Evidence-Based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-Site Infections in Plastic and Reconstructive Surgery.

BACKGROUND: After nearly a decade of new data, the Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons was updated for prophylactic systemic antibiotics to prevent surgical-site infections (SSI). Pharmacotherapeutic concepts using antimicrobial stewardship were applied for clinical interpretation and management to optimize patient outcomes and minimize resistance. METHODS: PRISMA, Cochrane, and GRADE certainty of evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched for randomized controlled trials (RCTs). The authors included patients who had plastic and reconstructive surgery and were treated with prophylactic systemic antibiotics administered perioperatively (preoperatively, intraoperatively, or postoperatively). Comparisons were made between active interventions and nonactive interventions (placebo) at different prespecified durations to determine the development of an SSI. Meta-analyses were performed. RESULTS: The authors included 138 RCTs that met eligibility criteria. RCTs consisted of 18 breast, 10 cosmetic, 21 hand/peripheral nerve, 61 pediatric/craniofacial, and 41 reconstructive studies. The authors examined bacterial data extracted from studies for patients who did or did not take prophylactic systemic antibiotics for prevention of SSI. Clinical recommendations were provided using level I evidence. CONCLUSIONS: Surgeons have long been overprescribing systemic antibiotic prophylaxis in plastic and reconstructive surgery. Evidence supports antibiotic prophylaxis to prevent SSI for specific indications and durations. Prolonged antibiotic use has not been linked to reductions in SSIs, and misuse may increase the bacterial diversity of infections. Greater efforts should focus on transitioning from practice-based to pharmacotherapeutic evidence-based medicine. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

EARLY INITIATION OF VASOPRESSIN REDUCES ORGAN FAILURE AND MORTALITY IN SEPTIC SHOCK.

ABSTRACT: Purpose : The aim of the study is to determine whether initiating vasopressin earlier in septic shock reduces organ dysfunction and in-hospital all-cause mortality. Methods : This multicenter, retrospective, cohort study evaluated patients admitted to the medical intensive care unit between October 2011 and August 2018 with septic shock who received vasopressin within 48 hours of shock onset. The primary composite outcome was the proportion of patients with a change in the Sequential Organ Failure Assessment score greater than 3 from baseline to 72 hours after initiation of vasopressin and/or in-hospital all-cause mortality. Secondary outcomes included time to hemodynamic stability, acute kidney injury, and intensive care unit length of stay. Results : A total of 385 patients included in the final evaluation with a mean Acute Physiology and Chronic Health Evaluation II score of 31 and a mean baseline Sequential Organ Failure Assessment score of 13. Median time to initiation of vasopressin after norepinephrine was 7.3 hours. The primary composite outcome was significantly reduced in patients who had vasopressin initiated earlier in septic shock (odds ratio = 1.08, 95% confidence interval = 1.03-1.13, P < 0.001). After controlling for baseline data in a multivariable regression model the primary outcome remained statistically significant (odds ratio = 1.04, 95% confidence interval = 1.02-1.07, P = 0.001). Conclusions : Early initiation of vasopressin in septic shock may reduce the risk of in-hospital all-cause mortality and/or organ dysfunction.

Management of Chronic Hypertension Following Intracerebral Hemorrhage.

Acute blood pressure control after a cerebrovascular event is integral in the immediate care of these patients to preserve perfusion to ischemic areas and prevent intracerebral bleeding. The majority of patients with ischemic stroke or intracerebral hemorrhage (ICH) present with preexisting hypertension and therefore require a treatment plan after the acute phase. The presence of chronic hypertension after ICH has often been discussed as a modifiable risk factor for recurrent events. Clinical evidence is relatively lacking for clinicians to understand the extent of blood pressure lowering and the optimal agents to use in this setting. Limited data exist describing the long-term management of hypertension in patients after cerebrovascular events. This review provides nurses with a summary of the available literature on long-term blood pressure management to minimize the risk of secondary ICH and ischemic stroke. It focuses on oral antihypertensive medications available in the United States that may be utilized to manage chronic hypertension immediately after the postacute phase of care to lower blood pressure and to improve long-term outcomes.