Single versus combination intravenous anti-pseudomonal antibiotic therapy for people with cystic fibrosis.

BACKGROUND: The choice of antibiotic, and the use of single or combined therapy are controversial areas in the treatment of respiratory infection due to Pseudomonas aeruginosa in cystic fibrosis (CF). Advantages of combination therapy include wider range of modes of action, possible synergy and reduction of resistant organisms; advantages of monotherapy include lower cost, ease of administration and reduction of drug-related toxicity. Current evidence does not provide a clear answer and the use of intravenous antibiotic therapy in CF requires further evaluation. This is an update of a previously published review. OBJECTIVES: To assess the effectiveness of single compared to combination intravenous anti-pseudomonal antibiotic therapy for treating people with CF. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Most recent search of the Group's Trials Register: 07 October 2020. We also searched online trials registries on 16 November 2020. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing a single intravenous anti-pseudomonal antibiotic with a combination of that antibiotic plus a second anti-pseudomonal antibiotic in people with CF. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. We assessed the certainty of the data using GRADE. MAIN RESULTS: We identified 59 trials, of which we included eight trials (356 participants) comparing a single anti-pseudomonal agent to a combination of the same antibiotic and one other. There was a wide variation in the individual antibiotics used in each trial. In total, the trials included seven comparisons of a beta-lactam antibiotic (penicillin-related or third generation cephalosporin) with a beta-lactam-aminoglycoside combination and three comparisons of an aminoglycoside with a beta-lactam-aminoglycoside combination.  There was considerable heterogeneity amongst these trials, leading to difficulties in performing the review and interpreting the results. These results should be interpreted cautiously. Six of the included trials were published between 1977 and 1988; these were single-centre trials with flaws in the randomisation process and small sample size. Overall, the methodological quality was poor and the certainty of the evidence ranged from low to moderate. The review did not find any differences between monotherapy and combination therapy in either the short term or in the long term for the outcomes of different lung function measures, bacteriological outcome measures, need for additional treatment, adverse effects, quality of life or symptom scores. AUTHORS' CONCLUSIONS: The results of this review are inconclusive. The review raises important methodological issues. There is a need for an RCT which needs to be well-designed in terms of adequate randomisation allocation, blinding, power and long-term follow-up. Results need to be standardised to a consistent method of reporting, in order to validate the pooling of results from multiple trials.

Granulomatous mastitis in multiparae during pregnancy and lactation: Observational study (STROBE compliant).

ABSTRACT: The incidence of granulomatous mastitis (GLM) in multiparae as seriously affected the quality of life and breastfeeding of pregnant women after delivery, but the treatment is rarely reported. In this article, the development, healing, and lactation of 13 cases were reported and a retrospective analysis was performed. 10 cases of GLM were treated at the Breast Disease Prevention and Treatment Center of Haidian Maternal & Child Health Hospital of Beijing and 3 cases of GLM were treated in the Breast Department of Weihai Municipal Hospital of Shandong province from February 2017 to May 2019.Among the 13 patients, conservative symptomatic treatment was adopted during pregnancy and lactation: anti-infective therapy consisting of oral cephalosporin antibiotic for patients; ultrasound-guided puncture and drainage of pus or incision and drainage after abscess formation. Observation continued during the sinus tract phase. Postpartum breastfeeding was encouraged, especially on the affected side. In this study, the median healing time was 20 months and the average healing time was 30.4 months in 5 healthy breast lactation cases. In 8 cases of bilateral breast lactation, the median healing time was 30 months and the average healing time was 26.5 months. Linear regression test analysis: whether the affected breast was breast-fed after delivery had no effect on the postpartum wound healing time, P = .792. The wounds of 13 patients healed well after lactation, and none of them recurred since the last follow-up visit. There were no adverse events in all infants.Conservative symptomatic treatment for GLM of multiparous women during pregnancy and lactation and encouraging breastfeeding after delivery have no effect on infant health and the recovery time of patients.

Three-day postoperative antibiotics reduces post-hepatectomy infection rate in hepatitis B virus-related hepatocellular carcinoma.

BACKGROUND AND AIM: The evidences for use of postoperative antibiotics (POA) in hepatocellular carcinoma (HCC) patients who underwent hepatectomy are controversial. We aimed to explore the relationship between POA and hepatectomy-related infection in a hepatitis B virus (HBV)-related HCC population. METHODS: We retrospectively collected 934 HCC patients who underwent hepatectomy for curative intent from three tertiary hospitals in China. The incidences of postoperative infection including surgical site infection and remote site infection were recorded and calculated. Univariable and multivariable logistic regression analyses were performed to explore related factors of postoperative infection and POA. And the relationship between infection rates with different durations of POA was investigated. RESULTS: The overall infection rate was 8.2% (77/934), including 6.5% (61/934) of surgical site infection and 2.0% (19/934) of remote site infection. Multivariable analysis revealed that the administration of POA was negatively related with the incidence of postoperative infection significantly (odds ratio = 0.50, 95% confidence interval = 0.30 to 0.83; P = 0.008). Albumin-bilirubin score, Barcelona Clinic Liver Cancer (BCLC) stage and extent of hepatectomy were independently related to the POA. And 3-day regimen seemed to be the shortest duration of POA to gain the lowest incidence of postoperative infection. CONCLUSIONS: Postoperative antibiotic is necessary for HBV-related HCC patients to prevent postoperative infection, especially for those with higher albumin-bilirubin score, at BCLC stage B-C, or who underwent major hepatectomy. For HBV-related HCC patients, postoperative second-generation cephalosporins, or ceftriaxone for 3 days after surgery might be proper.

The Intestinal Flora at Kasai Procedure in Children with Biliary Atresia Appears Not to Affect Postoperative Cholangitis.

INTRODUCTION: Evidence supports long-term oral antibiotic prophylaxis to prevent cholangitis after Kasai procedure. Data regarding perioperative intravenous prophylaxis are lacking. Ascending pathogens from the intestine are made responsible for recurrent cholangitis. Therefore, we analyzed the flora in the upper jejunum during the Kasai procedure and their potential impact on postoperative cholangitis. MATERIALS AND METHODS: In 26 patients, swabs were taken at the bowel prepared for the Roux-en-Y-loop. Our postoperative protocol includes intravenous third-generation cephalosporins for 2 weeks and rectal steroids starting at day 4. Cholangitis was defined as the postoperative reappearance of acholic stools or increase of serum bilirubin in combination with fevers or increase of inflammatory parameters. In this scenario, Tazocin was administered for another 2 weeks. RESULTS: Swabs remained sterile in nine patients (34.6%). In 17 patients (65.4%), gram-positive and gram-negative pathogens were identified; all belonging to physiological intestinal flora. A total of 96.2% pathogens were covered by the antibiotic prophylaxis. The cholangitis incidence was 55.6% in the sterile cohort, and 23.5% in the gram-positive and gram-negative cohort (p = 0.06). In the cholangitis cohort, no significant differences were detected for the age at Kasai and the pre- and postoperative total bilirubin. CONCLUSION: We found that our antibiotic regiment covered bacteria in the upper gastrointestinal (GI) tract in the majority of our patients at the time of Kasai. Nonetheless, a significant proportion of patients developed signs of cholangitis. There was no higher rate of cholangitis in patients with resistant bacteria. Thus, our data do not support the hypothesis of extended postoperative intravenous antibiotics to prevent ascending cholangitis.

[Antibiotic stewardship - recent developments]. / Aktuelle Entwicklungen im Bereich Antibiotic Stewardship.

Both in hospitals and outpatient settings, fewer fluoroquinolones have been prescribed in Germany in recent years. The consumption of cephalosporins also decreased somewhat in favor of penicillin derivatives. The aminoglycosides, which have only rarely been prescribed, can now be used again as a suitable alternative - but only parenterally - due to their relatively favorable activity and low resistance rates among typical urinary tract infection pathogens. In acute severe infection such as sepsis, addition, e. g. of tobramycin, to a suitable betalactam of a single dose has been discussed as a useful option, but the evidence for such a recommendation is weak. There is little news about the rational use of antibiotics in hematology-oncology patients. In the case of fever and neutropenia, the initial empirical regimens of choice remain piperacillin-tazobactam or a pseudomonas-active carbapenem as monotherapy. These betalactams should be given with extended infusion times, e. g. over 4 hours. Linezolid should be considered as a reserve drug and not be used empirically, but only in targeted therapy. With regard to an alleged penicillin allergy, the risk of true allergic reactions can be differentiated by careful taking of the history; on that ground patient subgroups can be defined that may be re-exposed without further allergological examinations.

Development and validation of a quantitative LC-MS/MS method for the simultaneous determination of ceftolozane and tazobactam in human plasma and urine.

The purpose of this work was to develop and validate a single sensitive, selective and rapid bioanalytical method to determine ceftolozane and tazobactam concentrations in human plasma and urine and to use this method to analyze samples from a human clinical study. Human plasma and urine samples were prepared by protein precipitation using a solution of acetonitrile, water and formic acid. Following protein precipitation, samples were analyzed by liquid chromatography tandem mass spectrometry. Chromatographic resolution was achieved on a Kinetex PFP column using a gradient elution, a flow rate of 0.4 mL/min, and a total run time of 5 min. Positive electrospray ionization was employed and analytes were quantitated using multi-reaction monitoring mode. Method validation was conducted in accordance with Unites States Food and Drug Administration's regulatory guidelines for bioanalytical method validation. Calibration curves were determined to linear over the range of 0.1 to 40 µg/mL for ceftolozane and 0.05 to 20 µg/mL for tazobactam. The method was determined to be accurate (-6.24 to 12.53 percent relative error), precise (less than 13.28 percent standard deviation) and sensitive in both human plasma and urine. Ceftolozane and tazobactam were determined to be stable across a battery of stability studies including autosampler, benchtop, freeze/thaw and long-term stability. This validated method successfully applied to human clinical samples to determine the concentration versus time profiles of the intravenously administered combination of Zerbaxa (ceftolozane-tazobactam) in burn patients.

Surgical infection prophylaxis prior to left ventricular assist device implantation: A survey of clinical practice.

BACKGROUND: Short duration, antimicrobial prophylaxis that includes antistaphylococcal activity is recommended at the time of left ventricular assist device (LVAD) implantation to reduce infection-related complications. There continues to be wide variability in surgical infection prophylaxis (SIP) regimens among implantation centers. The aim of this study is to characterize current SIP regimens at different LVAD centers. METHODS: A survey study was conducted from 26 September 2017 to 25 October 2017. Surveys were distributed electronically to LVAD coordinators and infectious diseases specialists at 75 US medical centers identified as having an LVAD program. Data collection included information about antimicrobial selection, duration, Staphylococcus aureus screening, and decolonization procedures. RESULTS: We received 29 survey responses. The majority of surveys were completed by infectious diseases physicians (72.4% [21 out of 29]). Most responding centers reported LVAD programs established for greater than 10 years (20 out of 29 [69%]). Cardiac transplantation was performed in 28 out of 29 (96%) centers. Of centers reporting a defined SIP regimen for non-penicillin allergic patients (96% [28 out of 29]), 17.9% (5 out of 28) reported a four-drug regimen, 35.7% (10 out of 28) reported a three-drug regimen, and 46.4% (13 out of 28) reported a two-drug regimen, while no centers reported a single-drug regimen. Empiric fluconazole was common (50% [14 out of 28]) and 96.4% (27 out of 28) of regimens included vancomycin. Duration of antimicrobial prophylaxis (24 hours to 5 days), S. aureus screening, decolonization procedures, and alterations due to drug allergies varied across participating centers. CONCLUSIONS: Our survey results indicate wide variation in SIP regimens among participating LVAD centers. These results highlight the need for studies evaluating the implications of SIP regimens, and whether clinical factors that prolong antimicrobial duration impact postoperative infection rates.

Antibiotic prophylaxis for gynecologic cancer surgery.

OBJECTIVES: The use of prophylactic antibiotics in elective gynecologic cancer surgery is essential. We aimed to establish the optimal duration of antibiotic administration to reduce the overuse of antibiotics in gynecologic cancer surgery. MATERIALS AND METHODS: We conducted a retrospective study based on the descriptive and statistical analysis of the clinical records of patients who underwent a radical hysterectomy or staging operation for gynecologic cancer between January 2014 and October 2015 at Busan Paik Hospital. Postoperative outcomes, such as surgical site infection (SSI), urinary tract infection (UTI), length of hospital stay, duration of urinary catheterization, and duration of surgical drainage, were compared between the antibiotic prophylaxis for 1-day and greater than 1-day groups. RESULTS: A total of 139 patients were included in the study. There were 79 patients in the 1-day group (56.8%) and 60 patients in the >1-day (43.2%) group. The two groups were similar in terms of demographics, American Society of Anesthesiologists score, stage, surgical approach, and type of operation. Blood loss was smaller in the 1-day group than in the >1-day group (582.2 ± 278.3 cc vs. 795.9 ± 617.9 cc, P = 0.007). The average length of hospital stay was shorter in the 1-day group than in the >1-day group (10.8 ± 2.7 days vs. 11.8 ± 2.8 days, P = 0.039). The rate of SSI and UTI was not significantly different between the 1-day and >1-day groups (6.3% vs. 8.2% and 11.4% vs. 6.7%, respectively [P = 0.903 and P = 0.393]). CONCLUSION: One-day first generation cephalosporin administration is appropriate for preventing post-surgical complications such as wound infections, UTIs, and vaginal cuff cellulitis in gynecologic cancer surgery.

Combining bacteriophages with cefiderocol and meropenem/vaborbactam to treat a pan-drug resistant Achromobacter species infection in a pediatric cystic fibrosis patient.

Cystic fibrosis is associated with significant morbidity and early mortality due to recurrent acute and chronic lung infections. The chronic use of multiple antibiotics without pathogen eradication increases the possibility of extensive drug resistance or even pan-drug resistance (PDR). It is imperative that new or alternative treatment options be explored. We present a clinical case of a 10-year-old female cystic fibrosis patient, infected with a PDR Achromobacter spp. She was treated with cefiderocol, meropenem/vaborbactam, and bacteriophage therapy (Ax2CJ45ϕ2) during two separate admissions in an attempt to clear her infection and restore baseline pulmonary function. The Centers for Disease Control and Prevention confirmed antibiotic susceptibilities, which showed resistance to both cefiderocol and meropenem/vaborbactam. However, after using all three agents concomitantly during the second treatment course, our patient's pulmonary function improved dramatically, and the Achromobacter spp. could not be isolated from sputum samples obtained 8 and 16 weeks after completion of therapy. Overall, the treatment regimen consisting of cefiderocol, meropenem/vaborbactam, and bacteriophage was safe and well-tolerated in our patient.

Periprosthetic joint infection with streptococcus dysgalactiae subspecies equisimilis: Case report.

Streptococcus dysgalactiae (SD) is a common pathogen among elderly population. However, to our knowledge, there is no periprosthetic joint infection case reported that is infected with Streptococcus dysgalactiae subspecies equisimilis (SDSE) in the English literature. In this article, we report a 77-year-old male patient who had undergone total knee arthroplasty three years ago and had the diagnosis of cellulitis at his leg followed by swelling, pain and hyperemia localized at his knee. Three knee aspirations were performed and the SDSE was identified. There was no direct contact of patient to animals.

Pharmacokinetics of ceftiofur sodium in Peekapoo dogs following a single intravenous and subcutaneous injection.

The present study aimed to determine the pharmacokinetic profiles of ceftiofur (as measured by ceftiofur and its active metabolites concentrations) in a small-size dog breed, Peekapoo, following a single intravenous or subcutaneous injection of ceftiofur sodium. The study population comprised of five clinically healthy Peekapoo dogs with an average body weight (BW) of 3.4 kg. Each dog received either intravenous or subcutaneous injection, both at 5 mg/kg BW (calculated as pure ceftiofur). Plasma samples were collected at different time points after the administration. Ceftiofur and its active metabolites were extracted from plasma samples, derivatized, and further quantified by high-performance liquid chromatography. The concentrations versus time data were subjected to noncompartmental analysis to obtain the pharmacokinetic parameters. The terminal half-life (t1/2 λz ) was calculated as 7.40 ± 0.79 and 7.91 ± 1.53 hr following intravenous and subcutaneous injections, respectively. After intravenous treatment, the total body clearance (Cl) and volume of distribution at steady-state (VSS ) were determined as 39.91 ± 4.04 ml hr-1  kg-1 and 345.71 ± 28.66 ml/kg, respectively. After subcutaneous injection, the peak concentration (Cmax ; 10.50 ± 0.22 µg/ml) was observed at 3.2 ± 1.1 hr, and the absorption half-life (t1/2 ka ) and absolute bioavailability (F) were calculated as 0.74 ± 0.23 hr and 91.70%±7.34%, respectively. The pharmacokinetic profiles of ceftiofur and its related metabolites demonstrated their quick and excellent absorption after subcutaneous administration, in addition to poor distribution and slow elimination in Peekapoo dogs. Based on the time of concentration above minimum inhibitory concentration (T > MIC) values calculated here, an intravenous or subcutaneous dose at 5 mg/kg of ceftiofur sodium once every 12 hr is predicted to be effective for treating canine bacteria with a MIC value of ≤4.0 µg/ml.

Poor penetration of cefcapene into aqueous humor after oral administration of cefcapene pivoxil to patients undergoing cataract surgery.

OBJECTIVES: Studies on the penetration of orally administered cephalosporins to the aqueous humor are scarce. Therefore, in this study, we determined the concentration of cefcapene, a third-generation cephalosporin administrated orally as pivalate ester (cefcapene pivoxil), in the aqueous humor of patients undergoing cataract surgery to assess its potential for preventing postoperative endophthalmitis. METHODS: Forty-four patients were administered a single dose of 100 mg cefcapene pivoxil preoperatively. Blood and aqueous humor samples were obtained at the time of surgery, and cefcapene concentrations were measured using ultra-performance liquid chromatography with tandem mass spectrometric detection. RESULTS: The samples were obtained from 41 eyes of 39 patients (two patients underwent surgery in both eyes). The median cefcapene concentrations in the aqueous humor after 1-2 h, 2-3 h, and later than 3 h were 8.3, 18.4, and 23.7 ng/mL, respectively. The median cefcapene concentrations in serum after 1-2 h, 2-3 h, and later than 3 h were 198.5, 287.2, and 170.3 ng/mL, respectively. Aqueous humor penetration of cefcapene after 1-2 h, 2-3 h, and later than 3 h was 4.1, 7.9, and 13.5% respectively. CONCLUSIONS: Aqueous humor penetration of orally-administered cefcapene pivoxil in patients undergoing cataract surgery was poor. Therefore, cefcapene pivoxil was unlikely to be effective for preventing endophthalmitis after cataract surgery.

Extended Postoperative Prophylactic Antibiotics with First-Generation Cephalosporin Do Not Reduce the Risk of Periprosthetic Joint Infection following Aseptic Revision Total Knee Arthroplasty.

Postoperative prophylactic antibiotics administered within 24 hours of primary total knee arthroplasty (TKA) have been documented to prevent periprosthetic joint infection (PJI). However, the effectiveness of this regimen is still unclear in aseptic revision TKA. The purpose of this study was to evaluate whether extended postoperative prophylactic antibiotics would reduce the PJI rate compared with the current 24-hour standard postoperative prophylactic antibiotics after aseptic revision TKA. A retrospective review of 236 patients (46 men, 190 women, 252 knees) who underwent aseptic revision TKA between 2005 and 2013 was conducted. Patients who underwent septic revision, had a positive intraoperative culture, or who had less than 2 years of follow-up were excluded. Patients were divided according to the duration of postoperative prophylactic antibiotics to standard group (76 knees, ≤ 24 hours) or extended group (176 knees, > 24 hours). PJI was determined by the Musculoskeletal Infection Society criteria. A multivariate Cox proportional hazards regression analysis was performed. The mean follow-up was 5.2 ± 2.5 years. Patients with extended postoperative prophylactic antibiotics had a lower PJI rate (1.1%) compared with standard group (3.9%), but the difference was not statistically significant (p = 0.14). Body mass index ≥ 30 kg/m2 was the only independent risk factor of PJI (adjusted hazard ratio [HR]: 9.59; 95% confidence interval [CI]: 1.07-86.04, p = 0.043). The use of extended postoperative prophylactic antibiotics was not a risk factor for PJI (adjusted HR: 0.34; 95% CI: 0.06-2.04, p = 0.238). After 10 years, the two groups had similar infection-free implant survival rate (95.9 vs. 98.9%, p = 0.15). Our findings demonstrate that extended postoperative prophylactic antibiotics did not reduce PJI rate compared with the standard group in aseptic revision TKA. A further prospective, randomized study with a standardized postoperative antibiotic protocol is necessary to address this topic. Level of evidence is prognostic Level III.

Clinical pharmacokinetics of flomoxef in prostate tissue and dosing considerations for prostatitis based on site-specific pharmacodynamic target attainment.

Flomoxef is used to treat bacterial prostatitis; however, its prostatic pharmacokinetics have not been fully clarified. Flomoxef (500 or 1000 mg) was administered to patients with benign prostatic hypertrophy (n = 54). After a 0.5-h infusion, venous blood samples were drawn at time points of 0.5-5 h, and prostate tissue samples were collected at time points of 0.5-1.5 h during transurethral resection of the prostate. The drug concentrations in plasma and prostate tissue were analyzed pharmacokinetically and used for a stochastic simulation to predict the probability of attaining pharmacodynamic target in prostate tissue. Showing dose linearity in the prostatic pharmacokinetics, flomoxef rapidly penetrated into prostate tissue, with a prostate/plasma ratio of 0.48-0.50 (maximum drug concentration) and 0.42-0.55 (area under the drug concentration-time curve). Against the tested populations of Escherichia coli, Klebsiella and Proteus species isolates, 0.5-h infusion of 1000 mg three times daily achieved a ≥90% expected probability of attaining the bactericidal target (70% of the time above the minimum inhibitory concentration [MIC]) in prostate tissue. The site-specific pharmacodynamic-based breakpoint (the highest MIC at which the target-attainment probability in prostate tissue was >90%) values were 0.25 mg/L (MIC for 90th percentile of E. coli and Klebsiella species) for 500 mg four times daily and 0.5 mg/L (MIC90 of Proteus species) for 1000 mg four times daily. These results help to fully characterize the prostatic pharmacokinetics of flomoxef, while also helping to rationalize and optimize the dosing regimens for prostatitis based on site-specific pharmacodynamic target attainment.

Use of continuous infusion ceftolozane-tazobactam with therapeutic drug monitoring in a patient with cystic fibrosis.

PURPOSE: The safe and effective use of ceftolozane-tazobactam delivered via continuous infusion in a cystic fibrosis (CF) patient with reduced body weight and presumed augmented renal clearance is reported. SUMMARY: A 30-year-old woman with CF was admitted for acute pulmonary exacerbations with positive respiratory cultures for Pseudomonas aeruginosa and extended-spectrum ß-lactamase-producing Escherichia coli. Susceptibility testing confirmed multidrug resistance, and the patient was transitioned to ceftolozane-tazobactam for definitive therapy. A novel strategy of administering ceftolozane-tazobactam 6 g by continuous i.v. infusion over 24 hours was initiated during hospitalization and continued at discharge for a total of 10 days. Therapeutic drug monitoring over the first 36 hours of the continuous infusion confirmed adequate exposure. The patient had clinical resolution with return to baseline of pulmonary function tests and no noted adverse drug events. CONCLUSION: A continuous infusion regimen of ceftolozane-tazobactam was successfully used in a CF patient with augmented renal clearance.

Dual-Pharmacophore Pyrithione-Containing Cephalosporins Kill Both Replicating and Nonreplicating Mycobacterium tuberculosis.

The historical view of ß-lactams as ineffective antimycobacterials has given way to growing interest in the activity of this class against Mycobacterium tuberculosis (Mtb) in the presence of a ß-lactamase inhibitor. However, most antimycobacterial ß-lactams kill Mtb only or best when the bacilli are replicating. Here, a screen of 1904 ß-lactams led to the identification of cephalosporins substituted with a pyrithione moiety at C3' that are active against Mtb under both replicating and nonreplicating conditions, neither activity requiring a ß-lactamase inhibitor. Studies showed that activity against nonreplicating Mtb required the in situ release of the pyrithione, independent of the known class A ß-lactamase, BlaC. In contrast, replicating Mtb could be killed both by released pyrithione and by the parent ß-lactam. Thus, the antimycobacterial activity of pyrithione-containing cephalosporins arises from two mechanisms that kill mycobacteria in different metabolic states.

Route of antibiotic prophylaxis for prevention of cerebrospinal fluid-shunt infection.

BACKGROUND: The main complication of cerebrospinal fluid (CSF) shunt surgery is shunt infection. Prevention of these shunt infections consists of the perioperative use of antibiotics that can be administered in five different ways: orally; intravenously; intrathecally; topically; and via the implantation of antibiotic-impregnated shunt catheters. OBJECTIVES: To determine the effect of different routes of antibiotic prophylaxis (i.e. oral, intravenous, intrathecal, topical and via antibiotic-impregnated shunt catheters) on CSF-shunt infections in persons treated for hydrocephalus using internalised CSF shunts. SEARCH METHODS: We conducted a systematic electronic search without restrictions on language, date or publication type. We performed the search on the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and Embase, with the help of the Information Specialist of the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group. The search was performed in January 2018. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials that studied the effect of antibiotic prophylaxis, in any dose or administration route, for the prevention of CSF-shunt infection in patients that were treated with an internal cerebrospinal fluid shunt. Patients with external shunts were not eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from included studies. We resolved disagreements by discussion or by referral to an independent researcher within our department when necessary. Analyses were also performed by at least two authors. MAIN RESULTS: We included a total of 11 small randomised controlled trials, containing 1109 participants, in this systematic review. Three of these studies included solely children, and the remaining eight included participants of all ages. Most studies were limited to the evaluation of ventriculoperitoneal shunts. However, five studies included participants with ventriculoatrial shunts, of which one study contained four participants with a subduroperitoneal shunt. We judged four out of 11 (36%) trials at unclear risk of bias, while the remaining seven trials (64%) scored high risk of bias in one or more of the components assessed.We analysed all included studies in order to estimate the effect of antibiotic prophylaxis on the proportion of shunt infections regardless of administration route. Although the quality of evidence in these studies was low, there may be a positive effect of antibiotic prophylaxis on the number of participants who had shunt infections (RR 0.55, 95% CI 0.36 to 0.84), meaning a 55% reduction in the number of participants who had shunt infection compared with standard care or placebo.Within the different administration routes, only within intravenous administration of antibiotic prophylaxis there may be evidence of an effect on the risk of shunt infections (RR 0.55, 95% CI 0.33 to 0.90). However, this was the only route that contained more than two studies (8 studies; 797 participants). Evidence was uncertain for both, intrathecal administration of antibiotics (RR 0.73, 95% CI 0.28 to 1.93, 2 studies; 797 participants; low quality evidence) and antibiotic impregnated catheters (RR 0.36, 95% CI 0.10 to 1.24, 1 study; 110 participants; very low quality evidence) AUTHORS' CONCLUSIONS: Antibiotic prophylaxis may have a positive effect on lowering the number of participants who had shunt infections. However, the quality of included studies was low and the effect is not consistent within the different routes of administration that have been analysed. It is therefore uncertain whether prevention of shunt infection varies by different antibiotic agents, different administration routes, timing and doses; or by characteristics of patients, e.g. children and adults. The results of the review should be seen as hypothesis-generating rather than definitive, and the results should be confirmed in adequately powered trials or large multicentre studies in order to obtain high-quality evidence in the field of ventricular shunt infection prevention.

Presença de resíduo de ceftiofur no leite / Presence of ceftiofur residue in milk

Atualmente um novo grupo de fármaco vem ganhando destaque para tratamento de mastite clínica em bovinos: as cefalosporinas. Neste grupo encontra-se o ceftiofur; um antimicrobiano bactericida de amplo espectro que segundo os laboratórios não apresenta período de carência por não ser excretado via leite. Este estudo teve como objetivo analisar o leite de animais tratados com este medicamento. Cinco animais positivos para a afecção foram selecionados e tratados durante cinco dias, com dose de 1mg/Kg e aplicação com intervalo de 24 horas. A cada 12 horas foi realizada a análise do leite com o teste qualitativo Beta Star Combo®. Após a aplicação da droga todos os animais apresentaram resíduos no leite. Um animal teve carência até 60 horas, três animais com 84 horas e um animal 120 horas após última aplicação. Isso mostra que o ceftiofur apresenta carência tendo efeito residual significativo quando usado via sistêmico, necessitando-se de mais estudos para entendimento da ação do fármaco.

Post-arthroscopic septic arthritis of the knee. Analysis of the outcome after treatment in a case series and systematic literature review.

OBJECTIVE: The aim of this study was to review the characteristics of patients with septic arthritis after ACL reconstruction comparing our results with those deriving from the literature review. PATIENTS AND METHODS: Patients with suspected post arthroscopic septic arthritis of the knee occurring within 6 months after surgery were evaluated to be included in the investigation. Septic arthritis was defined by i) clinical evidence; ii) laboratory investigations; iii) synovial fluid leukocyte count of more than 2,5 x 104/µL or positive cultures obtained by synovial fluid aspirate. RESULTS: Thirty-nine patients (median age 25 years, range 17-42) with septic arthritis following ACL reconstruction were enrolled. Staphylococci were the main bacteria identified. Resolution within 4 weeks of local signs was observed more frequently in those receiving arthroscopic debridement and synovectomy coupled with antibiotic therapy (18/21 vs. 9/18, p<0.05). Fever was present in 33 (85%) cases. Fever disappearance and CRP normalization within 4 weeks were reported more frequently in patients receiving intravenous antibiotics (17/20 vs. 9/19, p<0.05). Similar findings were retrieved by literature analysis. CONCLUSIONS: An intravenous antibiotic therapy with surgical debridement is the first-line treatment for septic arthritis. Staphylococci are the main causative agents, justifying an empiric therapeutic approach with an anti-MRSA agent and cephalosporin.