Approach to antimicrobial prophylaxis for urology procedures in the era of increasing fluoroquinolone resistance.

OBJECTIVE: To evaluate rationale antimicrobial prophylaxis options in patients undergoing urologic procedures in the era of increasing fluoroquinolone resistance. DATA SOURCES: Literature was accessed through MEDLINE (1980-October 2013) using the search terms "urologic surgical procedures," "antibiotic prophylaxis," and "drug resistance." STUDY SELECTION AND DATA EXTRACTION: Pertinent article titles and abstracts were reviewed by the authors in addition to reference citations from publications. All English language publications identified were evaluated. DATA SYNTHESIS: The American Urology Association guidelines recommend fluoroquinolones (FQs) as first-line agents for preoperative prophylaxis to prevent infection after urologic procedures. Since the latest publication of these guidelines in 2008, resistance within this class of drugs has been increasing especially among common urologic pathogens like Escherichia coli. Limited data are available to support non-FQ alternatives for preoperative prophylaxis, and small studies published prior to 2000 have been conducted using such regimens with success. FQs have become the mainstay of prophylaxis in this population because of ease of administration, relatively low cost, and excellent oral bioavailability; however, ß-lactam class antimicrobials may be emerging as effective alternatives based on more favorable resistance profiles. CONCLUSIONS: Based on the current available literature, geographic areas with increasing FQ resistance should consider using cephalosporin agents as alternatives for prophylaxis in patients undergoing urologic procedures, reserving FQ in patients unable to tolerate ß-lactams because of type-1 hypersensitivity reactions or other adverse effects.

Foot and ankle infections: diagnosis and management.

Infections of the foot are a common source of morbidity, disability, and potential limb loss. A large proportion of lower extremity infections occurs in the setting of diabetic neuropathy, with or without circulatory compromise, and are potentially preventable with regular surveillance. Adequate diagnosis and treatment of foot infections can be challenging. Successful treatment is dependent on factors such as etiology; vascular, neurologic, and immune status; and the identity of the offending organism.

Evaluation of an aerosolized hydrogen peroxide disinfection system for the reduction of Clostridioides difficile hospital infection rates over a 10 year period.

BACKGROUND: Clostridioides difficile infections (CDI) cause significant morbidity and mortality in healthcare facilities worldwide. We examined the use of an aerosolized hydrogen peroxide (aHP) disinfection system for reduction of CDI rates. METHODS: We conducted a retrospective analysis of CDI rates at an acute care facility over a 10-year period. The first 5-year period investigated the before and after implementation of an aHP system followed by another 5-year period of continued use on CDI rates. RESULTS: The before and after period showed a reduction in CDI rates from 4.6 per 10,000 patient days down to 2.7 per 10,000 patient days after implementation (P < .001). The second study period for the continued aHP use exhibited a consistent decrease in CDI rates to 1.4 per 10,000 patient days at the end of the study. CONCLUSIONS: The addition of a touchless aHP whole room disinfection system as part of terminal cleaning resulted in a significant reduction in CDI rates that have been sustained year after year.

Effect of Quadrivalent Human Papillomavirus Vaccination on Oral Squamous Cell Papillomas.

IMPORTANCE: Cutaneous verruca vulgaris lesions (warts) and oral squamous cell papillomas are common lesions caused by human papillomavirus (HPV). Multiple reports have described cases of wart resolution following quadrivalent HPV vaccination. We report the case of a patient with chronic oral papillomas with resolution after quadrivalent HPV vaccination and perform a review of the literature. OBSERVATIONS: An immunocompetent man in his 60s presented with chronic verrucous papules on the lips, tongue, and buccal mucosa refractory to multiple excisions. Biopsy showed squamous cell papilloma, and DNA sequencing revealed HPV-32. He received the quadrivalent HPV vaccine resulting in clearance of all lesions after 3 months. We found 8 reported cases of disseminated, recurrent warts with resolution after quadrivalent HPV vaccination. Improvement was seen within 4 weeks of vaccination, and resolution after 3 to 8 months. CONCLUSIONS AND RELEVANCE: We report the case of recurrent oral papillomas caused by HPV-32 with complete resolution after quadrivalent HPV vaccination and reviewed reports of resolution of recalcitrant and disseminated warts after vaccination. Production of cross-protective immunoglobulins and cytotoxic T cells is a possible mechanism. There remains a critical need for randomized clinical trials to assess efficacy of quadrivalent HPV vaccination for treatment of oral squamous papillomas and cutaneous verruca vulgaris.

Self-administered preoperative antiseptic wash to prevent postoperative infection after deep brain stimulation.

BACKGROUND: Prevention of surgical site infections is critical in deep brain stimulation (DBS). In the present study, we tested the ability of a self-administered preoperative alcohol-based (70% ethyl alcohol) preparation to reduce the rate of postoperative infection after DBS surgery. METHODS: This Institutional Review Board-approved retrospective review was conducted at our institution between January 2005 and October 2007 (mean follow-up, 23 months). The participants comprised a consecutive sample of 172 patients with movement disorders who underwent DBS surgery at our institution. Starting in January 2007, all patients were required to use the alcohol-based preparation. These patients (n = 48) were instructed to self-administer the wash on the night before surgery and the morning of surgery. Before this time, no self-administered wash was used (n = 122). RESULTS: There was no difference in preoperative skin cleansing between the 2 groups, and all patients received intravenous antibiotics immediately before and after surgery for 24 hours. We compared the rate of postoperative infection in the 2 groups and reviewed other possible factors underlying infection. We found 11 cases of infection (6.47%), all in the group without the preoperative antiseptic wash. The infection rate was 9.02% in the group without the preoperative wash and 0 in the group with the preoperative wash (P < .029). There was no difference between the 2 groups in terms of mean age, duration of operative procedure, or number of microelectrode tracts attempted. CONCLUSIONS: Our results support the incorporation of this self-administered antiseptic wash into our standard antiseptic protocol for patients undergoing DBS surgery.

Risk factors associated with infection of lower extremity revascularization: analysis of 365 procedures performed at a teaching hospital.

Infection of arterial reconstructions is associated with high rates of mortality and limb loss despite optimal treatment. Lower extremity revascularization procedures performed at a teaching hospital were reviewed to identify risk factors associated with wound infection. Medical records, postoperative infection surveillance forms, and a computerized vascular registry for lower extremity revascularizations involving a common femoral or more distal artery during a 3-year period were reviewed. There were 335 bypass operations (184 femoral-distal, 36 popliteal-distal, 17 aortofemoral, 13 femorofemoral, 11 axillofemoral, 74 graft revisions) and 30 other vascular procedures (arterial thrombectomy or endarterectomy). Factors analyzed included age, gender, diabetes mellitus, dialysis dependence, malnutrition, obesity, ipsilateral foot ulcer or gangrene, separate admissions within the month preceding surgery, length of hospital stay before surgery, length of operation, wound hematoma requiring reoperation, vein or prosthetic grafts, or redo surgery. Risk factors commonly thought to increase wound infection following lower extremity revascularizations, such as diabetes, obesity, renal failure, redo surgery, and prosthetic grafts, did not predict this complication in this series. Given the correlation of operative time with infection, efforts to minimize operative time by "double-teaming" staff participation in teaching cases may decrease infection rates, although this is speculative. Vascular services should institute strategies to ensure that appropriate prophylactic antibiotics are administered in a timely fashion before lower extremity revascularizations.