Robotic-Assisted Hip and Knee Arthroplasty: A Bibliometric Analysis Using the Scopus Database.

Robotic-assisted hip and knee arthroplasty represents cutting-edge advancements in orthopedic surgery, harnessing robotic technology to enhance precision, improve clinical outcomes, and facilitate intra-operative procedures. In these robotic-assisted surgeries, the robotic systems assist surgeons in planning and executing joint replacement surgeries, thereby facilitating personalized implant positioning and optimizing the fit and alignment of hip and knee implants. Despite the increasing attention garnered by robotic-assisted hip and knee arthroplasty in recent years, a comprehensive bibliometric analysis using the Scopus database has yet to be conducted. This bibliometric analysis reviews the Scopus database from 1961 until 2022 to investigate the literature on the field of robotic-assisted hip and knee arthroplasty. A total of 577 articles that satisfied the selection criteria were included in this review. The majority of the articles focus more on total knee replacement, compared to total hip replacement and unicompartmental knee arthroplasty. The overwhelming majority of the articles were authored by researchers and clinicians from the United States of America (USA) and the United Kingdom (UK). Similarly, most of the articles with the highest number of citations were authored by researchers and clinicians from these regions. This comprehensive bibliometric analysis using Scopus in the domain of robotic-assisted hip and knee replacement has the potential to act as a roadmap for researchers, clinicians, and policymakers, facilitating informed decision-making, promoting collaborative initiatives, and guiding the development of future studies to further advance the field of robotic-assisted hip and knee arthroplasty.

Evaluation of Feasibility of Medial Plantar Artery Flap With Computed Tomography Angiography in Diabetic Patients: A Pilot Radioanatomic Study.

Background A soft tissue defect resulting from a diabetic heel ulcer can be difficult to address due to limited reconstructive options and unique local area demand. The medial plantar artery flap is ideal for heel defect coverage as it provides a thick glabrous skin with good sensory feedback. The prerequisite of medial plantar artery flap surgery is a patent medial plantar artery, which is a branch of the posterior tibial artery (PTA). Nevertheless, no feasibility study of the medial plantar artery flap in diabetic patients with vascular insufficiency has been reported so far. We conducted a pilot study with the aim of investigating the patency of the medial plantar artery in diabetic patients with suspected peripheral artery disease to determine the vascular feasibility of the medial plantar artery flap in these patients. Material and methods A pilot study was performed at Sultan Ahmad Shah Medical Centre at International Islamic University Malaysia (IIUM). A total of 15 diabetic patients with suspected vascular insufficiency who had undergone lower limb computed tomography angiography (CTA) from January 2022 to June 2023 were included in this study. All patients were identified via the electronic record system. Lower limb CTA images were retrieved from the Radiology Information System (RIS) and Picture Archiving and Communication System (PACS) and were double-reviewed. Both the posterior tibial artery (PTA) and medial plantar artery (MPA) were assessed for their patency, and the diameter of the lumens was measured if they were patent. Bedside clinical assessments such as palpation of pulses and portable Doppler assessment were evaluated to determine whether they could serve as substitutes for computed tomography angiography (CTA) in assessing the feasibility of medial plantar artery flap using the McNemar test. Results In this study cohort, the medial plantar artery was present in 16 legs and absent in another 14 legs. The largest diameter of the medial plantar artery was 2.5mm (range 0-2.5mm). Palpation of the posterior tibial artery was not optimal for predicting the patency of the medial plantar artery, with a false positive of 21.4% and a false negative of 68.7%. Similarly, a hand-held Doppler assessment of the posterior tibial artery was also ineffective, with a false positive of 64.3% and a false negative of 18.8%. While the medial plantar artery is a continuation of the posterior tibial artery (PTA), PTA patency did not necessarily correlate with medial plantar artery patency. This was demonstrated on CTA assessment, where two legs with absent PTA still have reconstitution, resulting in patency of the medial plantar artery. Additionally, one leg with patent PTA did not have a patent medial plantar artery distally due to calcified vessels. Conclusion This is a first-of-its-kind pilot study attempting to determine the feasibility of medial plantar artery in diabetic patients with vascular insufficiency. The medial plantar artery was present in more than 50% of the investigated lower limbs, paving the way for using the medial plantar artery flap in these patients. Nevertheless, a computed tomography angiogram is essential to determine the patency of the medial plantar artery prior to the flap procedure, as palpation and hand-held Doppler were inadequate to predict the patency of the medial plantar artery in these high-risk patients.

Bibliometric Analysis of Diagnostic Yield of CT Pulmonary Angiogram (CTPA) in the Diagnosis of Pulmonary Embolism (PE).

CT pulmonary angiography (CTPA) is the investigation of choice for diagnosing pulmonary embolism (PE). Due to the speed and ease of performing the CTPA scans, more clinicians are becoming overly reliant on them, even for patients without strong suspicion of PE. We conducted a bibliometric analysis on the PubMed database from 1990 to 2022 to investigate the literature on the diagnostic yield of CTPA in the diagnosis of PE. A total of 166 articles were published in 98 journals. The number of publications has steadily increased since 2010 and peaked in 2020. Authors from 24 countries contributed to these publications, with the overwhelming majority emanating from United States of America, totaling 66 articles. The authors' contributions were relatively well spread out, with the top four authors publishing the highest number of articles at six each. When we investigated the collaboration between the authors, we found limited multinational and multi-institutional collaborations on this topic. Therefore, more multinational and multi-institutional collaborations will be valuable in future studies. In conclusion, this bibliometric analysis summarizes the literature on diagnostic yield of CTPA in the diagnosis of PE and sheds light on the future pathway that researchers and institutions can focus on.

The Role of Medial Plantar Artery Flap in Heel Pad Reconstruction: A Report of Two Cases.

The heel and sole possess unique anatomical characteristics that serve a weight-bearing and shock-absorbing function. The heel is particularly vital, as any defects in this area can lead to gait instability. Reconstructing a heel defect presents challenges, as the donor flap must be durable enough to withstand high force loads while also providing protective sensation. Recently, the medial plantar artery flap has been successfully employed for the reconstruction of defective heel pads. This flap offers glabrous skin capable of weight transmission and intact protective sensation. In this report, we present two cases of heel pad loss secondary to chronic diabetic complications and trauma, respectively, which were treated with medial plantar artery flap reconstruction. Both cases were successfully treated, and they showed a good functional outcome.

Diagnostic Yield of CT Pulmonary Angiogram in the Diagnosis of Pulmonary Embolism and Its Predictive Factors.

Introduction Computed tomography pulmonary angiography (CTPA) is the reference investigation of choice to diagnose pulmonary embolism (PE). Nevertheless, the use of CTPA should be weighed against its risks, such as radiation and contrast-induced nephropathy. We aim to assess the yield of CTPA in diagnosing PE at a tertiary centre in Malaysia. We also identify predictive factors associated with the yield of CTPA in this cohort. Methods This was a cross-sectional study involving all patients who had had CTPA done at Hospital Tengku Ampuan Afzan, Kuantan, Malaysia, from January 1, 2021, to November 30, 2021. All patients' records were retrieved and reviewed. CTPA images were retrieved from the Radiology Information System (RIS) and Picture Archiving and Communication System (PACS). They were double-reviewed by the authors, with the initial reports redacted from reporting radiologists to prevent reporting bias. The predictive factors were determined using simple logistic regression and multiple logistic regression. Results A total of 351 CTPAs were reviewed, of which 93 were found to be positive for PE, giving rise to an overall CTPA yield of 26.5%. Upon simple logistic regression, factors such as gender, discipline, history of trauma, presence of COVID-19 infection, and pneumonia were found to be associated with positive CTPA. Upon multiple logistic regression, male patients were found to have a higher chance of positive CTPA results. On the other hand, patients with COVID-19 infection and pneumonia have a lower chance of positive results in CTPA. Conclusion The yield of CTPA in diagnosing PE at our institution was acceptable at 26.5%. Upon multiple logistic regression, patients with COVID-19 infection and pneumonia were more likely to have a negative CTPA result, highlighting the need for clinicians to be more prudent in requesting CTPAs in these patients.

COVID-19 Infodemiology: Association Between Google Search and Vaccination in Malaysian Population.

Background In light of the ongoing coronavirus disease 2019 (COVID-19) pandemic, vaccination is one of the most important defensive strategies in combating the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Vaccine hesitancy or anti-vaccination attitude has become a barrier to the nationwide vaccination program, potentially sabotaging the effectiveness of vaccination. Thus far, Google Trends (GT) has been used extensively for monitoring information-seeking behavior during the pandemic. We aimed to investigate the association between Google search, the vaccination rate, and the number of vaccinated and infected cases among the Malaysian population. Material and method GT's customizable geographic and temporal filters were applied to include results for predetermined keywords from January 1, 2021, to December 31, 2021. Both Malay and English languages were used to reflect the multi-racial and multi-lingual community in Malaysia. The search volume index (SVI) derived was compared with the numbers of vaccinated and infected cases which were extracted from the open-access database (COVIDNOW in Malaysia) within the same period. Both analyses were performed independently by two authors to ensure accuracy of the data extraction process. A descriptive analysis was used to compare GT analyses and the number of daily vaccinations and positive COVID-19 cases. Results The information-seeking behavior in the public fluctuated from time to time. The interest surged during the initiation of vaccination program and upon the outbreak of COVID-19 in Malaysia. The surge in interest prior to the peak of vaccination rate also indicated that the public tended to get information online prior to getting the vaccines.  Conclusion This observational study illustrates the ability of GT to monitor the interest of vaccination among the Malaysian population during the pandemic. By monitoring the dynamic changes in Google Trends, healthcare authorities can get a glimpse of public perceptions such as attitude towards COVID-19 vaccine, hence potentially identify and stymie any dangerous online anti-vaccination rhetoric swiftly.

Malaysian Public Interest in Common Medical Problems: A 10-Year Google Trends Analysis.

Background An analysis of internet search has been performed to evaluate the public interest in health problems. Google Trends (GT) serves as a free platform to analyse the search traffic for specific terms in the Google search engine. This observational study aims to investigate the trend of Malaysian population in using the Google search engine on common medical problems and explore the geographical influence on the language used. Material and method Fifteen pairs of keywords, in Malay and English language, were chosen after going through forward and backward translation and vetting by a panel of experts. GT data for the selected keywords from 1st of January 2011 to 31st of December 2020 was extracted. Trend analysis was performed using paired t-test between the first half of the decade and the second half of the decade. The different languages used were analysed based on geographical variation using paired t-test. Results The public interest on those keywords was markedly increased in the second half of the decade with 29 out of 30 keywords showing statistically significant difference. Majority of the states preferred to use Malay keywords, especially those residing at the East Coast of Peninsular Malaysia. Conclusion This observational study illustrates the ability of GT to track healthcare interest among Malaysian population. GT provides a good platform to analyse specific healthcare interest in Malaysian population, but investigators have to bear in mind the geographical influence on the language used.

The Creation of Articulating Cement Spacer Using Custom-Fabricated Silicone Mold for the Treatment of Periprosthetic Joint Infection: Two Case Reports.

Joint replacement surgeries have been performed to treat joint arthropathies with excellent outcomes. As the number of joint replacement surgeries surges, the incidence of periprosthetic joint infection (PJI) has also increased. Currently, two-stage revision surgery is the gold standard in the treatment of periprosthetic joint infection. Two-stage revision surgery involves joint washout, the removal of the primary implant, the insertion of a cement spacer, and subsequently the reimplantation of prosthesis after the infection has been eliminated. Custom-made articulating cement spacer has been used with success to improve the patient's ambulatory status and quality of life. Nevertheless, custom-made articulating cement spacer or commercialized cement mold is generally costly. By the modification of previous authors' techniques, we manage to fabricate reusable silicone molds, which can be used to create articulating cement spacers for both hip and knee joints. We share two case reports to illustrate how these fabricated silicone molds can be a cost-effective technique to create articulating cement spacers to manage periprosthetic joint infection in both hip and knee joints. Surgeons in resource-deprived countries can utilize this technique to create articulating cement spacers with minimal cost, but they need to discuss with their patients and check with the local regulatory board on the feasibility of this technique to create cement spacer that will be used in a patient.

Arthroscopic Subacromial Decompression in the Treatment of Shoulder Impingement Syndrome: A Prospective Study in Malaysia.

Introduction Shoulder impingement syndrome (SIS) is one of the common problems which lead to shoulder disabilities. This condition has been described as impingement to the rotator cuff by the anterior third of the acromion process and has been classified into three stages. Treatment option varies depending on the grade of the disease. Arthroscopic subacromial decompression (ASAD) has become more popular in recent years and has shown to have a good outcome. The purpose of this study is to evaluate the outcomes following ASAD in terms of the functional, clinical, and radiological parameters in treating SIS in the ageing population in Kuantan, Pahang, Malaysia. Materials and methods This was an observational study looking at the outcomes of patients with stage 2 and stage 3 (partial cuff tear) impingement syndrome who underwent ASAD in Hospital Tengku Ampuan Afzan and International Islamic University Malaysia Medical Centre from May 2018 to June 2019. The functional outcomes were evaluated using American Shoulder and Elbow Surgeons (ASES) score taken at pre-operative, six weeks, three months, and six months post-operation. Clinical outcomes were evaluated using Constant score (CS) taken at six months post-operation. Radiological outcomes were measured by comparing acromiohumeral distance pre- and post-operation on anteroposterior (AP) view radiograph of the affected shoulder. Results A total of 28 patients were selected for the study. On functional outcome, there was a significant effect of time on the ASES scoring system (p-value <0.05) from pre-operative to six months post-operation. On clinical outcome, the CS at six months showed 13 patients have excellent scores, 10 have good, and five have fair scores. There was a statistically significant difference in mean values of all categories (p-value <0.05). In terms of the radiological outcome, this study observed a significant increase in patients' subacromial space on X-ray from the pre-operative and post-operative treatment stages. In this study, we also observed that there was no significant difference in outcomes between partial and intact rotator cuff (RC) tears at six-month post-operation. Conclusion In this study, ASAD was found to be a beneficial intervention in the treatment of patients with shoulder impingement evidenced by the significant outcomes in terms of functional, clinical, and radiological parameters.

COVID-19 Collateral Damage: Management of Periprosthetic Joint Infection in Malaysia.

Background and objective Periprosthetic joint infection (PJI) is one of the dreaded complications in patients after arthroplasty surgeries, owing to the risk of morbidity and arduous investigations and management associated with it. Nevertheless, as Malaysia is currently battling against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced coronavirus disease 2019 (COVID-19) pandemic head-on, the treatment for other non-life-threatening diseases including PJI has taken a backseat. In this study, we present a case series of 11 patients with PJI who were managed surgically at the largest tertiary hospital in Malaysia and we hope to shed some light on the difficulties we have encountered during this trying period. Patients and methods Patients with PJIs who underwent surgical intervention during the ongoing COVID-19 pandemic (March 1, 2020, to June 30, 2021) were reviewed and included in this study. The demographic profile of the patients, presenting complaints, prosthesis topography, biochemical investigative findings, surgical interventions, and short-term outcomes were summarized. Results A total of 11 patients were treated surgically at Hospital Kuala Lumpur for PJI. Among them, five patients are still awaiting their second-stage surgeries despite the completion of their antibiotic regimes, and they are fit for the procedure. Conclusion The COVID-19 pandemic has wreaked havoc on the treatment of patients with PJI. In a setting with scarce resources, surgeons should strongly consider single-stage revision surgeries for the treatment of patients with PJI.

Outcomes of Femoral Neck Fractures in Young Patients and the Factors Associated With Complications: A Multicenter Study From Malaysia.

Background and objective Femoral neck fractures are relatively rare in young adults, but they result in prolonged loss of function in these patients, thereby placing a huge burden on a country's healthcare and economy. Femoral neck fractures in young adults are normally treated with head salvage surgery. However, primary head replacement surgeries have been gaining traction recently to expedite the recovery of these patients. In this study, we aimed to investigate the outcomes in young patients with femoral neck fractures and factors associated with their complications. Patients and methods Patients with femoral neck fractures who underwent surgery in three tertiary hospitals [Hospital Tengku Ampuan Afzan (HTAA), Hospital Sultan Haji Ahmad Shah (HOSHAS), and Hospital Kuala Lipis] in Pahang state in Malaysia were reviewed and included in this study. The demographic profile of the patients, injury patterns, intervention details, functional outcomes, and complications were analyzed. The comparison between the sociodemographics, clinical assessment, and complication outcomes was analyzed using statistical software. Results The complications were associated with the mechanism of injury, capsulotomy, and type of fixation. A total of 46 patients were included in the study. Most of the patients were found to have severe displacement based on Garden and Pauwels classification. The majority of the patients underwent femoral head salvage surgeries. Almost half of the patients sustained complications and were unable to achieve weight-bearing status at six months postoperatively. Conclusion Despite a relatively short follow-up period in our study, femoral neck fractures in young adults were found to be associated with a high rate of complications. Primary head replacement surgeries should be considered in high-risk patients with femoral neck fractures.

Neck of Femur Fracture in Young Patients With End-Stage Renal Disease and Hyperparathyroidism: A Report of Three Cases and Proposed Treatment Algorithm.

Secondary hyperparathyroidism is a complication arising from untreated end-stage renal disease (ESRD). It can invariably lead to osteoporosis and subsequently cause pathological neck of femur (NOF) fracture. Despite being young, osteosynthesis in neck of femur fractures of these patients often leads to nonunion and implant failure due to severely osteoporotic bone. We present our experience in managing three young patients with ESRD and secondary hyperthyroidism who sustained NOF fractures. All three patients were successfully treated and showed no complication at one year post-operation. Based on our experience and literature review, we propose a simple algorithm to guide the management of these patients.

Primary B-cell Lymphoma of the Thoracic Spine: A Rare Cause of Spinal Cord Compression.

Primary non-Hodgkin lymphoma arising from the spine is exceedingly rare. Spinal cord compression can be the first presentation of a patient with primary spinal non-Hodgkin lymphoma. Due to its rarity and vague clinical presentation, the diagnosis can be confused with tuberculosis of the spine, a more common disease in this country. We present a case of primary thoracic spine B-cell lymphoma in a 45-year-old lady who presented with spinal cord compression. This case highlights the importance of obtaining histopathological samples for examination and the treating physician should be vigilant on this rare cause of spinal cord compression. Treatment can be initiated promptly once the diagnosis is established as primary spinal non-Hodgkin lymphoma carries a dire prognosis.

Scurvy: A Neglected Cause of Muscle Pain and Weakness in a Child With Picky Eating Behavior.

Ascorbic acid (vitamin C) is an essential micronutrient that the human's body cannot synthesize endogenously. Scurvy, a disease of ascorbic acid deficiency, can manifest in a myriad of presentations. Due to its rarity in the modern world, scurvy is considered as a disease of the past. We present a paediatric case of scurvy with musculoskeletal manifestations as a result of picky eating behavior.  We report a previously healthy nine-year-old boy who presented with unexplained progressive bilateral lower limb generalized weakness and pain for two months. All initial biochemical and radiological investigations were unremarkable. Upon further history taking, he had severe picky eating behavior which raised the suspicion of scurvy. The diagnosis was confirmed with a serum ascorbic acid test. After ascorbic acid supplementation, his symptoms resolved immediately. Further food behavioral modification counselling to his family members helped to change his diet in a lasting way. As a result, he had no recurrence of symptoms. This case highlights the importance of having a high index of suspicion for an uncommon disease and emphasizes the need for a detailed dietary history upon patient's presentation.

MRI Evaluation of Anterolateral Ligament of the Knee: A Cross-Sectional Study in Malaysia.

Introduction After detailed anatomical delineation of the anterolateral ligament (ALL) of the knee, there is a surge in research on this anatomical structure. Owing to the anatomical variation and lack of experience in the identification of this structure, magnetic resonance (MR) evaluation of the ALL produces mixed results. It was aimed to evaluate the ALL using the routinely performed MR imaging of the knee and to determine any associated factors with ALL injuries. Materials and methods Thirty-six MR images of the knee from 31 patients from January 1, 2017, to June 30, 2017, are evaluated. MR sequences performed include T1-weighted, T2-weighted, proton density (PD), and PD fat saturation (FS). All MR images were double-read by two authors and approved by a consultant radiologist with more than 20 years of radiological experience. The ALL was divided into three portions: femoral, meniscal, and tibial, and the ALL was considered fully visualized when all three portions were seen on MR images. Results At least a portion of the ALL was visualized in 27 scans (75%), and it was fully visualized in 20 scans (55.6%). The femoral portion was the most commonly identified (75%), followed by the meniscal portion (69.4%) and the tibial portion (58.3%). ALLs were best visualized on coronal view in PD FS with the lateral inferior genicular artery as a guide to locate the bifurcation of the meniscal and tibial components. Conclusion The ALL can be visualized in routine 1.5-T MR imaging, either full delineation (55.6%) or partially visualized (75%). It is best characterized via a PD-weighted sequence with fat saturation on the coronal plane. The ALL injury was associated with an anterior cruciate ligament (ACL) injury.

Surgical Reconstruction of an Open Medial Malleolus Fracture Using a Novel Technique: A Case Report.

CASE: A 17-year-old male sustained an open fracture of the right medial malleolus (MM) with significant bone and soft tissue loss following a motor-vehicle accident. Following serial wound debridement, his ankle was effectively reconstructed with MM antiglide plate stabilization, iliac autogenous bone graft, and a free radial forearm soft tissue flap. CONCLUSIONS: Open MM fracture with bone and soft tissue loss is rare. It is feasible to treat this injury with a novel surgical reconstruction technique involving autogenous bicortical iliac bone graft and radial forearm free flap.

Factors Associated with Deep Surgical Site Infection Following Spinal Surgery: A Pilot Study.

Introduction Surgical site infection (SSI) is the most common healthcare-related infection in surgical patients. Patients who have undergone spinal surgeries and have contracted postoperative SSI face increased morbidity and mortality, which invariably leads to additional burden on the healthcare system and higher costs. The risk factors for the increase in SSI in patients who have undergone spinal surgery have been investigated in numerous studies but no studies have been performed in Malaysia. The aim of this pilot study is to determine the incidence and factors associated with deep SSIs in patients that have undergone spinal surgeries. Methods This retrospective study includes all patients who underwent spinal surgeries at Tengku Ampuan Afzan Hospital, Kuantan, from 1 January 2016 to 31 December 2017. Patients with an active spinal infection, polytrauma, and open fractures were excluded from this study. Patient characteristics and laboratory investigations were extracted to determine the risk factors for deep SSI events. Associations between SSI and risk factors were analyzed with SPSS V21.0 (IBM, Armonk, NY). Results The univariate analysis indicated that fracture dislocation at the thoraco-lumbar junction (p=0.008) and a history of preoperative blood product transfusion (p=0.003) were associated with deep SSI. Other factors such as age (p=0.162), gender (p=0.262), body mass index (p=0.215), smoking status (0.272), number of vertebrae involved in the surgery (p=0.837), spinal cord involvement (p=0.259), postoperative hemoglobin reduction (p=0.816), and preoperative white blood cell count (p=0.278) were not associated with deep SSI. Conclusions This pilot study highlights the factors associated with deep SSI in spinal surgeries. A larger study is needed to further confirm these findings.

Microbiology of diabetic foot infections in three district hospital in Malaysia and comparison with South East Asian Countries

@#Introduction: Diabetic foot infection, a complication that is associated with lower-limb amputation, incurs a huge economic burden to the hospital and health care system of Malaysia. The bacteriological profile of pathogens in diabetic foot infections in Malaysia has been sparsely studied. We investigated the microbiology of diabetic foot infections in patients admitted to the district hospitals on the east coast of Malaysia. Methods: A retrospective analysis was conducted in three district hospitals (Hospital Kuala Lipis, Hospital Bentong and Hospital Raub) in Malaysia from 1st of January 2016 to 31st December 2016. The clinical specimens were cultured using Clinical and Laboratory Standards Institute (CLSI) guidelines. Antibiotic sensitivity testing to different antibiotics was carried out using the disc diffusion method. Result: A total of 188 pathogens were isolated from 173 patients, with an average of 1.09 pathogens per lesion. Majority of the pathogens isolated were gram negative pathogens (73.4%). The most commonly isolated pathogens were Staphylococcus aureus (17.5%). This was followed by Klebsiella spp. (17%), Pseudomonas spp. (15.4%) and Proteus spp. (13.8%). Gram positive pathogens were sensitive to most of the antibiotics tested except penicillin and fusidic acid. Gram negative pathogens were sensitive to all antibiotics tested except ampicillin and amoxicillin/clavulanic acid. Amikacin provide coverage for all gram negative pathogens in DFI. Conclusion: For the management of patient with infection in diabetic foot, the choice of antibiotic therapy depends on the sensitivity of the pathogens, the severity of the infection, the patient’s allergies history, toxicity and excretion of the antibiotics.