Perceptions of surgeons on surgical antibiotic prophylaxis use at an urban tertiary hospital in Tanzania.

BACKGROUND: Surgical Site Infections are a major cause of morbidity and mortality among operated patients. In spite of the accessibility of universal and national guidelines for surgical prophylaxis, recent studies surveying the present routine of prophylaxis have demonstrated overutilization of a wide range antibacterial medication for a single patient. Few studies have shown qualitatively factors influencing this and perceptions of surgeons on surgical antibiotic prophylaxis use. Unfortunately, none of these studies have been done in Tanzania. OBJECTIVE: To describe the perceptions of surgeons on surgical antibiotic prophylaxis use at an urban tertiary hospital. METHODS: A qualitative study involving in-depth interviews with surgeons was conducted in English by the primary investigator. The interviews were audio-recorded and transcribed verbatim. Systematic text condensation by Malterud was used for data analysis. FINDINGS: Fourteen surgeons and obstetrics and gynaecologists participated. Their perceptions were summarized into three main categories: Inadequate data to support practice; one who sees the patient decides the antibiotic prophylaxis; prolonged antibiotic use for fear of unknown. The participants perceived that choice of antibiotic should be based on local hospital data for bacterial resistance pattern, however the hospital guidelines and data for surgical site infection rates are unknown. Fear of getting infection and anticipating complications led to prolonged antibiotics use. CONCLUSION: The study provides an understanding of surgical antibiotic prophylaxis use and its implementation challenges. This was partly expressed by unavailability of local data and guidelines to enhance practice. To improve this, there is a need of guidelines that incorporates local resistance surveillance data and enhanced antibiotic stewardship programmes. A strong consideration should be placed into ways to combat the fears of surgeons for complications, as these significantly affect the current practise with use of surgical antibiotic prophylaxis.

Peri-Operative Intracameral Antibiotics: The Perfect Storm?

In our University journal club we discussed a large, retrospective study of cataract surgery endophthalmitis rates before and after instituting the use of an intracameral fluoroquinolone antibiotic. We identified several factors involved in the use of off-label, compounded moxifloxacin in intraocular surgery. The introduction of phacoemulsification for cataract surgery led to the potential for smaller incisions. Intraocular lens technology improved to allow for foldable lenses, obviating the requirement to enlarge the incision. This allowed for clear corneal incisions, which unfortunately allow bidirectional passage of liquid. Preservatives were introduced into multi-dose ophthalmic products in the mid 20th century to retard microbial growth. However, more recently, chronic use of benzalkonium chloride has led to concerns about concerns about conjunctival toxicity, especially in patients with ocular surface disease. In the formulation of ocular moxifloxacin, developers were able to develop a "self-preserved", multi-dose product. Other concerns with eyedrops include varying levels of adherence and performance, and the expansion of compounding pharmacies from a named-patient basis to widespread national delivery, with concerns for lower quality. Integrating these factors, use of intracameral moxifloxacin as a prophylactic during cataract and other anterior segment surgery has become a standard of care in much of the U.S. We are concerned that the current position is on a narrow ledge-the standard of care for millions of surgeries each year based upon off-label, compounting use of a single product. We discuss possible ramifications and solutions to this public health issue.

Trends in the use of surgical antibiotic prophylaxis in general pediatric surgery: Are we missing the mark for both stewardship and infection prevention?

BACKGROUND: The purpose of this study was to assess compliance with antimicrobial spectrum guidelines in the use of surgical antibiotic prophylaxis (SAP) in pediatric surgery. METHODS: A retrospective cohort study of children undergoing elective clean-contaminated and clean surgical procedures with foreign body implantation using the Pediatric Health Information System database (10/2015-6/2018) was performed. Compliance rates with consensus guidelines surrounding appropriate spectrum of SAP coverage were calculated for each procedure. Undertreatment was defined as the use of SAP with inappropriately narrow coverage (or omission altogether), while overtreatment was defined as inappropriately broad coverage. RESULTS: Eight procedure groups including a total of 15,708 patients were included. Overall, 44% of cases received inappropriate prophylaxis, of which 58% were considered undertreatment and 42% overtreatment. Procedures with the highest rates of overtreatment included small bowel procedures (77%), colorectal procedures (29%), and hepatobiliary procedures (20%), while the highest rates of undertreatment were associated with placement of tunneled central venous catheters and ports (43%), hepatobiliary procedures (24%), and colorectal procedures (20%). CONCLUSION: Noncompliance with the recommended spectrum of coverage for surgical antibiotic prophylaxis is common in pediatric surgery, with both over and undertreatment being common themes. Improved compliance is needed to optimize both antibiotic stewardship and infection prevention. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level III.

Obesity is not strongly associated with increased risk for febrile neutropenia during levofloxacin prophylaxis in patients with hematological malignancies receiving intermediate-risk myelosuppressive chemotherapy.

Levofloxacin given at a standard dose of 500 mg daily is recommended for antibacterial prophylaxis in patients receiving myelosuppressive chemotherapy. Obese patients have been shown to exhibit enhanced clearance of levofloxacin and may be at risk for prophylactic failure. This single center, retrospective cohort study from June 2014 to May 2017 evaluated adult patients with estimated creatinine clearance ≥50 mL/min receiving their first cycle of a National Comprehensive Cancer Network defined intermediate-risk regimen. Primary endpoint was incidence of febrile neutropenia. Secondary endpoints included 30-day mortality and the correlation between estimated levofloxacin area under the concentration-time curve and rates of febrile neutropenia. Febrile neutropenia occurred in 26 patients: 12 (35.3%) obese and 14 (21.9%) non-obese (P = 0.16). Six (23.1%) of these patients required intensive care, but there were no deaths within 30 days of a febrile neutropenia event. Estimated creatinine clearance was similar between obese and non-obese patients (median 97.5 vs. 91.8 mL/min, P = 0.39), as was estimated levofloxacin area under the concentration-time curve (median 85.6 vs. 90.8 mg×h/L, P = 0.39). There were no significant associations between body weight-related variables - total body weight (median 83.4 vs. 80.6 kg, P = 0.51), body mass index (mean 29.6 vs. 26.8 kg/m2, P = 0.35), or body surface area (1.98 vs. 1.99 m2, P = 0.68) - and febrile neutropenia in this cohort of patients with similar renal function. Obesity should not be a justification for more aggressive levofloxacin dosing schemes when used for febrile neutropenia prophylaxis.

Antibiotic prophylaxis in orthopaedic surgery: Clinical practice guidelines or individualized prophylaxis? / Profilaxis antibiótica en cirugía ortopédica: ¿guías de práctica clínica o profilaxis individualizada?

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Antibiotic Use Without Indication During Delivery Hospitalizations in the United States.

OBJECTIVE: To analyze trends in unindicated antibiotic use during vaginal delivery hospitalization. METHODS: This study used an administrative database to analyze antibiotic use during delivery hospitalizations from January 2006 to March 2015. Women were classified by mode of delivery and whether they had an evidence-based indication for antibiotics. Indications for antibiotics included preterm prelabor rupture of membranes (PROM), cesarean delivery, group B streptococcus (GBS) colonization, chorioamnionitis, endometritis, urinary tract infections, and other infections. The Cochran-Armitage test was used to assess trends of antibiotic administration. Unadjusted and adjusted analyses for antibiotic receipt including demographic, hospital, and obstetric and medical factors were performed with unadjusted and adjusted risk ratios (RRs) with 95% CIs as measures of association. RESULTS: A total of 5,536,756 delivery hospitalizations, including 2,872,286 vaginal deliveries without an indication for antibiotics, were analyzed. The most common indication for antibiotics was cesarean delivery (33.6% of the entire cohort), followed by GBS colonization (15.8%), chorioamnionitis (1.7%), preterm PROM (1.6%), endometritis (1.2%), urinary tract infections (0.6%), and other infections (total less than 0.5%). The proportion of women receiving unindicated antibiotics decreased 44.4%, from 38.1% in 2006 to 21.2% in 2015. Adjusted risk for receipt of unindicated antibiotics was lower in 2015 vs 2006 (adjusted RR 0.56, 95% CI 0.55-0.57). CONCLUSION: Use of antibiotics during vaginal delivery hospitalizations without an indication for antibiotic use declined significantly based on an analysis of a large administrative data set.

Clinical and organizational management of cardiac implantable electronic device replacements: an Italian Survey promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing).

AIMS: The aim of this survey was to assess the management and organization of cardiac implantable electronic device (CIED) replacement in Italy. METHODS: A questionnaire consisting of 24 questions on organizational aspects and on the peri-procedural management of anticoagulant therapies and antibiotic prophylaxis was sent via the Internet to 154 Italian arrhythmia centers. RESULTS: A total of 103 out of 154 centers completed the questionnaire (67% response rate). In 43% of the centers, the procedures were performed under day-case admission, in 40% under ordinary admission, and in 17% under either day-case or ordinary admission. The most frequent reason (66%) for choosing ordinary admission rather than day-case admission was to obtain full reimbursement. Although warfarin therapy was continued in 73% of the centers, nonvitamin K oral anticoagulants were discontinued, without bridging, 24 h or less prior to replacement procedures in 88%. Prophylactic antibiotic therapy was systematically administered in all centers; in 97%, the first antibiotic dose was administered 1-2 h prior to procedures. Local antibacterial envelopes were also used in 43% of the centers in patients with a higher risk of device infection. CONCLUSION: This survey provides a representative picture of how CIED replacements are organized and managed in current Italian clinical practice. The choice of the type of hospitalization (short versus ordinary) was more often motivated by economic reasons (reimbursement of the procedure) than by clinical and organizational factors. Peri-procedural management of anticoagulation and prophylactic antibiotic therapy was consistent with current scientific evidence.

Extended Dosing Regimens for Fungal Prophylaxis.

Invasive fungal diseases carry high morbidity and mortality in patients undergoing chemotherapy for hematological malignancies or allogeneic hematopoietic stem cell transplantation. In order to prevent these life-threatening infections, antifungal chemoprophylaxis plays an important role in daily clinical practice. Broad-spectrum antifungal triazoles are widely used but exhibit disadvantages such as relevant drug-drug interactions. Therefore, amphotericin B products or echinocandins can be an alternative in selected patient populations. As these compounds are available as intravenous formulations only, there is growing interest in extended dosing regimens. Although not approved for these agents, this strategy is a rational option, as these compounds have properties suitable for this strategy, including dose-proportional pharmacokinetics, prolonged elimination half-life, and a large therapeutic window. As the use of extended dosing regimens in antifungal prophylaxis is expanding in clinical practice, we reviewed the pharmacokinetic and pharmacodynamic rationale for this strategy, animal model data, dose escalation studies, and clinical trials supporting this concept.

Infective Endocarditis Hospitalizations and Antibiotic Prophylaxis Rates Before and After the 2007 American Heart Association Guideline Revision.

BACKGROUND: In 2007, the American Heart Association recommended antibiotic prophylaxis for the prevention of infective endocarditis (IE) for only the highest-risk patients. Whether this change affected the use of antibiotic prophylaxis and the incidence of IE is unclear. METHODS: IE-related hospitalizations were identified from 2002 to 2014 among all adults and those at high and moderate risk for IE, stratified by age. Prescriptions for antibiotic prophylaxis were obtained from the Ontario Drug Benefit database for adults ≥65 years of age. Outcomes were antibiotic prophylaxis prescription rates and incidence of IE-related hospitalization. Trends in patient and pathogen characteristics were analyzed. Time series analyses were performed with segmented regression and change-point analyses. RESULTS: Prescriptions for antibiotic prophylaxis decreased substantially in the moderate-risk cohort after the guideline revision (mean quarterly prescriptions, 30 680 versus 17 954 [level change, -6,481; P=0.0004] per 1 million population) with a minimal, yet significant, decrease followed by a slow increase in the high-risk group. There were 7551 IE-related hospitalizations among 6884 adults ≥18 years of age. Among adults ≥65 years of age, the mean IE rate increased from 872 to 1385 and 229 to 283 per 1 million population at risk per quarter in the high- and moderate-risk groups, respectively. Change-point analyses indicated that this increase occurred in the second half of 2010 in adults ≥65 years of age, 3 years after the American Heart Association guideline revision. Staphylococcus aureus and streptococcal species accounted for 30.3% and 26.4% of all IE, with a decrease in streptococcal infections over time. CONCLUSIONS: Antibiotic prophylaxis decreased significantly in the moderate-risk group with minimal change in the high-risk group after the American Heart Association guideline revision in 2007. However, IE-related hospitalizations increased among both high- and moderate-risk patients 3 years after the revision. Our study provides support for the cessation of antibiotic prophylaxis in the moderate-risk population.

Profilaxis antibiótica en la uretrocistoscopia flexible. Perspectivas para latinoamérica y el caribe / No disponible

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Current Trends in Breast Augmentation: Analysis of 2011-2015 Maintenance of Certification (MOC) Tracer Data.

BACKGROUND: Breast augmentation is the most common aesthetic surgery performed in the United States. Despite its popularity, there is no consensus on many aspects of the procedure. OBJECTIVES: The authors assessed current trends and changes in breast augmentation from January 1, 2011 to December 31, 2015. METHODS: A retrospective cross-sectional study of 11,756 women who underwent breast augmentation based on the American Board of Plastic Surgery (ABPS) Maintenance of Certification Tracer Database was performed. RESULTS: There were clearly dominant trends in how ABPS-certified plastic surgeons performed breast augmentations. Most surgeries were performed in freestanding outpatient (47.3%) or office operating room (33.7%). The inframammary fold incision was most popular (75.1%), followed by periareolar (17.8%) and transaxillary approaches (4.1%). Implants were more commonly placed in a submuscular pocket (30.6%) compared with dual plane (26.7%) or subglandular (6.7%). Silicone implants (66.8%) were favored over saline (25.1%), with a statistically significant increase in silicone prostheses from 2011 to 2015. Data were "not applicable" or "other" in the remainder of cases. Administration of both preoperative antibiotics (3.8% in 2011, 98.7% in 2015, P < 0.05) and deep venous thromboembolism (DVT) prophylaxis (3.8% in 2011, 90.6% in 2015, P < 0.05) dramatically increased during the study period. Overall adverse events (7.4%) and reoperation rates (2.2%) were low. CONCLUSIONS: Changes in standard of care for breast augmentation are reflected by the evolving practice patterns of plastic surgeons. This is best evidenced by the dramatic increase in use of antibiotic and DVT prophylaxis from 2011 to 2015.

Pneumocystis jirovecii pneumonia (PJP) prophylaxis patterns among patients with rheumatic diseases receiving high-risk immunosuppressant drugs.

INTRODUCTION/OBJECTIVES: Pneumocystis jirovecii pneumonia (PJP) is a rare but potentially fatal opportunistic infection; however, consensus varies around which conditions or medications confer a level of risk sufficient to justify antibiotic prophylaxis for PJP. We used electronic health record (EHR) data to assess the current patterns of PJP prophylaxis, PJP outcomes, and prophylaxis-related adverse events among patients with rheumatic diseases who were receiving high-risk immunosuppressant drugs. METHODS: Data derive from the EHR of a large health system. We included new immunosuppressant users with diagnoses of vasculitis, myositis, or systemic lupus erythematosus. We calculated the proportion of patients who received PJP prophylaxis for each diagnosis and drug combination. We also calculated the number of PJP infections and the number of antibiotic adverse drug events (ADEs) per patient-year of exposure. RESULTS: We followed 316 patients for 23.2 + /- 14.2 months. Overall, 124 (39%) of patients received prophylactic antibiotics for PJP. At least 25% of patients with the highest risk conditions (e.g. vasculitis) or highest risk immunosuppressants (e.g. cyclophosphamide) did not receive PJP prophylaxis. We found no cases of PJP infection over 640 patient-years of follow up, including among those not receiving prophylaxis, and an overall incidence rate of ADEs of 2.2% per patient-year. CONCLUSIONS: PJP prophylaxis for patients with rheumatic conditions is inconsistent, with one quarter of patients who have high risk conditions or high risk immunosuppressants not receiving prophylaxis. However, given extremely low rates of PJP infection, but detectable ADEs to prophylactic antibiotics, our findings suggest that evidence to guide more personalized risk assessments are needed to inform PJP prophylaxis.

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.

Optimal timing of surgical antimicrobial prophylaxis in laparoscopic surgery: a before-after study.

Background: The optimal timing of preoperative surgical antimicrobial prophylaxis (SAP) remains uncertain. This study aimed to evaluate the impact of changing the timing of SAP on the incidence of surgical site infection (SSI) in laparoscopic surgery. Methods: We performed a before-after study from August 2014 through June 2017 to assess the impact of changes in the timing of SAP on the incidence of SSI at a 790-bed tertiary care center in Japan. The intervention was the administration of SAP immediately after the study patients entered the operating room for laparoscopic surgery. Results: In total, 1397 patients who met the inclusion criteria were analyzed. After the intervention, the median time between the time of SAP completion and the time of surgical incision changed from 8 min to 26 min (p <  0.001), and the number of cases without SAP completion prior to surgical incision decreased (16.8% vs. 1.8%; p <  0.001). However, changes in the overall incidence of SSI did not significantly differ between the pre-intervention and the intervention groups (13.8% vs. 13.2%; p = 0.80). Conclusions: Although the timing of preoperative SAP improved, the intervention did not have a significant impact on reducing the incidence of SSI in the current study. Besides preoperative SAP, multidisciplinary approaches should be incorporated into projects aimed at comprehensively improving surgical quality to reduce SSI.

Facing the facts on prophylactic antibiotics for facial fractures: 1 day or less.

BACKGROUND: To evaluate the role of initial prophylactic antibiotics on facial fractures, outcomes were compared between a short course (≤24 hours) of antibiotics to those who received an extended course (>24 hours). METHODS: Adults admitted (2010-2015) to a Level I trauma center intensive care unit with at least one facial bone fracture and major injuries isolated to the head and neck were included. Our primary analysis compared infectious complications of the head or neck (H/N infection) between patients given short or extended courses of antibiotic prophylaxis. Multivariate logistic regression and analysis of propensity score matched pairs were performed. RESULTS: A total of 403 patients were included, 85.6% had blunt injuries and 72.7% had their facial fracture managed nonoperatively. The H/N infection rate was 11.2%. Two hundred eighty patients received a short course of antibiotics and 123 patients received an extended course. Median Injury Severity Score was 14 in both groups (p = 0.78). Patients receiving an extended course of antibiotics had higher rates of H/N infection (20.3% vs. 7.1%, p < 0.001). Factors associated with development of H/N infection included younger age, penetrating injury, open fracture, upper face or mandible fracture, fractures in multiple facial thirds, vascular injury, hypertension, and extended antibiotic course. Multivariate logistic regression identified younger age (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96-1.00; p = 0.02), multiple facial third fractures (OR, 4.9; 95% CI, 2.4-10.2; p < 0.001), and penetrating mechanism (OR, 3.1; 95% CI, 1.5-6.4; p = 0.003) as independent predictors of H/N infection, but not antibiotic duration. Propensity score-matched analysis found no differences in H/N infection between short and extended antibiotic courses (11.4% vs. 12.5%; p = 1.0). Subgroup analyses demonstrated no differences in H/N infection between short or extended antibiotic courses by injury pattern, mechanism, or treatment (operative or nonoperative). CONCLUSION: These results lead us to believe that we should limit antibiotics to 24 hours or less upon admission for facial fractures. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Surgery:The way of the future.

The devastation wrought by bacterial infection in the preantibiotic era is perhaps best exemplified by the First World War. Bacterial infection in soldiers was high because of soil-contaminated shrapnel and shells. As a result, many soldiers lost life and limb. If antibiotics had been available, many may have lived. The pioneering work of Sir Alexander Fleming on the battlefields led to his discovery of penicillin which revolutionised the treatment of bacterial infections and supports so much of modern medicine.

Utilization of surgical antibiotic prophylaxis for obstetrics and gynaecology surgeries in Northern Nigeria.

Background Audit of antibiotic prophylaxis is an important strategy used to identify areas where stewardship interventions are required. Objectives To evaluate compliance with surgical antibiotic prophylaxis in obstetrics and gynaecology surgeries and determine the Defined Daily Dose (DDD) of antibiotic. Settings Three public tertiary hospitals located in Northern Nigeria. Methods This prospective study included women who had obstetrics and gynaecology surgeries with no infection at the time of incision. Appropriateness of antibiotic prophylaxis was determined by a clinical pharmacist. DDD of antibiotics was determined using ATC/DDD index 2017 from the World Health Organization Collaborating Centre for Drugs Statistics Methodology. Main outcome measure Compliance with antibiotic prophylaxis and DDD of antibiotic per procedure. Results A total of 248 procedures were included (mean age: 31.7 ± 7.9 years). Nitroimidazole in combination with either beta-lactam/beta-lactamase inhibitor or third generation cephalosporin were the most prescribed antibiotics. Redundant anaerobic antibiotic combination was detected in 71.4% of the procedures. Timing of antibiotic prophylaxis was optimal in 16.5% while duration of prophylaxis was prolonged in all the procedures (mean duration was 8.7 ± 1.0 days). The DDD of antibiotics prophylaxis was 16.75 DDD/procedure. Antibiotic utilisation was higher in caesarean section and myomectomy (17.9 DDD/procedure) than hysterectomy (14.5 DDD/procedure); P < 0.001. Redundant metronidazole represents one-third of total DDD and 87% of the DDD for metronidazole. Conclusion Excessive and inappropriate use of antibiotic prophylaxis was observed in women who had obstetrics and gynaecology surgeries. These observations underline the need for antimicrobial stewardship interventions to improve antibiotic use.