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1.
Br J Anaesth ; 124(1): 110-120, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31767144

RESUMO

BACKGROUND: We aimed to examine whether using a high fraction of inspired oxygen (FIO2) in the context of an individualised intra- and postoperative open-lung ventilation approach could decrease surgical site infection (SSI) in patients scheduled for abdominal surgery. METHODS: We performed a multicentre, randomised controlled clinical trial in a network of 21 university hospitals from June 6, 2017 to July 19, 2018. Patients undergoing abdominal surgery were randomly assigned to receive a high (0.80) or conventional (0.3) FIO2 during the intraoperative period and during the first 3 postoperative hours. All patients were mechanically ventilated with an open-lung strategy, which included recruitment manoeuvres and individualised positive end-expiratory pressure for the best respiratory-system compliance, and individualised continuous postoperative airway pressure for adequate peripheral oxyhaemoglobin saturation. The primary outcome was the prevalence of SSI within the first 7 postoperative days. The secondary outcomes were composites of systemic complications, length of intensive care and hospital stay, and 6-month mortality. RESULTS: We enrolled 740 subjects: 371 in the high FIO2 group and 369 in the low FIO2 group. Data from 717 subjects were available for final analysis. The rate of SSI during the first postoperative week did not differ between high (8.9%) and low (9.4%) FIO2 groups (relative risk [RR]: 0.94; 95% confidence interval [CI]: 0.59-1.50; P=0.90]). Secondary outcomes, such as atelectasis (7.7% vs 9.8%; RR: 0.77; 95% CI: 0.48-1.25; P=0.38) and myocardial ischaemia (0.6% [n=2] vs 0% [n=0]; P=0.47) did not differ between groups. CONCLUSIONS: An oxygenation strategy using high FIO2 compared with conventional FIO2 did not reduce postoperative SSIs in abdominal surgery. No differences in secondary outcomes or adverse events were found. CLINICAL TRIAL REGISTRATION: NCT02776046.


Assuntos
Oxigênio/uso terapêutico , Respiração Artificial/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Abdome/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Oxiemoglobinas/análise , Oxiemoglobinas/metabolismo , Assistência Perioperatória , Respiração com Pressão Positiva , Medicina de Precisão , Atelectasia Pulmonar/epidemiologia , Atelectasia Pulmonar/etiologia , Resultado do Tratamento
2.
Vasc Endovascular Surg ; 54(2): 147-161, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31736431

RESUMO

INTRODUCTION: Surgical site infection (SSI) presents a ubiquitous concern to surgical specialties, especially in the presence of prosthetic material. Antibiotic-impregnated beads present a novel and evolving means to combat this condition. This review aims to analyze the quality of evidence and methods of antibiotic bead use, particularly for application within vascular surgery. METHODS: A systematic scoping review was conducted within Embase, MEDLINE, and the Cochrane Registry of Randomized Controlled Trials. Articles were evaluated by 2 independent reviewers. Level of evidence was evaluated using the Oxford Center for Evidence-Based Medicine Criteria and the Cochrane Risk of Bias Tool for Randomized Controlled Trials. RESULTS: The search yielded 6951 papers, with 275 included for final analysis. Publications increased in frequency from 1978 to the present. The most common formulation was polymethyl methacrylate; however publications on biodegradable formulations, including calcium sulfate beads, have been published with increasing frequency. Most publications had positive conclusions (94.2%); however, the data was mainly subjective and may be prone to publication bias. Only 11 randomized controlled trials were identified and all but one was evaluated to be at a high risk of bias. The most common indication was for osteomyelitis (52%), orthopedic prosthetic infections (20%), and trauma (9%). Within vascular surgery, beads have been used primarily for the treatment of graft infection, with freedom from recurrence rates being reported from 41% to 87.5%. CONCLUSIONS: Antibiotic-impregnated beads provide a means to deliver high doses of antibiotic directly to a surgical site, without the risks of parenteral therapy. There has yet to be significant high-level quality data published on their use. There is a large body of evidence that suggests antibiotic beads may be used in SSIs in high-risk patients, prosthetic infections, and other complex surgical infections. Important potential areas of application in vascular surgery include graft infection, prevention of wound infection in high-risk patients, and diabetic foot infection.


Assuntos
Antibacterianos/administração & dosagem , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular/efeitos adversos , Portadores de Fármacos , Infecções Relacionadas à Prótese/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Antibacterianos/efeitos adversos , Humanos , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/microbiologia , Fatores de Risco , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/microbiologia , Resultado do Tratamento
3.
J Urol ; 203(2): 351-356, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31441676

RESUMO

PURPOSE: The primary rationale for antimicrobial prophylaxis (AP) is to decrease the incidence of surgical site infection (SSI) and other preventable periprocedural infections, with the secondary goal of reducing antibiotic overuse. This Best Practice Statement (BPS) updates the prior American Urological Association (AUA) BPS and creates a comprehensive and user-friendly reference for clinicians caring for adult patients who are undergoing urologic procedures. MATERIALS AND METHODS: Recommendations are based on a review of English language peer-reviewed literature from 2006 through October 2018 and were made by consensus by a multidisciplinary panel. The search parameters included timing, re-dosing, and duration of AP across urologic procedures where there was the possibility of SSI. Excluded from the search were the management of infections outside the genitourinary (GU) tract and pediatric procedures. RESULTS: Single-dose AP is recommended for most urologic cases and antimicrobials should only be used when medically necessary, for the shortest duration possible, and not beyond case completion. Surgeons are the most accurate discerners of an SSI, and should use standard definitions to make better calculations of patient risk. The risk classification developed is dependent on the likelihood of developing SSI, and not the associated consequences of SSI. CONCLUSIONS: The AUA developed a multi-disciplinary BPS to guide clinicians on the proper usage of AP across urologic procedures and wound classifications. It is recommended that the lowest dose of antimicrobials be administered to decrease the risk of infection and to minimize the risk of drug-resistant organisms.


Assuntos
Antibioticoprofilaxia/normas , Infecções Bacterianas/prevenção & controle , Micoses/prevenção & controle , Cuidados Pré-Operatórios/normas , Infecção da Ferida Cirúrgica/prevenção & controle , Procedimentos Cirúrgicos Urológicos , Humanos , Procedimentos Cirúrgicos Urológicos/classificação
4.
Ann Otol Rhinol Laryngol ; 129(1): 5-11, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31390881

RESUMO

OBJECTIVES: Intranasal septal splints are often used in nasal septal surgeries. Routine use of postoperative antibiotics is an accepted practice, although data regarding its efficacy in preventing postsurgical complications are limited. This study aimed to examine bacterial colonization on septal splints following prophylactic antibiotic therapy and the association with postoperative infections. METHODS: Fifty-five patients underwent septoplasty by a single surgeon between March 2015 and April 2016. All had intranasal septal splints and were given antibiotic prophylaxis for 7 days until removal of splints. Nasal cultures were taken before surgery, and septal splints were examined for bacterial colonization following their removal. RESULTS: Thirty-six patients (65%) had positive nasal culture prior to surgery. The most common isolates were Staphylococcus aureus (30%) and Enterobacteriaceae species (66%). All these patients had postoperative bacterial colonization on septal splints. In 15 patients with negative preoperative cultures, bacteria were isolated postoperatively. An increased resistance profile was documented postoperatively in 9 patients (16%), including two with multidrug resistance. In two of these patients preoperative wild-type strains acquired antibiotic resistance postoperatively. No adverse drug reactions to antibiotics were reported. CONCLUSIONS: Increased bacterial growth and emergence of resistant strains were observed on intranasal septal splints despite prophylactic antibiotic treatment. Nonetheless, this did not translate into clinical infection. Thus, considering antibiotics overuse and increasing bacterial resistance, further research is needed to determine the role of antibiotic prophylaxis in the setting of intranasal splints.


Assuntos
Antibacterianos/uso terapêutico , Antibioticoprofilaxia , Cavidade Nasal/microbiologia , Septo Nasal/cirurgia , Procedimentos Cirúrgicos Nasais/métodos , Contenções/microbiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Adolescente , Adulto , Idoso , Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Cefalexina/uso terapêutico , Técnicas de Cultura , Farmacorresistência Bacteriana , Farmacorresistência Bacteriana Múltipla , Enterobacteriaceae/isolamento & purificação , Infecções por Enterobacteriaceae/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Estafilocócicas/epidemiologia , Staphylococcus aureus/isolamento & purificação , Infecção da Ferida Cirúrgica/epidemiologia , Adulto Jovem
6.
Medicine (Baltimore) ; 98(49): e18068, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31804314

RESUMO

BACKGROUND: Surgical-site infections after primary total joint arthroplasty (TJA) are a significant issue. Antibiotic-impregnated bone cement (AIBC) has been widely used for the treatment of infected joints, but routine use of AIBC in primary TJA remains controversial. In this systematic review, we evaluated the efficacy of AIBC in reducing surgical-site infections after primary TJA. METHODS: We systematically searched Pubmed, EMbase, Cochrane Library, CMB, CNKI, and WanFang Data for studies (published until June 1, 2019) evaluating AIBC use in reducing infection rates. Two reviewers independently screened the literature according to inclusion and exclusion criteria, extracted data, and assessed the methodological quality of included studies. Meta-analysis was performed using Review Manager 5.3 software. The registration number is CRD42017078341 in PROSPERO. RESULTS: In total, 10 studies were included, resulting in a sample size of 13,909 arthroplasty cases. The overall pooled data demonstrated that, compared with systemic antibiotics, AIBC was more effective in decreasing deep infection rates (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.14-0.89, P = .030), although there were higher superficial infection rates with AIBC (OR = 1.53, 95% CI = 1.11-2.11, P = .010). Compared to systemic antibiotics alone, AIBC with systemic antibiotics significantly decreased deep infection rates (OR = 0.55, 95% CI = 0.41-0.75, P = .0001) but there was no difference in superficial infection rates (OR = 1.43, 95% CI = 0.81-2.54, P = .220). In the subgroup analysis, both randomized controlled trials and cohort studies had reduced deep infection rates after primary TJA (OR = 0.61, 95% CI = 0.37-0.99, P = .050 and OR = 0.49, 95% CI = 0.34-0.70, P = .0001, respectively). AIBC decreased deep infection rates in both total hip and knee arthroplasty (OR = 0.25, 95% CI = 0.12-0.52, P = .0002 and OR = 0.62, 95% CI = 0.45-0.87, P = .005, respectively). Deep infection rates were significantly decreased by AIBC with gentamicin (OR = 0.31, 95% CI = 0.20-0.49, P < .00001) but unaffected by AIBC with cefuroxime (OR = 0.35, 95% CI = 0.10-1.20, P = .100). Deep infection rates in the AIBC and control groups were similar when laminar airflow was applied to the operating room (OR = 0.90, 95% CI = 0.60-1.35, P = .620); however, without laminar airflow, the efficacy of AIBC in decreasing deep infection rates was significantly higher than that of control group (OR = 0.21, 95% CI = 0.08-0.59, P = .003). CONCLUSIONS: AIBC may significantly decrease deep infection rates after primary total hip and knee arthroplasty, with or without systemic antibiotics.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia/métodos , Artroplastia de Quadril/métodos , Artroplastia do Joelho/métodos , Cimentos para Ossos/química , Infecções Relacionadas à Prótese/prevenção & controle , Administração Oral , Antibacterianos/uso terapêutico , Humanos , Razão de Chances , Infecção da Ferida Cirúrgica/prevenção & controle
7.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(12): 1188-1195, 2019 Dec 25.
Artigo em Chinês | MEDLINE | ID: mdl-31874537

RESUMO

Objective: To compare the efficacy of purse-string skin closure (PSC) and linear skin closure (LSC) in stoma reversal. Methods: Randomized controlled trials (RCT) comparing the use of PSC and LSC during stoma reversal were searched from Embase, PubMed, Web of Science, CNKI net, Wanfang database, VIP Chinese Science and Technology Journal Database. Literature inclusion criteria: (1) randomized controlled trials about comparing PSC and LSC in stoma reversal published publicly; only including English literature; (2) patients undergoing stoma (ileostomy or colostomy) reversal without limitation of age, sex and ethnicity; (3) PSC group receiving the suture of the dermis layer of the skin by purse-string suture, and forming a pore channel in the center of the skin after tightening and knotting, in order to achieve the purpose of secondary healing; the LSC group receiving the suture of the skin with conventional simple interrupted suture; (4) the enrolled literatures needed to include at least one of the following outcome indicators: the primary outcome was the incidence of SSI; the secondary outcome included the operation time, incisional hernia, hospital stay and patient satisfaction. Literature exclusion criteria: (1) duplicate published studies, incomplete studies, reviews, case reports, unpublished literature, retrospective studies, non-RCT. The search time ended on November 15, 2018. The basic information and important outcome indicators of the included articles were extracted. The Cochrane bias risk assessment tool was used to evaluate the quality of the selected literatures. Patient satisfaction was assessed using the following scales: (1) the patient and observer scar assessment scale (POSAS); (2) the body image questionnaire (BIQ); (3) Likert scale; (4) short form 36 (SF-36), version 2; (5) visual analog scale (VAS). Meta-analysis was performed using Review manager 5.3 software provided by the Cochrane Collaboration. Results: A total of 9 randomized controlled trials were included, involving 806 patients with 411 cases in the PSC group and 395 cases in the LSC group. Baseline data such as age, gender, body mass index (BMI), underlying disease, and anesthesia grading were not significantly different between the two groups (all P>0.05). The quality of these nine randomized controlled trials was high. Because the evaluation methods for these studies are not uniform, it is impossible to conduct a meta-analysis of patient satisfaction. However, from the summary results of various studies, the postoperative satisfaction of the purse-string suture group was better than that of the linear suture group. The meta-analysis showed that there was significant difference in postoperative SSI incidence between the PSC group and the LSC group [OR=0.14, 95%CI: 0.08-0.24, P<0.00001], while there were no significant differences in incidence of incisional hernia [OR=0.66, 95%CI: 0.24-1.82, P=0.42], operation time [MD=0.61, 95%CI: -3.17-4.38, P=0.75], and hospital stay [MD=-0.26, 95%CI: -0.82-0.30, P=0.37]. Conclusions: PSC can be used for closure of the wound following stoma reversal. Compared with LSC, PSC can significantly reduce the incidence of SSI, and increase patients' satisfaction.


Assuntos
Anastomose Cirúrgica/métodos , Estomas Cirúrgicos , Infecção da Ferida Cirúrgica/prevenção & controle , Técnicas de Sutura , Colostomia , Humanos , Ileostomia , Ensaios Clínicos Controlados Aleatórios como Assunto , Procedimentos Cirúrgicos Reconstrutivos , Infecção da Ferida Cirúrgica/etiologia , Resultado do Tratamento
8.
Am Surg ; 85(11): 1228-1233, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31775964

RESUMO

SSIs after ventral hernia repair (VHR) represent a significant complication. The impact of postoperative prophylactic antibiotics on the SSI rates after VHRs is unclear. A systematic review of PubMed and Web of Science databases from inception through March 2016 investigating the effect of postoperative prophylactic antibiotics after VHRs was performed. Strict inclusion and exclusion criteria were implemented, and the methodological quality of the included studies was assessed. After systematic independent assessment of 216 citations, four studies, involving 344 patients, met the inclusion criteria. Among the included studies, 164 patients received >24 hours of postoperative prophylactic antibiotics, whereas 180 patients were controls. The overall incidence of SSI among patients receiving postoperative antibiotics was 14.6 per cent (95% confidence interval [CI], 9.9 to 20.9) which compares favorably with the control group: 35.5 per cent (95% CI, 28.9 to 42.7) (odds ratio: 0.3, 95% CI: 0.2 to 0.5, P < 0.01). Among patient's receiving postoperative antibiotics, the pooled average duration of postoperative antibiotic treatment was 6.2 ± 0.4 days. Based on the available evidence, the use of postoperative prophylactic antibiotics seems to be associated with lower SSI rates after VHRs. Future prospective randomized controlled trials should be conducted to further confirm the efficacy of this prophylactic intervention.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia , Hérnia Ventral/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Índice de Massa Corporal , Intervalos de Confiança , Humanos , Incidência , Pessoa de Meia-Idade , Duração da Cirurgia , Cuidados Pós-Operatórios , Infecção da Ferida Cirúrgica/epidemiologia
9.
Braz J Cardiovasc Surg ; 34(5): 588-595, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31719010

RESUMO

OBJECTIVE: To evaluate the efficacy of triclosan-coated suture for the reduction of infection in saphenectomy wounds of patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: A total of 508 patients who underwent saphenectomy in CABG surgery were included in a prospective, randomized, double-blind trial from February/2011 to June/2014. Patients were randomized into the triclosan-coated suture group (n= 251) and the conventional non-antibiotic suture group (n=257). Demographic (gender and age), clinical (body mass index, diabetes, and use of analgesics), and intraoperative (cardiopulmonary bypass and cross-clamp times) variables and those related to the saphenectomy wound (pain, dehiscence, erythema, infection, necrosis, and hyperthermia) were measured and analyzed. RESULTS: Of the 508 patients who underwent saphenectomy, 69.9% were males and 40.2% were diabetic. Thirty-three (6.5%) patients presented infection: 13 (5.3%) with triclosan and 20 (7.9%) with conventional suture (P=0.281). Among diabetic patients (n=204), triclosan suture was used in 45.1% with four cases of infection; conventional suture was used in 54.9% of them, with 11 cases of infection. Most patients (94.3%) underwent on-pump CABG. Wound pain was observed in 9.9% of patients with triclosan-coated suture and in 17.9% with conventional suture (P=0.011). Wound hyperthermia was found in 1.6% of patients with triclosan-coated suture and in 5.4% of those with conventional suture (P=0.028). CONCLUSION: Triclosan-coated suture shows lower infection rate in saphenectomy of patients undergoing CABG, although the differences were not statistically significant. Pain and wound hyperthermia were less frequent in patients with triclosan-coated sutures compared with conventional sutures.


Assuntos
Anti-Infecciosos Locais/uso terapêutico , Ponte de Artéria Coronária/métodos , Poliglactina 910/uso terapêutico , Veia Safena/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Técnicas de Sutura , Triclosan/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Ponte de Artéria Coronária/efeitos adversos , Complicações do Diabetes , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/prevenção & controle , Estudos Prospectivos , Reprodutibilidade dos Testes , Estatísticas não Paramétricas , Fatores de Tempo , Resultado do Tratamento
10.
Ned Tijdschr Tandheelkd ; 126(10): 527-532, 2019 Oct.
Artigo em Holandês | MEDLINE | ID: mdl-31613282

RESUMO

Recent literature indicates that in a healthy patient, who has sufficient bone volume to allow implant placement, it is justified to refrain from prophylactic administration of antibiotics. The patient should, however, rinse with chlorhexidine digluconate 1 day prior to treatment and at least 1 week postoperatively. In the case of an immune-compromised patient, a single antibiotic gift is indicated 1 hour before the procedure (2 grams of amoxicillin orally or 2 grams of cefazoline intravenously). In the case of a healthy patient, antibiotic (AB) prophylaxis is also indicated if autologous bone, a bone filler or membranes are applied. Although AB prophylaxis is not necessary when harvesting extraoral bone grafts, it is indicated because the harvested bone is applied intraorally in the same treatment session. The question whether postoperative administration of antibiotics is still needed remains open.


Assuntos
Antibacterianos/uso terapêutico , Antibioticoprofilaxia , Implantes Dentários , Complicações Pós-Operatórias/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Amoxicilina , Implantação Dentária Endo-Óssea , Falha de Restauração Dentária , Humanos
11.
Am Surg ; 85(10): 1139-1141, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657310

RESUMO

Decisions regarding whether to close the skin in trauma patients with hollow viscus injuries (HVIs) are based on surgeon discretion and the perceived risk for an SSI. We hypothesized that leaving the skin open would result in fewer wound complications in patients with HVIs. We performed a retrospective analysis of all adult patients who underwent operative repair of an HVI. The main outcome measure was superficial or deep SSIs. Of 141 patients, 38 (27%) had HVIs. Twenty-six patients developed SSIs, of which 13 (50%) were superficial or deep SSIs. On adjusted analysis, only female gender (P = 0.03) and base deficit were associated (P = 0.001) with wound infections Open wound management was not associated with a decreased incidence of SSIs (P = 0.19) in patients with HVIs. Further research is required to determine optimal strategies for reducing wound complications in patients sustaining HVIs.


Assuntos
Traumatismos Abdominais/cirurgia , Técnicas de Fechamento de Ferimentos Abdominais/efeitos adversos , Procedimentos Cirúrgicos Dermatológicos/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Ferida Cirúrgica/cirurgia , Técnicas de Fechamento de Ferimentos Abdominais/estatística & dados numéricos , Adulto , Antibioticoprofilaxia/estatística & dados numéricos , Procedimentos Cirúrgicos Dermatológicos/métodos , Duodeno/lesões , Feminino , Humanos , Intestino Delgado/lesões , Jejuno/lesões , Masculino , Estudos Retrospectivos , Pele , Estatísticas não Paramétricas , Estômago/lesões , Infecção da Ferida Cirúrgica/classificação , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle
12.
Cochrane Database Syst Rev ; 9: CD005360, 2019 09 26.
Artigo em Inglês | MEDLINE | ID: mdl-31557310

RESUMO

BACKGROUND: Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery. This is an update of a Cochrane Review first published in 2005 and last updated in 2014. OBJECTIVES: To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery. SEARCH METHODS: For this fourth update, in August 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: We included randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions. DATA COLLECTION AND ANALYSIS: Three review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. We contacted study authors to obtain missing information. We evaluated the certainty of evidence using the GRADE approach. We used standard methodological procedures expected by Cochrane. MAIN RESULTS: A total of 11 randomised controlled trials (2867 participants) were included in the review. No new studies were identified in this update. All studies included breast cancer patients and were based in the hospital setting. Ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with placebo or no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively probably reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.85; moderate certainty evidence). Anticipated absolute effects were calculated for the outcome incidence of SSI; 105 per 1000 for the none or placebo group and 71 per 1000 (95% CI 56 to 89) for the preoperative antibiotic prophylaxis group. Analysis of the single study comparing perioperative antibiotic with no antibiotic was inconclusive for incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95; very low certainty evidence). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.Secondary outcomes were not consistently included in the studies investigating preoperative antibiotic prophylaxis. It is very uncertain whether there is a difference in incidence of adverse events between the treatment and no treatment or placebo groups (10 studies, 2818 participants); very low certainty evidence downgraded one level for serious risk of bias, one level for serious inconsistency and one level for serious imprecision. It is unclear whether there is a difference in time to onset of infection between the treatment and no treatment or placebo groups (4 studies, 1450 participants); low certainty evidence downgraded one level for serious risk of bias and one level for serious inconsistency. It is unclear whether there is a difference in rates of readmission to hospital between the treatment and placebo groups (3 studies, 784 participants); low certainty evidence downgraded one level for serious inconsistency and one level for serious risk of bias. It is unclear whether there is a difference in cost of care between the treatment and no treatment or placebo groups (2 studies, 510 participants); low certainty evidence downgraded one level for serious risk of bias and one level for serious inconsistency. No analysable secondary outcome data were reported for the single study evaluating perioperative antibiotics. AUTHORS' CONCLUSIONS: Prophylactic antibiotics administered preoperatively probably reduce the risk of SSI in patients undergoing surgery for breast cancer. However, it is very uncertain whether there is an effect on incidence of adverse events. Furthermore, the effects on time to onset of infection, readmission to hospital and cost of care remain unclear. Further studies are required to establish the best protocols for clinical practice.


Assuntos
Antibioticoprofilaxia , Neoplasias da Mama/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Feminino , Humanos , Mastectomia , Cuidados Pré-Operatórios/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Cicatrização
13.
Rev Col Bras Cir ; 46(4): e2252, 2019 Sep 09.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31508737

RESUMO

OBJECTIVE: to present a descriptive analysis of the results of a care bundle applied to obese patients submitted to bariatric surgery, regarding infection control. METHODS: a care bundle was designed to control surgical site infection (SSI) rates in patients undergoing bariatric surgery. The bundle included smoking cessation, bathing with 4% chlorhexidine two hours before surgery, cefazolin (2g bolus) in anesthetic induction associated with a continuous infusion of the same drug at a dose of 1g over a two-hour period, appropriate trichotomy, glycemic control, supplemental oxygen, normothermia, intraspinal morphine for the relief of pain, and sterile dressing removal 48 hours after surgery. All patients were followed up for 30 days. RESULTS: among the 1,596 included patients, 334 (20.9%) underwent open surgery and 1,262 (79.1%) underwent videolaparoscopic surgery. SSI rates were 0.5% in the group submitted to laparoscopic surgery and 3% in the one submitted to open surgery. The overall incidence of SSI was 1%. Intra-abdominal, respiratory tract, and urinary tract infections occurred in 0.9%, 1.1%, and 1.5% of the sample, respectively. Higher body mass index was associated with higher incidence of SSI (p=0.001). Among patients with diabetes, 2.2% developed SSI, while the rate of infection among non-diabetics was only 0.6%. CONCLUSION: the established care bundle, structured by core evidence-based strategies, associated with secondary measures, was able to maintain low SSI rates after bariatric surgery.


Assuntos
Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/métodos , Pacotes de Assistência ao Paciente , Infecção da Ferida Cirúrgica/prevenção & controle , Adolescente , Adulto , Idoso , Índice de Massa Corporal , Brasil/epidemiologia , Diabetes Mellitus Tipo 2/complicações , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Obesidade/cirurgia , Assistência Perioperatória/métodos , Estudos Prospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Adulto Jovem
14.
New Microbiol ; 42(4): 205-209, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31524943

RESUMO

In this prospective, randomized, controlled study we investigated the effect of subcutaneous rifampicin and povidone-iodine irrigation on incisional surgical site infection. Superficial incisional surgical site infection (SSI) following gynecologic surgery is a serious problem for both patient and surgeon in terms of increased morbidity, length of hospital stay, anxiety, and costs. Three hundred patients scheduled for abdominal surgery due to various benign gynecological pathologies were randomly assigned to one of three groups of 100 members each, as follows: the subcutaneous tissue was irrigated with saline in group 1; saline + rifampicin in group 2; saline +10% povidone iodine in group 3. Patients were invited to follow-up once every 10 days in a 30-day period for evaluation. Patients who developed a superficial incisional SSI were recorded. The superficial incisional SSI rate increased significantly with the use of saline alone (p = 0.006). There was no significant difference between saline +10% povidone iodine and saline + rifampicin (p=0.055). The results suggest that the incidence of superficial incisional SSI is significantly reduced when irrigation is performed using rifampicin and povidone-iodine compared with using saline alone.


Assuntos
Anti-Infecciosos Locais , Procedimentos Cirúrgicos em Ginecologia , Povidona-Iodo , Rifampina , Administração Tópica , Adulto , Anti-Infecciosos Locais/administração & dosagem , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Pessoa de Meia-Idade , Povidona-Iodo/administração & dosagem , Estudos Prospectivos , Rifampina/administração & dosagem , Infecção da Ferida Cirúrgica/prevenção & controle , Resultado do Tratamento
16.
J Cardiothorac Surg ; 14(1): 162, 2019 Sep 09.
Artigo em Inglês | MEDLINE | ID: mdl-31500639

RESUMO

BACKGROUND: Sternal wound complications (SWC) are a rare but potentially life-threatening complication after coronary artery bypass grafting (CABG) surgery. Especially the use of bilateral IMA (BIMA) grafts as opposed to single IMA (SIMA) grafts is associated with an increased risk of SWC. Skeletonised harvesting has been proposed to reduce this risk. The purpose of this study was to retrospectively investigate the effect of skeletonisation on SWC after off-pump coronary artery bypass grafting (OPCAB) in a centre with a high volume of off-pump procedures and high frequencies of BIMA. METHODS: From January 2010 to November 2016, 1900 consecutive patients underwent OPCAB surgery at the University Hospitals of Leuven. The first group (n = 1487) received non-skeletonised IMA grafts, whereas the second group (n = 413) received skeletonised grafts. Optimal wound management was pursued in all patients. A new four-grade classification for SWC was developed. Incidence and grade of SWC as well as overall survival were assessed. RESULTS: Analysis of diabetic patients showed a lower incidence of SWC in the skeletonised (12/141, 8.5%) compared to the non-skeletonised group (82/414, 19.8%) [odds ratio 0.46, 95% confidence interval (0.23;0.88), p = 0.019] as well as a lower grade [0.45 (0.24;0.871), p = 0.018]. There was no significant effect on overall survival [0.67 (0.19;2.32), p = 0.529]. Subanalysis of this population revealed that the observed effects were most prominent in patients receiving BIMA grafts, with 6/56 (10.7%) SWC in the skeletonised and 62/252 (24.6%) in the non-skeletonised group [0.37 (0.15;0.90), p = 0.028 for incidence], as well as a lower grade [0.36 (0.15;0.88), p = 0.025]. These advantages were not significant in diabetic patients receiving SIMA grafts nor in the full study population. CONCLUSIONS: This study, using a more sensitive classification of SWC, shows in a large group of patients that, in combination with optimized wound management, the skeletonisation technique is associated with a clear reduction in the incidence and grade of SWC in diabetic patients receiving BIMA grafts. This encourages the extension of BIMA use in OPCAB to this risk population.


Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Artéria Torácica Interna/transplante , Esternotomia/efeitos adversos , Infecção da Ferida Cirúrgica/prevenção & controle , Coleta de Tecidos e Órgãos/métodos , Idoso , Bélgica/epidemiologia , Doença da Artéria Coronariana/cirurgia , Feminino , Humanos , Incidência , Masculino , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/epidemiologia
17.
J Pediatr Orthop ; 39(9): e694-e697, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31503226

RESUMO

BACKGROUND: Surgical-site infections are one of the most concerning complications in patients treated with growing rods (GR). The purpose of this study was to evaluate the use of preoperative screening for Staphylococcus aureus (SA) for all growing spine procedures, and if this would permit alteration of prophylactic antibiotics to cover the identified resistances. METHODS: All patients were identified who had SA screening during the course of GR treatment. In otal, 34 patients [23 neuromuscular (NMS), 4 congenital, 4 idiopathic scoliosis (IS), and 3 syndromic] were identified who had 111 preoperative screenings [79 lengthenings, 23 insertions, 6 revisions, and 3 conversions to posterior spinal fusions (PSF)]. Mean age at GR insertion was 5.5 years (2 to 11 y). RESULTS: There were 11 methicillin-resistant Staphylococcus aureus (MRSA) "+" screenings in 6 patients (5 NMS, 1 IS): 3 in 3 patients before GR insertion and 8 in 3 patients (all 3 were negative at GR insertion screening) at subsequent surgeries. There were 23 methicillin-sensitive Staphylococcus aureus (MSSA) "+" screenings in 12 patients (7 NMS, 2 congenital, 2 IS, 1 syndromic): 2 in 2 patients before GR insertion and 21 in 10 patients at subsequent surgeries (18 lengthenings, 3 revisions). Overall, 13 patients (3 MRSA+10 MSSA) were initially negative but screened positive for the first time at a subsequent surgery (12 lengthenings, 1 GR to PSF). All patients (n=5) with positive screenings before GR insertion were in patients with NMS (3 MRSA, 2 MSSA). On the basis of sensitivities, 9 patients demonstrated SA resistance to cefazolin (8 MRSA and 1 MSSA) and 6 to clindamycin (5 MRSA and 1 MSSA). Hence, if cefazolin was routinely used for all patients 26.5% of patients (9/34) would have been inadequately covered at some point during their GR treatment; clindamycin, 17.7% (6/34). CONCLUSION: The use of SA nasal swab screening in GR patients identified 9 patients (26.5%) whose prophylactic antibiotics (cefazolin) could be altered to permit appropriate SA coverage. LEVEL OF EVIDENCE: Level IV-retrospective case series.


Assuntos
Antibacterianos/uso terapêutico , Antibioticoprofilaxia , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Infecções Estafilocócicas/diagnóstico , Infecção da Ferida Cirúrgica/prevenção & controle , Cefazolina , Criança , Clindamicina , Humanos , Lactente , Programas de Rastreamento/métodos , Estudos Retrospectivos , Infecções Estafilocócicas/microbiologia , Staphylococcus aureus
18.
J Pediatr Orthop ; 39(9): e703-e707, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31503228

RESUMO

BACKGROUND: Despite clinical reports of improved pulmonary function and reduced spinal deformity with rib-based distraction surgery in early-onset scoliosis (EOS) patients, infection remains a common complication, reported as high as 32% in some studies. The purpose of this study was to evaluate intrawound vancomycin powder in pediatric patients managed with rib-based distraction for EOS. METHODS: This was a single institution retrospective cohort study of EOS patients treated with rib-based distraction. Patients treated with and without intrawound vancomycin were compared. Patients included were younger than 18 years of age, had undergone placement of a rib-based distraction construct, and had a minimum of 6 months' follow-up. For patients in the vancomycin group, 500 mg of vancomycin powder was placed before wound closure. Complications including infection and revision surgery were recorded. P-values and 95% confidence intervals (CIs) were reported for both unadjusted and adjusted complication rates for prevancomycin and postvancomycin powder. All P-values were calculated at a significance level of 0.05. RESULTS: In total, 118 patients were included, accounting for 1035 procedures in the nonvancomycin control group and 252 procedures in the vancomycin group. Both groups were similar with regard to age at initial implant, sex, diagnosis, ambulatory status, and bowel/bladder incontinence. There were 55 (5.3%; 95% CI, 4.1-7.6) postoperative infections in the control group and 3 (1.2%; 95% CI, 0.3-3.8) in the vancomycin group (P=0.008, unadjusted). After adjusting for surgery type and transfusions, the vancomycin group still had a significantly lower infection rate (1.4%; 95% CI, 0.3-3.7 vs. 5.5%; 95% CI, 3.04-6.5; P=0.022). We were unable to demonstrate a difference between the control (3.5%, 95% CI, 2.4-5.1) and vancomycin (1.8%, 95% CI, 0.5-5.7) groups for deep infection (P=0.27). CONCLUSIONS: Intrawound vancomycin powder significantly reduced the surgical site infection rates following rib-based distraction surgery for EOS. We therefore recommend the use of intrawound vancomycin powder as a standard of care for patients undergoing rib-based distraction surgery. LEVEL OF EVIDENCE: Pre-post intervention, retrospective cohort study-therapeutic level III.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia/métodos , Osteogênese por Distração/efeitos adversos , Escoliose/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Vancomicina/administração & dosagem , Administração Tópica , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pós , Próteses e Implantes/efeitos adversos , Reoperação , Estudos Retrospectivos , Costelas/cirurgia , Infecção da Ferida Cirúrgica/etiologia
19.
Transplant Proc ; 51(8): 2724-2730, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31477417

RESUMO

BACKGROUND: One of the most common infective complications after kidney transplant (KTx) is surgical site infection (SSI). Providing indications of improvement of perioperative antibiotic prophylaxis (PAP) and allowing the characterization of risk factors are critical to reduce SSI. The purpose of this study was to evaluate the SSI risk factors and impact of reoperation in the early post-transplant period on SSI occurrence and assess if standard PAP in those cases is a best consideration. METHODS: Between April 2014 and October 2015, a total of 236 KTxs were performed in our center. Deceased donor data, recipient data, and data related to surgical procedures were collected. RESULTS: Surgical site infections were reported in 5.6% (12/214) of patients. Seven patients were diagnosed as having superficial SSI (7/12; 58.3%), 2 with deep SSI (2/12; 16.6%), and 4 with organ-specific SSI (4/12; 33.3%). Extended criteria donor-related transplant, cold ischemia time > 22 hours, dialysis period > 30 months, recipient age older than 45 years, recipient body mass index > 27, induction therapy prior to transplant, diabetes prior to transplant, and ≥ 1 reoperation during 30 days of observation were independent risk factors of SSI occurrence. A total of 19 reoperations were performed in 17 patients. In 8 of all 12 patients with SSI diagnosis, the reoperation was performed (66.7%). In 202 patients of non-SSI patients, only 9 reoperations were performed (4.5%). CONCLUSIONS: Early reoperation after Ktx is a strong risk factor of SSI occurrence. There is a probability that > 4 SSI risk factors and reoperation in the early post-transplant period could require different and more aggressive proceeding, as standard PAP in those cases is insufficient.


Assuntos
Transplante de Rim , Reoperação/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Adulto , Idoso , Antibioticoprofilaxia/métodos , Feminino , Humanos , Transplante de Rim/efeitos adversos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Infecção da Ferida Cirúrgica/prevenção & controle
20.
Lancet ; 394(10201): 840-848, 2019 09 07.
Artigo em Inglês | MEDLINE | ID: mdl-31402112

RESUMO

BACKGROUND: Decreased surgical site infections (SSIs) and morbidity have been reported with mechanical and oral antibiotic bowel preparation (MOABP) compared with no bowel preparation (NBP) in colonic surgery. Several societies have recommended routine use of MOABP in patients undergoing colon resection on the basis of these data. Our aim was to investigate this recommendation in a prospective randomised context. METHODS: In this multicentre, parallel, single-blinded trial, patients undergoing colon resection were randomly assigned (1:1) to either MOABP or NBP in four hospitals in Finland, using a web-based randomisation technique. Randomly varying block sizes (four, six, and eight) were used for randomisation, and stratification was done according to centre. The recruiters, treating physicians, operating surgeons, data collectors, and analysts were masked to the allocated treatment. Key exclusion criteria were need for emergency surgery; bowel obstruction; colonoscopy planned during surgery; allergy to polyethylene glycol, neomycin, or metronidazole; and age younger than 18 years or older than 95 years. Study nurses opened numbered opaque envelopes containing the patient allocated group, and instructed the patients according to the allocation group to either prepare the bowel, or not prepare the bowel. Patients allocated to MOABP prepared their bowel by drinking 2 L of polyethylene glycol and 1 L of clear fluid before 6 pm on the day before surgery and took 2 g of neomycin orally at 7 pm and 2 g of metronidazole orally at 11 pm the day before surgery. The primary outcome was SSI within 30 days after surgery, analysed in the modified intention-to-treat population (all patients who were randomly allocated to and underwent elective colon resection with an anastomosis) along with safety analyses. The trial is registered with ClinicalTrials.gov, NCT02652637, and EudraCT, 2015-004559-38, and is closed to new participants. FINDINGS: Between March 17, 2016, and Aug 20, 2018, 738 patients were assessed for eligibility. Of the 417 patients who were randomised (209 to MOABP and 208 to NBP), 13 in the MOABP group and eight in the NBP were excluded before undergoing colonic resection; therefore, the modified intention-to-treat analysis included 396 patients (196 for MOABP and 200 for NBP). SSI was detected in 13 (7%) of 196 patients randomised to MOABP, and in 21 (11%) of 200 patients randomised to NBP (odds ratio 1·65, 95% CI 0·80-3·40; p=0·17). Anastomotic dehiscence was reported in 7 (4%) of 196 patients in the MOABP group and in 8 (4%) of 200 in the NBP group, and reoperations were necessary in 16 (8%) of 196 compared with 13 (7%) of 200 patients. Two patients died in the NBP group and none in the MOABP group within 30 days. INTERPRETATION: MOABP does not reduce SSIs or the overall morbidity of colon surgery compared with NBP. We therefore propose that the current recommendations of using MOABP for colectomies to reduce SSIs or morbidity should be reconsidered. FUNDING: Vatsatautien Tutkimussäätiö Foundation, Mary and Georg Ehrnrooth's Foundation, and Helsinki University Hospital research funds.


Assuntos
Antibacterianos/administração & dosagem , Cefuroxima/administração & dosagem , Colectomia/métodos , Metronidazol/administração & dosagem , Cuidados Pré-Operatórios/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Administração Intravenosa , Idoso , Catárticos/administração & dosagem , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polietilenoglicóis/administração & dosagem , Estudos Prospectivos , Método Simples-Cego
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