). The only criterion associated with SDE for these two patients was a greater number of reoperations for CSDH recurrence (P=0.013). DISCUSSION: The incidence of postoperative empyema was 1%, similar to the range of 0.2%-2.1% reported in the literature. This rare incidence explains why we found no significant effect of AP. The medical decision taken at the MMC did not help to reduce the rate of postoperative SDE. MMCs can help to define factors associated with adverse surgical events and identify opportunities for improvement. CONCLUSION: AP, introduced after an MMC, did not impact SDE rates. In practice, AP should be required only in case of reoperation for CSDH recurrence. However, we still continue to use AP following the MMC considering different parameters discussed in the manuscript.

[Evaluation of French practices in 2019 regarding prevention and treatment of urinary tract infections related to ureteral stent]. / Évaluation des pratiques professionnelles françaises par questionnaire en 2019 concernant la prévention et le traitement des infections urinaires sur matériel endo-urétéral.

INTRODUCTION: Urological recommendations never focused on prevention and treatment of urinary tract infections related to endo-ureteral material. METHODS: We conducted an evaluation of French professional practices in May 2019 in the aim of highlighting the important heterogeneity of practices using a Survey Monkey inquiry. RESULTS: One-hundred-and-seventy-five urologists answered the inquiry, as to say 13% of French urologists. Questions regarding the management of pre-surgical polymicrobial urine sample, medical and surgical management of pyelonephritis on endo-ureteral material and regarding the need to diagnose and treat asymptomatic bacteriuria before endo-ureteral stent removal are the main points a majority of French urologists felt uncomfortable with. CONCLUSION: This study evaluated French practices in 2019. The diversity of the answers highlights the need for new recommendations on these subjects of daily practice. Future recommendations should allow their homogenization based on the existing evidence-based data.

[Proposal of guidelines for antibiotic prophylaxis in plastic, reconstructive, and aesthetic surgery]. / Proposition de recommandations sur l'antibioprophylaxie en chirurgie plastique, reconstructrice et esthétique.

BACKGROUND: In plastic surgery, guidelines about antibiotic prophylaxis are inaccurate and incomplete, due to result the absence of high-level studies on this subject. The main aim is to establish national common recommendations for plastic surgery antibiotic prophylaxis. MATERIALS AND METHODS: A working group will discuss and validate a multi-center analysis of practices in three University Hospital Centers compared to an interdisciplinary analysis of recommendations to the French Society of Anaesthesia and Intensive Care Medicine and scientific literature. This working group is composed of plastic surgeon members of the French Society of Aesthetic Reconstructive Plastic Surgery, infectious disease physicians, and anaesthesiologists to define clear and precise antibiotic prophylaxis recommendations. RESULTS: Antibiotic prophylaxis with cefazoline (or clindamycine±gentamicine in case of allergy), has been recommended for general surgery with flap or implants, for breast surgery, lipofilling, and rhinoplasty. In other plastic surgery, no antibiotic prophylaxis has been recommended. CONCLUSION: We established common recommendations for plastic surgery antibiotic prophylaxis that is the first step to update these recommendations. Now, they can be evaluated in clinical situation to validate them.

[Is it necessary to perform urine culture systematically prior to double J ureteral stent removal?] / Est-il nécessaire de faire systématiquement un ECBU avant l'ablation d'une sonde double J ?

OBJECTIVE: To assess the value of systematic urine culture before ureteric double j removal. MATERIAL AND METHODS: This prospective audit was performed to assess the validity of our current clinical practice. A cohort of informed patients without clinical signs of urinary tract infection and without predefined risk factors were programmed for ureteral double j stent removal in an outpatient setting. Urine was sampled for culture immediately before the procedure. Patients had to complete a self-questionnaire 15 days following stent removal, inquiring about tolerance and complications which were to be analyzed according to the culture results. The primary endpoint was the occurrence of febrile urinary tract infection. RESULTS: Among the 56 participants, immediate preoperative urine culture revealed colonization in 9 patients (16.1%) and contamination in 6 patients (10.7%). A significant association was found between bacteriuria and double j placement following surgery with urinary tract injury (P<0.02) and diabetes (P<0.009). Two patients had fever including a man with sterile urine and a woman with Staphylococcus Aureus infection. No hospitalization was necessary. Twelve patients reported functional signs with lumbar pain being the most common. There was no significant association between functional signs and patients' clinical characteristics. CONCLUSION: This evaluation was not in favor of modifying our protocol of care i.e. the lack of performing neither antibiotic prophylaxis nor systematic urine culture before JJ ureteral stent removal in a selected population. LEVEL OF EVIDENCE: 4.

Perioperative infectious risk in urology: Management of preoperative polymicrobial urine culture. A systematic review. By the infectious disease Committee of the French Association of urology.

INTRODUCTION: The aim was to assess the risk of postoperative infections in patients with preoperative polymicrobial urine culture and to provide the urologist with practices to minimise the risk of infection in these clinical situations. METHODS: A systematic literature review was carried. All national and international recommendations have been reviewed. Data collection has been performed from the Cochrane, LILACS and the Medline database. 31 publications were selected for inclusion. RESULTS: Risk of infection in patients without ureteral stents or urinary catheters with previous polymicrobial urine culture is low. In the absence of leukocyturia, the urine sample can be considered as sterile. With ureteral stents or urinary catheters, the colonisation by biofilm ranges from 4 to 100% depending on the duration and ureteral stents or urinary catheters type. Urine culture is positive 24 to 45% of the time when ureteral stents or urinary catheters are known to be colonised. The post-operative risk of infection in endo-urological surgery in a patient with ureteral stents or urinary catheters is estimated around 8 to 11% depending on the type of surgery. A retrospective study reports a postoperative infections rate of 18.5% in photo selective vaporization of the prostate with preoperative polymicrobial urine culture. CONCLUSIONS: Scientific data are limited but for patients without ureteral stents or urinary catheters, in the absence of leukocyturia, the polymicrobial urine culture can be considered as negative. Considering a preoperative polymicrobial urine culture as sterile in patients with colonised ureteral stents or urinary catheters is at risk of neglecting a high risk of postoperative infections or sepsis even in case of perioperative antibiotic prophylaxis. It should not always be considered sterile and therefore, a perioperative antibiotic therapy could be an acceptable option.

[Ecology and fluoroquinolon resistance profiles in febrile urinary tract infections (FUTI) after prostate needle biopsy: A retrospective study in 466 biopsies]. / Écologie et résistances aux fluoroquinolones dans les complications infectieuses urinaires fébriles (CIUF) après biopsies de prostate : étude rétrospective portant sur 466 biopsies.

OBJECTIVE: The biopsies of prostate are the reference examination to assert the diagnosis of prostate cancer. Even if the urinary infectious complications are rare thanks to the systematic oral antibiotic prophylaxis, they may still be serious. The SPILF (Society of Infectious Pathology and French language) published in 2014, an important increase of the resistances in fluoroquinolones for Escherichia coli (3 to 25%), whereas this is the most bacterium frequently found in the urinary infections (70-80%). The objectives of this study were to estimate the indicence of the febrile urinary tract infections after prostate needle biopsy and to define the ecology and the profile of E. coli's resistance. METHODS: A total of 466 transrectal ultrasound-guided needle prostate biopsy were included in the study from 2012 to 2015. All the patients were taken care according to the recommendations of the AFU (Ouzzane et al., 2011). We estimated, for all the inclusive patients, if they had presented a clinic sign of urinary infection like fever or burning which suggestive of an urinary infection, and having a urines and blood culture, in the next 30 days the realization of the medical exam. RESULTS: Among 466 realized biopsies, seven patients developed a febril urinary tract infection (1.5%) [prostatitis (n=6), orchitis (n=1)]. Five infections to E. coli were identified; two were resistant for fluoroquinolones (40%). No germ was able to be identified for two patients. CONCLUSION: The infectious complications post-biopsy of prostate are rare (1.5%). E. coli is the germ most frequently identified with 40% of resistance with fluoroquinolones. LEVEL OF EVIDENCE: 4.

[Surgical methods of abortion]. / Interruption volontaire de grossesse instrumentale.

OBJECTIVE: A state of the art of surgical method of abortion focusing on safety and practical aspects. MATERIAL AND METHODS: A systematic review of French-speaking or English-speaking evidence-based literature about surgical methods of abortion was performed using Pubmed, Cochrane and international recommendations. RESULTS: Surgical abortion is efficient and safe regardless of gestational age, even before 7 weeks gestation (EL2). A systematic prophylactic antibiotics should be preferred to a targeted antibiotic prophylaxis (grade A). In women under 25 years, doxycycline is preferred (grade C) due to the high prevalence of Chlamydia trachomatis. Systematic cervical preparation is recommended for reducing the incidence of complications from vacuum aspiration (grade A). Misoprostol is a first-line agent (grade A). When misoprostol is used before a vacuum aspiration, a dose of 400 mcg is recommended. The choice of vaginal route or sublingual administration should be left to the woman: (i) the vaginal route 3 hours before the procedure has a good efficiency/safety ratio (grade A); (ii) the sublingual administration 1 to 3 hours before the procedure has a higher efficiency (EL1). The patient should be warned of more common gastrointestinal side effects. The addition of mifepristone 200mg 24 to 48hours before the procedure is interesting for pregnancies between 12 and 14 weeks gestations (EL2). The systematic use of nonsteroidal anti-inflammatory drugs is recommended for limiting the operative and postoperative pain (grade B). Routine vaginal application of an antiseptic prior to the procedure cannot be recommended (grade B). The type of anesthesia (general or local) should be left up to the woman after explanation of the benefit-risk ratio (grade B). Paracervical local anesthesia (PLA) is recommended before performing a vacuum aspiration under local anesthesia (grade A). The electric or manual vacuum methods are very effective, safe and acceptable to women (grade A). Before 9 weeks gestation, the manual vacuum aspiration could have a subjective interest (grade B). The electric vacuum aspiration is recommended after 9 weeks gestation (best practice agreement). For a pregnancy of unknown location, the success of the procedure can reasonably be determined if hCG drops more than 50 % on day 5 and 80 % on day 7 (NP3). After a surgical abortion, paracetamol or addition of paracetamol and codeine is not recommended (grade B).

[Early macular edema after phacoemulsification and suspected overdose of cefuroxime: report of six cases]. / Œdème maculaire après phacoémulsification et suspicion de surdosage en céfuroxime : à propos de 6 cas.

Antibiotic prophylaxis by intracameral cefuroxime injection, 1mg/0.1 mL after cataract surgery is increasing in popularity. Several cases of early postoperative macular edema have recently been reported after cefuroxime injection, most of them due to accidental cefuroxime overdose. We report six additional cases of macular involvement after cataract surgery, with intracameral cefuroxime injection imputed to cause retinal toxicity. Formal proof of cefuroxime overdose has never been possible, due to rapid wash-out in a few hours and the diagnosis of the macular edema the day after surgery or within a few days. Thus, this strong suspicion is based on clinical, pharmacokinetic, tomographic and retinographic criteria. In our series of six cases, the first four patients involved the same surgeon in the same hospital, and two of them on the same day. For the sixth case, the diagnosis was made retrospectively and based on history and medium-term tomographic characteristics. All the patients underwent optical coherence tomography (OCT) relatively early. As early as day one after surgery, there is macular edema predominantly in the outer retinal layers associated with serous retinal detachment, similar to the cases described in the literature. In the late stage, three patients had functional impairment related to photoreceptor damage on OCT. Three cases are described with additional retinal imaging (angiography, autofluorescence) to better characterize this macular toxicity associated with cefuroxime.