Preventing complications in dermatologic surgery: Presurgical concerns.

Cutaneous surgery has become critical to comprehensive dermatologic care, and dermatologists must therefore be equipped to manage the risks associated with surgical procedures. Complications may occur at any point along the continuum of care, and therefore assessing, managing, and preventing risk from beginning to end becomes essential. This review focuses on preventing surgical complications pre- and postoperatively as well as during the surgical procedure.

Assessment of implementation of antibiotic stewardship program in surgical prophylaxis at a secondary care hospital in Ras Al Khaimah, United Arab Emirates.

Antibiotic overuse is a major factor for causing antibiotic resistance globally. However, only few studies reported the implementation and evaluation of antimicrobial stewardship programs in Gulf Cooperation Council. This study was conducted within 8-months periods to evaluate the effect of the newly implemented antibiotic stewardship program on improving the prescribing practice of surgical antibiotic prophylaxis in a secondary care hospital in the United Arab Emirates by releasing local hospital guidelines. The data of 493 in patients were documented in the predesigned patient profile form and the prescribing practice of surgical antibiotic prophylaxis for clean and clean-contaminant surgical procedures was compared and analyzed two months' prior (period A) and post (period B) the implementation of antibiotic stewardship program. The 347 patient's data (PD) were analyzed during period A and 146 PD during period B. The prescription of piperacillin/tazobactam was decreased from 2.4% from all surgical prophylaxis antibiotic orders in period A to 0% in period B. The appropriateness of the antibiotic therapy was found to differ non significantly for the selection of prophylactic antibiotic (p = 0.552) and for the timing of first dose administration (p = 0.061) between A and B periods. The total compliance was decreased non significantly (P = 0.08) from 45.3 to 40.2%. Overall, the guidelines have improved the prescribing practice of antibiotics prior to surgery. However, further improvement can be achieved by initiating educational intervention via cyclic auditing strategy.

Cefuroxime (Aprokam®) in the Prophylaxis of Postoperative Endophthalmitis After Cataract Surgery Versus Absence of Antibiotic Prophylaxis: A Cost-Effectiveness Analysis in Poland.

OBJECTIVE: The analysis aims to assess the cost-effectiveness of cefuroxime (Aprokam®) in the prophylaxis of postoperative endophthalmitis (POE) after cataract surgery compared with the absence of antibiotic prophylaxis from the National Health Fund perspective in Poland. METHODS: We performed a cost-effectiveness and cost-utility analysis using the decision tree and Markov model, respectively, for patients after cataract surgery. The efficacy of Aprokam was 0.21 (95% confidence interval [CI], 0.08-0.55) and is based on the results of the European Society of Cataract and Refractive Surgery study. According to the epidemiological data from Poland, the risk of POE is 0.377%. The costs associated with the Aprokam administration and POE treatment costs were included. We determined the utilities of the health states in the model depending on visual loss due to POE. To determine the uncertainty of estimates parameters, a one-way deterministic and probabilistic sensitivity analysis were performed. RESULTS: Using Aprokam allows avoiding 0.003 POEs per patient. The benefit from the intervention is 0.0007 quality-adjusted life years per patient in the lifetime horizon. The total costs of prophylaxis are higher at about €1.70. The cost of avoiding one POE (incremental cost-effectiveness ratio) is about €569.85. The estimated incremental cost-effectiveness utility ratio is equal to €2427.72/quality-adjusted life-years, and it is significantly lower than the cost-effectiveness threshold in Poland in 2019 (about 7.5% of the threshold). In all scenarios of performed one-way sensitivity analyses, Aprokam is cost-effective. CONCLUSIONS: In Poland, the use of Aprokam is cost-effective, with the estimated incremental cost-utility ratio significantly lower than the cost-effectiveness threshold.

Antibiotic Practices in Mohs Micrographic Surgery.

BACKGROUND: Mohs micrographic surgery is a safe procedure with low rates of infection. OBJECTIVE: To establish current antibiotic prescribing practices amongst Mohs surgeons. METHODS AND MATERIALS: 16-question survey sent to American College of Mohs Surgery members. RESULTS: 305 respondents with collectively 7,634+ years of experience. The majority performed outpatient surgery (95.0%) and avoided oral or topical antibiotics for routine cases (67.7% and 62.8%, respectively). Prophylactic antibiotics were routinely prescribed for artificial cardiac valves (69.4%), anogenital surgery (53.0%), wedge excision (42.2%), artificial joints (41.0%), extensive inflammatory skin disease (40.1%), immunosuppression (38.9%), skin grafts (36.4%), leg surgery (34.2%), and nasal flaps (30.1%). A minority consistently swabbed the nares to check for staphylococcus aureus carriage (26.7%) and decolonized carriers prior to surgery (28.0%). CONCLUSION: Disparity exists in antibiotic prescribing practices amongst Mohs surgeons. There may be under-prescription of antibiotics for high risk factors like nasal flaps, wedge excisions, skin grafts, anogenital/lower extremity site, and extensive inflammatory disease. Conversely, there may be over-prescription for prosthetic joints or cardiac valves. Increased guideline awareness may reduce post-operative infections and costs/side effects from antibiotic over-prescription. J Drugs Dermatol. 2020;19(5): doi:10.36849/JDD.2020.4695.

Compliance with national guidelines for antibiotic prophylaxis in hip fracture patients: a quality assessment study of 13 329 patients in the Norwegian Hip Fracture Register.

OBJECTIVE: We assessed compliance with new guidelines for prophylactic antibiotics in hip fracture surgery in Norway introduced in 2013. DESIGN: The data from the Norwegian Hip Fracture Register was used to assess the proportion of antibiotics given according to the national guidelines. SETTING: All hospitals in Norway performing hip fracture surgery in the period from 2011 to 2016. PARTICIPANTS: We studied 13 329 hemiarthroplasties (HAs) for acute hip fracture. MAIN OUTCOME MEASURE: Type and timing between first and last dose of prophylactic antibiotics compared with the national guidelines. RESULTS: Before the guidelines were introduced, the recommended drugs cephalotin or clindamycin was used in only 86.2% of all HAs. In 2016, one of the two recommended drugs was administered in 99.2% of HAs. However, hospitals' adaption of the recommended administration of the two drugs improved slowly, and by the end of the study period, only three out of five HAs were performed with the correct drug administered in the correct manner. We found major differences in compliance between hospitals. CONCLUSIONS: The change towards correct administration of antibiotic prophylaxis was varied both when investigating university and non-university hospitals. We suggest that both hospital leaders and the national Directorate of Health need to investigate routines for better dissemination of information and education to involved parties. Strong leadership concerning evidence-based guidelines on antibiotic prophylaxis in surgery may take away some autonomy from executing healthcare professionals, but will result in better patient care and antibiotic stewardship.

Vascular Quality Initiative assessment of compliance with Society for Vascular Surgery clinical practice guidelines on the care of patients with abdominal aortic aneurysm.

OBJECTIVE: Professional societies publish clinical practice guidelines to provide evidence-based recommendations to improve care and to reduce practice variation. However, the degree of compliance with the guidelines and its impact on outcomes have not been well defined. This study used the Vascular Quality Initiative (VQI) abdominal aortic aneurysm (AAA) registries to determine current compliance with and impact of recent Society for Vascular Surgery (SVS) AAA guidelines. METHODS: Recommendations from the SVS AAA guidelines were reviewed and assessed as to whether they could be evaluated with current VQI data sets. The degree of compliance with these individual recommendations was calculated by center and correlated with clinical outcomes. Data were analyzed by univariate analysis and mixed effects multivariable logistic regression. Statistical significance was measured at P < .05. RESULTS: Of the 111 SVS recommendations, 10 could be evaluated using VQI registries. The mean center-specific compliance rate ranged from 40% (smoking cessation 2 weeks before open AAA [OAAA] repair) to 99% (preservation of flow to one internal iliac artery during endovascular aneurysm repair [EVAR]). Some recommendations were associated with improved outcomes (eg, cell salvage for OAAA repair and antibiotic prophylaxis), whereas others were not (eg, EVAR at a center with >10 cases per year or door-to-intervention time <90 minutes for ruptured AAA). With multivariable analysis, compliance with preservation of flow to the internal iliac artery decreased major adverse cardiac events in EVAR and marginally decreased in-hospital and 1-year mortality in OAAA repair. Antibiotic administration decreased surgical site infection, major adverse cardiac events, and in-hospital mortality and marginally decreased respiratory complications and 1-year mortality in EVAR. Cell salvage for OAAA repair decreased 1-year mortality. Tobacco cessation before EVAR or OAAA repair decreased respiratory complications and 1-year mortality. CONCLUSIONS: The VQI registry is a valuable tool that can be used to measure compliance with SVS AAA guidelines. Compliance with recommendations was associated with improved outcomes and should be encouraged for providers. Participation in the VQI registry provides an objective assessment of performance and compliance with guidelines. VQI provider and center reports may be used as a focus for quality improvement efforts.

Getting It Right First Time: the national survey of surgical site infection rates in NHS trusts in England.

INTRODUCTION: Surgical site infections are associated with increased morbidity and mortality in patients. The Getting It Right First Time surgical site infection programme set up a national survey to review surgical site infection rates in surgical units in England. The objectives were for frontline clinicians to assess the rates of infection following selected procedures, to examine the risk of significant complications and to review current practice in the prevention of surgical site infection. METHODS: A national survey was launched in April 2017 to assess surgical site infections within 13 specialties: breast surgery, cardiothoracic surgery, cranial neurosurgery, ear, nose and throat surgery, general surgery, obstetrics and gynaecology, ophthalmology, oral and maxillofacial surgery, orthopaedic surgery, paediatric surgery, spinal surgery, urology and vascular surgery. All participating trusts prospectively identified and collected supporting information on surgical site infections diagnosed within the six-month study period. RESULTS: Data were received from 95 NHS trusts. A total of 1807 surgical site infection cases were reported. There were variations in rates reported by trusts across specialties and procedures. Reoperations were reported in 36.2% of all identified cases, and surgical site infections are associated with a delayed discharge rate of 34.1% in our survey. CONCLUSION: The Getting It Right First Time surgical site infection programme has introduced a different approach to infection surveillance in England. Results of the survey has demonstrated variation in surgical site infection rates among surgical units, raised the importance in addressing these issues for better patient outcomes and to reduce the financial burden on the NHS. Much work remains to be done to improve surgical site infection surveillance across surgical units and trusts in England.

Surgical Antimicrobial Prophylaxis Among Pediatric Patients in South Africa Comparing Two Healthcare Settings.

BACKGROUND: Appropriate use of surgical antimicrobial prophylaxis (SAP) is a concern in view of its impact on morbidity, mortality and costs. Little is currently known about SAP in South Africa. OBJECTIVE: To assess compliance to SAP guidelines for pediatric patients undergoing surgery in 1 of 4 surgical subspecialties among hospitals in South Africa. METHODS: An eight-month retrospective chart review in both a teaching hospital and a private hospital between February and August 2015. Prescriptions of antimicrobials as SAP were compared with current SAP Guidelines, consolidated from a literature review, regarding 5 criteria-appropriate antimicrobial selection, dosing, timing of administration, redosing and duration of treatment. RESULTS: We reviewed 224 charts, 112 from each hospital type. The majority (P = 1.000) of patients received SAP when indicated (77.3% and 100.0%, respectively, from the teaching and private hospitals). A noteworthy 21.1% and 45.9% of patients received antimicrobials without an indication, respectively, from teaching and private hospitals. Compliance to all 5 of the criteria was not met by either hospital type. Overall, the teaching hospital met the most criteria (3 out of 5) in 58.8% of situations. CONCLUSIONS: Current SAP practices in South Africa's teaching and private hospitals diverge from current SAP Guidelines. Inappropriate overuse of SAP occurs in both hospital sectors, while underuse was found in the teaching hospital. Full compliance to the 5 criteria was not met by either hospital. Noncompliance was largely attributed to inappropriate selection and dosing. Quality improvement interventions, continued surveillance and local standardized evidence-based SAP Guidelines are needed to improve care. This is already happening.

Antibiotic Prophylaxis and Incidence of Endocarditis Before and After the 2007 AHA Recommendations.

BACKGROUND: The American Heart Association updated its recommendations for antibiotic prophylaxis (AP) to prevent infective endocarditis (IE) in 2007, advising that AP cease for those at moderate risk of IE, but continue for those at high risk. OBJECTIVES: The authors sought to quantify any change in AP prescribing and IE incidence. METHODS: High-risk, moderate-risk, and unknown/low-risk individuals with linked prescription and Medicare or commercial health care data were identified in the Truven Health MarketScan databases from May 2003 through August 2015 (198,522,665 enrollee-years of data). AP prescribing and IE incidence were evaluated by Poisson model analysis. RESULTS: By August 2015, the 2007 recommendation change was associated with a significant 64% (95% confidence interval [CI]: 59% to 68%) estimated fall in AP prescribing for moderate-risk individuals and a 20% (95% CI: 4% to 32%) estimated fall for those at high risk. Over the same period, there was a barely significant 75% (95% CI: 3% to 200%) estimated increase in IE incidence among moderate-risk individuals and a significant 177% estimated increase (95% CI: 66% to 361%) among those at high risk. In unknown/low-risk individuals, there was a significant 52% (95% CI: 46% to 58%) estimated fall in AP prescribing, but no significant increase in IE incidence. CONCLUSIONS: AP prescribing fell among all IE risk groups, particularly those at moderate risk. Concurrently, there was a significant increase in IE incidence among high-risk individuals, a borderline significant increase in moderate-risk individuals, and no change for those at low/unknown risk. Although these data do not establish a cause-effect relationship between AP reduction and IE increase, the fall in AP prescribing in those at high risk is of concern and, coupled with the borderline increase in IE incidence among those at moderate risk, warrants further investigation.

Antibiotic use in a tertiary healthcare facility in Ghana: a point prevalence survey.

Background: The global rise and spread of antibiotic resistance is limiting the usefulness of antibiotics in the prevention and treatment of infectious diseases. The use of antibiotic stewardship programs guided by local data on prescribing practices is a useful strategy to control and reduce antibiotic resistance. Our objective in this study was to determine the prevalence and indications for use of antibiotics at the Korle-Bu Teaching Hospital Accra, Ghana. Methods: An antibiotic point prevalence survey was conducted among inpatients of the Korle-Bu Teaching Hospital between February and March 2016. Folders and treatment charts of patients on admission at participating departments were reviewed for antibiotics administered or scheduled to be administered on the day of the survey. Data on indication for use were also collected. Prevalence of antibiotic use was determined by dividing the number of inpatients on antibiotics at the time of survey by the total number of patients on admission. Results: Of the 677 inpatients surveyed, 348 (51.4%, 95% CI, 47.6-55.2) were on treatment with antibiotics. Prevalence was highest among Paediatric surgery where 20/22 patients (90.9%, 95% CI, 70.8-98.9) were administered antibiotics and lowest among Obstetrics patients with 77/214 (36%, 95% CI, 29.5-42.8). The indications for antibiotic use were 245/611 (40.1%) for community-acquired infections, 205/611 (33.6%) for surgical prophylaxis, 129/611 (21.1%) for healthcare associated infections and 33/611 (5.4%) for medical prophylaxis. The top five antibiotics prescribed in the hospital were metronidazole 107 (17.5%), amoxicillin-clavulinic acid 82 (13.4%), ceftriaxone 17(12.1%), cefuroxime 61 (10.0%), and cloxacillin 52 (8.5%) respectively. Prevalence of meropenem and vancomycin use was 12(2%) and 1 (.2%) respectively. The majority of patients 181 (52%) were being treated with two antibiotics. Conclusion: This study indicated a high prevalence of antibiotic use among inpatients at the Korle-Bu Teaching Hospital. Metronidazole was the most commonly used antibiotic; mainly for surgical prophylaxis. There is the need to further explore factors contributing to the high prevalence of antibiotic use and develop strategies for appropriate antibiotic use in the hospital.

The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm

BACKGROUND: Decision-making related to the care of patients with an abdominal aortic aneurysm (AAA) is complex. Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operative risk, and need to intervene. Careful attention to the choice of operative strategy along with optimal treatment of medical comorbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative surveillance is necessary to minimize subsequent aneurysm-related death or morbidity. METHODS: The committee made specific practice recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. Three systematic reviews were conducted to support this guideline. Two focused on evaluating the best modalities and optimal frequency for surveillance after endovascular aneurysm repair (EVAR). A third focused on identifying the best available evidence on the diagnosis and management of AAA. Specific areas of focus included (1) general approach to the patient, (2) treatment of the patient with an AAA, (3) anesthetic considerations and perioperative management, (4) postoperative and long-term management, and (5) cost and economic considerations. RESULTS: Along with providing guidance regarding the management of patients throughout the continuum of care, we have revised a number of prior recommendations and addressed a number of new areas of significance. New guidelines are provided for the surveillance of patients with an AAA, including recommended surveillance imaging at 12-month intervals for patients with an AAA of 4.0 to 4.9 cm in diameter. We recommend endovascular repair as the preferred method of treatment for ruptured aneurysms. Incorporating knowledge gained through the Vascular Quality Initiative and other regional quality collaboratives, we suggest that the Vascular Quality Initiative mortality risk score be used for mutual decision-making with patients considering aneurysm repair. We also suggest that elective EVAR be limited to hospitals with a documented mortality and conversion rate to open surgical repair of 2% or less and that perform at least 10 EVAR cases each year. We also suggest that elective open aneurysm repair be limited to hospitals with a documented mortality of 5% or less and that perform at least 10 open aortic operations of any type each year. To encourage the development of effective systems of care that would lead to improved outcomes for those patients undergoing emergent repair, we suggest a door-to-intervention time of <90 minutes, based on a framework of 30-30-30 minutes, for the management of the patient with a ruptured aneurysm. We recommend treatment of type I and III endoleaks as well as of type II endoleaks with aneurysm expansion but recommend continued surveillance of type II endoleaks not associated with aneurysm expansion. Whereas antibiotic prophylaxis is recommended for patients with an aortic prosthesis before any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, antibiotic prophylaxis is not recommended before respiratory tract procedures, gastrointestinal or genitourinary procedures, and dermatologic or musculoskeletal procedures unless the potential for infection exists or the patient is immunocompromised. Increased utilization of color duplex ultrasound is suggested for postoperative surveillance after EVAR in the absence of endoleak or aneurysm expansion. CONCLUSIONS: Important new recommendations are provided for the care of patients with an AAA, including suggestions to improve mutual decision-making between the treating physician and the patients and their families as well as a number of new strategies to enhance perioperative outcomes for patients undergoing elective and emergent repair. Areas of uncertainty are highlighted that would benefit from further investigation in addition to existing limitations in diagnostic tests, pharmacologic agents, intraoperative tools, and devices

Compliance With a Comprehensive Antibiotic Protocol Improves Infection Incidence in Pediatric Spine Surgery.

BACKGROUND: A multidisciplinary task force, designated Target Zero, has developed protocols for prevention of surgical site infection (SSI) for spine surgery at our institution. The purpose of this study was to evaluate how compliance with an antibiotic bundle impacts infection incidences in pediatric spine surgery. METHODS: After institutional review board approval, a consecutive series of 511 patients (517 procedures) who underwent primary spine procedures from 2008 to 2012 were retrospectively reviewed to identify patients who developed SSI. Patients were followed for a minimum of 90 days postoperatively. Compliance data were collected prospectively in 511 consecutive patients and a total of 517 procedures. Three criteria were required for antibiotic bundle compliance: appropriate antibiotics completely administered within 1 hour before incision, antibiotics appropriately redosed intraoperatively for blood loss and time, and antibiotics discontinued within 24 hours postoperatively. A multivariable logistic regression analysis was used to test the association between compliance and the development of an infection. RESULTS: Overall antibiotic bundle compliance rate was 85%. After adjusting for risk category, estimated blood loss, and study year, the likelihood of an infection was increased in the noncompliant group compared with the compliant group (adjusted odds ratio: 3.0, 95% CI, 0.96-9.47, P=0.0587). When expressed as the number needed to treat, strict adherence to antibiotic bundle compliance prevented 1 SSI within 90 days of surgery for every 26 patients treated with the antibiotic bundle. Reasons for noncompliance included failure to infuse preoperative antibiotics 1 hour before incision (10.3%), failure to redose antibiotics intraoperatively based on time or blood loss (5.5%), and failure to discontinue antibiotics within 24 hours postoperatively (1.9%). CONCLUSIONS: Compliance with a comprehensive antibiotic protocol can lead to meaningful reductions in SSI incidences in pediatric spine surgery. Institutions should focus on improving compliance with prophylactic antibiotic protocols to decrease SSI in pediatric spine surgery. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

2016 guideline strategies for the use of antifungal agents in patients with hematological malignancies or hematopoietic stem cell transplantation recipients in Taiwan.

The Infectious Diseases Society of Taiwan (IDST), the Hematology Society of Taiwan, the Taiwan Society of Blood and Marrow Transplantation, Medical Foundation in Memory of Dr. Deh-Lin Cheng, Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Education, and CY Lee's Research Foundation for Pediatric Infectious Diseases and Vaccines cooperatively published this guideline for the use of antifungal agents in hematological patients with invasive fungal diseases (IFDs) in Taiwan. The guideline is the first one endorsed by IDST focusing on selection of antifungal strategies, including prophylaxis, empirical (or symptom-driven) and pre-emptive (or diagnostic-driven) strategy. We suggest a risk-adapted dynamic strategy and provide an algorithm to facilitate decision making in population level as well as for individual patient. Risk assessment and management accordingly is explicitly emphasized. In addition, we highlight the importance of diagnosis in each antifungal strategy among five elements of the antimicrobial stewardship (diagnosis, drug, dose, de-escalation and duration). The rationale, purpose, and key recommendations for the choice of antifungal strategy are summarized, with concise review of international guidelines or recommendation, key original articles and local epidemiology reports. We point out the interaction and influence between elements of recommendations and limitation of and gap between evidences and daily practice. The guideline balances the quality of evidence and feasibility of recommendation in clinical practice. Finally, this version introduces the concept of health economics and provides data translated from local disease burdens. All these contents hopefully facilitate transparency and accountability in medical decision-making, improvements in clinical care and health outcomes, and appropriateness of medical resource allocation.

Assessment of implementability of an adapted clinical practice guideline for surgical antimicrobial prophylaxis at a tertiary care university hospital.

RATIONALE, AIMS AND OBJECTIVES: Surgical site infections are the most common healthcare-associated infections. Appropriate surgical antimicrobial prophylaxis (SAP), which is an integral part of surgical site infection SSI prevention, is one of the major preventable risks to surgical patient safety. Several clinical practice guidelines (CPGs) for SAP have been published. The aim of this study was to adapt a CPG for SAP and to assess its implementability. METHODS: The methodology was based on two validated tools for CPGs, namely, the ADAPTE and the Guideline Implementability Appraisal (GLIA). RESULTS: The ADAPTE CPG adaptation process methodology was utilized to produce an adapted CPG for SAP based on the American Society of Health System Pharmacists 2013 CPG. The finalized CPG was then assessed to identify any possible intrinsic barriers for implementation. CONCLUSIONS: In conclusion, the ADAPTE tool is a practical and successful tool for production of CPGs. The GLIA tool is useful for assessing and preparing the finalized adapted CPG for the transition from the production stage to the implementation stage. GLIA could be added to the ADAPTE process either as a final step or to check the draft of the CPG before finalization.

[Assessment of antibiotic prophylaxis adequacy in rectal surgery]. / Evaluación de la adecuación de la profilaxis antibiótica en la cirugía de recto.

OBJECTIVE: Antibiotic prophylaxis is the most suitable tool for preventing surgical site infection (SSI), so the development of guidelines and assessment of its monitoring is essential. In this study protocol compliance of antibiotic prophylaxis in rectal surgery and the effect of its adequacy in terms of pre-ention of SSI was assessed. METHODS: Prospective cohort study was conducted from 1 January 2009 to 30 December 2015. The degree of compliance with antibiotic prophylaxis and causes of non-compliance in rectal surgery was evaluated. The incidence of SSI was studied after a maximum period of 30 days of incubation. To assess the effect of prophylaxis non-compliance on SSI the relative risk (RR) adjusted with the aid of a logistic regression model was used. RESULTS: The study covered a total of 244 patients. The patients infected reached 20 cases with a SSI cumulative incidence of 8.2% (CI95%: 4.8-11.6). Antibiotic prophylaxis was indicated in all patients and was administered in 98% of cases, with an overall protocol compliance 92.5%. The principal cause of non-compliance was the choice of antibiotic 55.6% (n=10). The effect of inadequacy of antibiotic prophylaxis on surgical infection was RR=0.58, CI95%: 0.10-4.10 (P>0.05). CONCLUSIONS: Compliance with antibiotic prophylaxis was high. No relationship between the adequacy of prophylaxis and incidence of surgical site infection in rectal surgery was found.

Pre-treatment clinical assessment in head and neck cancer: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. This paper provides recommendations on the pre-treatment clinical assessment of patients presenting with head and neck cancer. Recommendations • Comorbidity data should be collected as it is important in the analysis of survival, quality of life and functional outcomes after treatment as well as for comparing results of different treatment regimens and different centres. (R) • Patients with hypertension of over 180/110 or associated target organ damage, should have antihypertensive medication started pre-operatively as per British Hypertension Society guidelines. (R) • Rapidly correcting pre-operative hypertension with beta blockade appears to cause higher mortality due to stroke and hypotension and should not be used. (R) • Patients with poorly controlled or unstable ischaemic heart disease should be referred for cardiology assessment pre-operatively. (G) • Patients within one year of drug eluting stents should be discussed with the cardiologist who was responsible for their percutaneous coronary intervention pre-operatively with regard to cessation of antiplatelet medication due to risk of stent thrombosis. (G) • Patients with multiple recent stents should be managed in a centre with access to interventional cardiology. (G) • Surgery after myocardial infarction should be delayed if possible to reduce mortality risk. (R) • Patients with critical aortic stenosis (AS) should be considered for pre-operative intervention. (G) • Clopidogrel should be discontinued 7 days pre-operatively; warfarin should be discontinued 5 days pre-operatively. (R) • Patients with thromboembolic disease or artificial heart valves require heparin therapy to bridge peri-operative warfarin cessation, this should start 2 days after last warfarin dose. (R) • Cardiac drugs other than angotensin-converting enzyme inhibitors and angiotensin II antagonists should be continued including on the day of surgery. (R) • Angotensin-converting enzyme inhibitors and angiotensin II antagonists should be withheld on the day of surgery unless they are for the treatment of heart failure. (R) • Post-operative care in a critical care area should be considered for patients with heart failure or significant diastolic dysfunction. (R) • Patients with respiratory disease should have their peri-operative respiratory failure risk assessed and critical care booked accordingly. (G) • Patients with severe lung disease should be assessed for right heart disease pre-operatively. (G) • Patients with pulmonary hypertension and right heart failure will be at extraordinarily high risk and should have the need for surgery re-evaluated. (G) • Perioperative glucose readings should be kept within 4-12 mmol/l. (R) • Patients with a high HbA1C facing urgent surgery should have their diabetes management assessed by a diabetes specialist. (G) • Insulin-dependent diabetic patients must not omit insulin for more than one missed meal and will therefore require an insulin replacement regime. (R) • Patients taking more than 5 mg of prednisolone daily should have steroid replacement in the peri-operative period. (R) • Consider proton pump therapy for patients taking steroids in the peri-operative phase if they fit higher risk criteria. (R) • Surgery within three months of stroke carries high risk of further stroke and should be delayed if possible. (R) • Patients with rheumatoid arthritis should have flexion/extension views assessed by a senior radiologist pre-operatively. (R) • Patients at risk of post-operative cognitive dysfunction and delirium should be highlighted at pre-operative assessment. (G) • Patients with Parkinson's disease (PD) must have enteral access so drugs can be given intra-operatively. Liaison with a specialist in PD is essential. (R) • Intravenous iron should be considered for anaemia in the urgent head and neck cancer patient. (G) • Preoperative blood transfusion should be avoided where possible. (R) • Where pre-operative transfusion is essential it should be completed 24-48 hours pre-operatively. (R) • An accurate alcohol intake assessment should be completed for all patients. (G) • Patients considered to have a high level of alcohol dependency should be considered for active in-patient withdrawal at least 48 hours pre-operatively in liaison with relevant specialists. (R) • Parenteral B vitamins should be given routinely on admission to alcohol-dependent patients. (R) • Smoking cessation, commenced preferably six weeks before surgery, decreases the incidence of post-operative complications. (R) • Antibiotics are necessary for clean-contaminated head and neck surgery, but unnecessary for clean surgery. (R) • Antibiotics should be administered up to 60 minutes before skin incision, as close to the time of incision as possible. (R) • Antibiotic regimes longer than 24 hours have no additional benefit in clean-contaminated head and neck surgery. (R) • Repeat intra-operative antibiotic dosing should be considered for longer surgeries or where there is major blood loss. (R) • Local antibiotic policies should be developed and adhered to due to local resistance patterns. (G) • Individual assessment for venous thromboembolism (VTE) risk and bleeding risk should occur on admission and be reassessed throughout the patients' stay. (G) • Mechanical prophylaxis for VTE is recommended for all patients with one or more risk factors for VTE. (R) • Patients with additional risk factors of VTE and low bleeding risk should have low molecular weight heparin at prophylactic dose or unfractionated heparin if they have severe renal impairment. (R).

Risk-benefit assessment for antibiotic prophylaxis in asplenic dental patients.

A review of the published literature revealed that discourse on the topic of antibiotic prophylaxis guidelines for the asplenic dental patient is limited and that guidelines regarding this issue have not been updated for years. The review determined that the professional protocol for the treatment of asplenic dental patients has changed over the last 30 years, particularly with reference to adult patients. Furthermore, as dentists and physicians now understand that blood-borne bacteremias are produced from everyday occurrences such as chewing and toothbrushing, bacteremias secondary to dental procedures are no longer viewed as seriously as in the past; therefore, the guidelines for antibiotic prophylaxis have changed. Antibiotic prophylaxis is not routinely indicated prior to dental procedures for asplenic adult dental patients without risk factors. However, antibiotic prophylaxis should be considered for young children, immunocompromised patients with underlying causative disease, or any patient during the first 3 years after a splenectomy.

Antibiotic Use in Primary Palatoplasty: A Survey of Practice Patterns, Assessment of Efficacy, and Proposed Guidelines for Use.

BACKGROUND: The literature provides no guidelines for antibiotic use in palatoplasty. The authors sought to ascertain practice patterns; review a large, single-surgeon experience, and propose guidelines for antibiotic use in primary palatoplasty. METHODS: A six-question survey was e-mailed to all surgeons of the American Cleft Palate-Craniofacial Association. A retrospective study was also conducted of the senior author's 10-year primary palatoplasty series, and two groups were studied. Group 1 received no antibiotics. Group 2 received preoperative and/or postoperative antibiotics. RESULTS: Three hundred twelve of 1115 surgeons (28 percent) responded to the survey. Eighty-five percent administered prophylactic antibiotics, including 26 percent who used a single preoperative dose. A further 23 percent gave 24 hours of postoperative therapy; 12 percent used 25 to 72 hours, 16 percent used 4 to 5 days, and 12 percent used 6 to 10 days. Five percent of surgeons administered penicillin, 64 percent administered a first-generation cephalosporin, 13 percent administered ampicillin/sulbactam, and 8 percent gave clindamycin. The authors reviewed 311 patients; 173 receive antibiotics and 138 did not. Delayed healing and fistula rates did not differ between groups: 16.8 percent versus 15.2 percent (p = 0.71) and 2.9 percent versus 1.4 percent (p = 0.47), respectively. A single patient treated without antibiotics developed a postoperative bacteremia. This case did not meet the Centers for Disease Control definition of a surgical site infection, but the patient developed a palatal fistula. CONCLUSIONS: Antibiotic use in primary palatoplasty varies widely. The authors' data support a clinician's choice to forego antibiotic use; however, given the significance of palatal fistulae and the single case of postoperative streptococcal bacteremia, the study group recommends a single preoperative dose of ampicillin/sulbactam. Current evidence cannot justify the use of protracted antibiotic regimens. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.