Survey of antibiotic prophylaxis in gastrointestinal surgery in Scotland.

The current use of prophylactic antibiotics in gastrointestinal surgery in Scotland was established by postal questionnaire. Twenty-one per cent of surgeons used prophylactic antibiotics during cholecystectomy, 49% during appendicectomy, and 95% for elective colorectal surgery. Two-thirds of those surgeons who did not provide routine antibiotic cover considered that the incidence of wound sepsis in their surgical practice was too low to merit special measures. Most surgeons using prophylaxis chose an appropriate antibiotic. The parenteral route for administration of antibiotic was used by 93% of surgeons during cholecystectomy, 29% during appendicectomy, and 45% in elective colorectal surgery. Most did not prolong cover beyond 24 hours postoperatively. This survey shows that the concepts governing the use of antibiotic prophylaxis have been absorbed into current surgical practice. Most surgeons used appropriate antibiotic regimens; many prefer the parenteral route of administration; most do not prolong cover beyond 24 hours.     

Rational use of antibiotic therapy after appendicectomy.

A prospective randomised trial was carried out on 263 patients admitted for appendicectomy. In those patients with normal or inflamed appendix only, wound sepsis occurred in five (5%) of the 96 patients receiving metronidazole compared with seven (7%) of the 91 controls. In patients with gangrenous or perforated appendices, however, 15 of the 32 patients (47%) receiving ampicillin and five (16%) of 31 patients receiving metronidazole developed a wound infection (p less than 0.025). Therapeutic courses of metronidazole significantly reduced wound sepsis rate in those with gangrenous or perforated appendices. Together with another antibiotic it should form part of the management of such patients, but antibiotics are unlikely to reduce further the low rate of wound infection in patients with normal or inflamed appendices.     

Wound sepsis after cholecystectomy: effect of incidental appendicectomy.

The records of a consecutive series of 224 patients were analysed to discover the effect of incidental appendicectomy on the wound sepsis rate after cholecystectomy. One hundred and five patients had had a cholecystectomy alone and 119 cholecystectomy with incidental appendicectomy. The incidence of wound sepsis in patients not given adequate antibiotic prophylaxis was significantly lower (16-1%) when cholecystectomy alone was carried out than when the appendix was removed as well (41-1%).     

Topical ampicillin in the appendicectomy wound: Report of double-blind trial

One hundred and thirty unselected patients undergoing appendicectomy were treated with topical ampicillin powder or topical placebo powder (lactose) before closing the wound. The postoperative wound infection rates were 3% in the ampicillin-treated group and 24% in the control group, a significant difference. This difference was not influenced by the degree of inflammation in the appendix. No side-effects of treatment were observed.     

Fertility patterns after appendicectomy: historical cohort study

Surgical exploration for suspected appendicitis is the most common acute abdominal operation in children and young adults. However, in 20-30% of such explorations, the appendix is not inflamed. It is commonly thought that a perforated appendix may result in tubal dysfunction because of peritoneal adhesions after inflammation and a subsequent increased risk for extrauterine pregnancy and female infertility. Findings are reported from an examination of fertility patterns in women who had their appendix removed in childhood. 9840 women under age 15 years when they underwent appendicectomy between 1964 and 1983 were age-matched with 47,590 control women from the Swedish general population and followed until 1994. Women with a history of perforated appendix had a similar rate of first birth as the control women, as well as a similar distribution of parity at the end of follow-up. Women who had had a normal appendix removed had an increased rate of first births, and on average had their first child at an earlier age and reached a higher parity than control women. These findings therefore suggest that a history of perforated appendix in childhood does not seem to have long-term negative consequences upon female fertility.     

Synthesis and in vitro evaluation of bisphosphonated glycopeptide prodrugs for the treatment of osteomyelitis

As therapeutic agents of choice in the treatment of complicated infections, glycopeptide antibiotics are often preferentially used in cases of osteomyelitis, an infection located in bone and notoriously difficult to successfully manage. Yet frequent and heavy doses of these systemically administered antibiotics are conventionally prescribed to obtain higher antibiotic levels in the bone and reduce the high recurrence rates. Targeting antibiotics to the bone after systemic administration would present at least three potential advantages: (i) greater efficacy, by concentrating the therapeutic agent in bone; (ii) greater convenience, through a reduction in the frequency of administration; and (iii) greater safety, by reducing the levels of systemic drug exposure. We present here the design, synthesis and in vitro evaluation of eight prodrugs of the glycopeptide antibacterial agents vancomycin and oritavancin taking advantage of the affinity of the bisphosphonate group for bone for delivery to osseous tissues.     

Meta-analysis of randomised controlled trials of selective decontamination of the digestive tract. Selective Decontamination of the Digestive Tract Trialists' Collaborative Group.

OBJECTIVE--To determine the clinical benefits of selective decontamination of the digestive tract in patients treated in intensive care units. DESIGN--Meta-analysis of 22 randomised trials that compared different combinations of oral non-absorbable antibiotics, with or without a systemic component, with no treatment in controls. SUBJECTS--4142 patients seen in general and specialised intensive care units around the world. 2047 received some form of antibiotic treatment, the remainder no prophylaxis. DATA ANALYSIS--Each trial was reviewed through direct contact with study investigators. Data collected were: the randomisation procedure, number of patients, number excluded from the analysis, and numbers of respiratory tract infections and deaths. Data were combined according to an intention to treat analysis with the Mantel-Haenszel-Peto method. MAIN OUTCOME MEASURES--Respiratory tract infections and total mortality. RESULTS--Selective decontamination of the digestive tract significantly reduced respiratory tract infections (odds ratio 0.37; 95% confidence interval 0.31 to 0.43). The value of the common odds ratio for total mortality (0.90; 0.79 to 1.04) suggested at best a moderate treatment effect, reaching statistical significance only when the subgroup of trials of topical and systemic treatment combined was considered separately (odds ratio 0.80; 0.67 to 0.97). No firm conclusions could be drawn owing to large variations in patient mix and severity within and between trials. CONCLUSIONS--The findings strongly indicate that selective decontamination significantly reduces infection related morbidity in patients receiving intensive care. They also highlight why definite conclusions about the effect of prophylaxis on mortality cannot be drawn despite the large number of trials available. Based on the most favourable results obtained by pooling data from trials in which combined topical and systemic treatment was used it may be estimated that 6 (range 5-9) and 23 (13-139) patients would need to be treated to prevent one respiratory tract infection and one death respectively.     

Etiology of nosocomial surgical infections caused by gram-negative bacteria, and profile of their antibiotic resistance

Microbiological monitoring of microbial landscape of gram-negative bacteria--etiological agents of nosocomial surgical infections--was performed as well as their level of antibiotic resistance was studied. Two hundred forty-four strains were isolated. Antimicrobial susceptibility was assessed by the method of serial microdilutions. Spectrum of Gram-negative microorganisms was represented by 3 groups: fermenting (62.7%), nonfermenting (34.8%), and nonidentified microbes (2.5%). Spectrum of gram-negative etiological agents of nosocomial surgical infections was represented mainly by Pseudomonas aeruginosa, Acinetobacter baumanii, Escherichia coli, and Klebsiella. Most active antibacterial drugs against studied strains were carbapenems (imipenem and meropenem).     

Antibiotic Therapy in Current Surgical Practice

The clinical surgeon is required to assume important responsibilities in the management of microbial infections. To be effective, antibiotics should be used against sensitive organisms, the lesion should be infused adequately, and, ideally, the antibiotic should be bactericidal and compatible with other antibiotic agents in combination. A survey of commonly used antibiotics disclosed that penicillin in its synthetic and natural forms is still the drug of choice in most cases, particularly since, in its different forms, it may be used in combination with other agents to give a wide antibacterial spectrum. As a major surgical problem, Gram-positive septicemia has been superseded by Gram-negative septicemia and attendant endotoxin shock. Most authorities advocate a combination of bactericidal and bacteriostatic antibiotics in the treatment of endotoxin shock. However, while antibiotic therapy is considered crucial in the treatment of this condition, the mortality rate is still high and no uniform regimen of antibiotic therapy has been accepted.     

Use of a topical antibiotic spray in vaginal surgery.

During vaginal hysterectomy with or without colporrhaphy a topical aerosol spray containing neomycin sulfate, polymyxin B sulfate and zinc bacitracin was used in 50 patients to decrease the change of postoperative pelvic infection; a placebo spray was used in another 50 patients. All patients were treated preoperatively with povidone iodine and postoperatively with nitrofurantoin and an antibacterial irrigating solution for the bladder if catheter drainage was necessary. The frequency of postoperative pelvic infection was 16% in the group sprayed with the antibiotic combination and 34% in the group sprayed with the placebo, a significant difference (P less than 0.05).     

Antibacterial chemotherapy in anaerobic osteomyelitis caused by gunshot wounds

Thirty three patients with a 7-year history of chronic gunshot osteomyelitis were examined. Non-sporogenic anaerobes were isolated from 28 patients. Gram-positive cocci and gram-negative rods predominated in the anaerobic microflora. Radical surgical interventions combined with adequate antibacterial chemotherapy yielded satisfactory results. The postoperative cavities were drained to provide aerobic conditions in all the parts. Antibacterial drugs and in particular dioxidine solutions and KF were used locally. When antibioticograms were available 7 to 10 days after, the antibiotics in combination with enzymes such as terrylitin and lidase were used with constant irrigation of wounds with furacillin or boric acid solutions. In the empirical therapy, the following scheme was most frequently used: 600 mg of lincomycin, thrice, intramuscularly; 80 mg of gentamicin, thrice, intramuscularly and as an obligatory agent 500 mg of trichopol, thrice, orally. After availability of the antibioticograms the use of the antibiotics was adjusted and continued up to 10 to 12 days. In severe cases 0.1% solution of dioxidine was used intravenously drop-wise in a dose of 300 mg 2 times a day as well as tiberal or clindamycin, intravenously, drop-wise. The antibacterial drugs were added to the drainage until the latter was removed. Relapses of the disease over 4 years were observed only in 3 out of 26 operated patients.     

Use of antibiotics for the prevention of postoperative suppurative complications in planned surgery

Two methods for antibiotic prophylaxis in scheduled surgical treatment were studied comparatively. In the main group antibiotic prophylaxis with respect to 621 operations was started simultaneously with premedication, the duration of the course being defined by the operation type. With respect to 252 pure operations antibiotics were not used in 69.8 per cent of the cases or used for 2-3 days in 27.8 per cent of the cases. With respect to 253 conditionally pure operations shorter courses of antibiotic prophylaxis, i.e. for 2-3 days were used in 50.2 per cent of the cases. In the control group the antibiotics were used after operations in mean therapeutic doses, the duration of the course being defined by the clinical findings. The number of purulent complications in the main group decreased, while the amounts of the antibiotics used were much lower.     

Changing Use of Surgical Antibiotic Prophylaxis in Thika Hospital,Kenya: A Quality Improvement Intervention with an Interrupted Time Series Design

Introduction

In low-income countries, Surgical Site Infection (SSI) is a common form of hospital-acquired infection. Antibiotic prophylaxis is an effective method of preventing these infections, if given immediately before the start of surgery. Although several studies in Africa have compared pre-operative versus post-operative prophylaxis, there are no studies describing the implementation of policies to improve prescribing of surgical antibiotic prophylaxis in African hospitals.

Methods

We conducted SSI surveillance at a typical Government hospital in Kenya over a 16 month period between August 2010 and December 2011, using standard definitions of SSI and the extent of contamination of surgical wounds. As an intervention, we developed a hospital policy that advised pre-operative antibiotic prophylaxis and discouraged extended post-operative antibiotics use. We measured process, outcome and balancing effects of this intervention in using an interrupted time series design.

Results

From a starting point of near-exclusive post-operative antibiotic use, after policy introduction in February 2011 there was rapid adoption of the use of pre-operative antibiotic prophylaxis (60% of operations at 1 week; 98% at 6 weeks) and a substantial decrease in the use of post-operative antibiotics (40% of operations at 1 week; 10% at 6 weeks) in Clean and Clean-Contaminated surgery. There was no immediate step-change in risk of SSI, but overall, there appeared to be a moderate reduction in the risk of superficial SSI across all levels of wound contamination. There were marked reductions in the costs associated with antibiotic use, the number of intravenous injections performed and nursing time spent administering these.

Conclusion

Implementation of a locally developed policy regarding surgical antibiotic prophylaxis is an achievable quality improvement target for hospitals in low-income countries, and can lead to substantial benefits for individual patients and the institution.     

动态监测血清降钙素原水平在优化全身性感染患者抗菌治疗策略中的价值

目的:评估动态监测血清降钙素原水平(PCT)在优化全身性感染患者抗菌治疗策略中的价值。方法:选取2015年4月~2015年12月全身性感染患者85例,随机分为常规组42例和PCT组43例。常规组按照《抗菌药物临床应用指导原则(2015年版)》决定抗生素疗程;PCT组在抗生素治疗后第3、5、7、10、14 d监测血清PCT水平,若PCT0.25 ng/mL停用抗生素、PCT≥0.25 ng/mL继续使用抗生素。分别比较两组患者间一般情况、传统全身炎症性反应指标及抗生素使用的种类、时间、费用以及预后的差异。结果:两组患者间治疗前后传统全身炎症性反应指标无明显差异(P0.05);两组患者间常用的抗生素种类并无明显统计学差异(P0.05);PCT组患者抗生素使用的天数为(9.9±3.9)d,明显少于常规组的(13.9±5.2)d,差异有统计学意义(P0.05);PCT组患者抗生素日均费用为(422.39±139.9)元,明显低于常规组的(514.78±155.2)元,差异有统计学意义(P0.05);两组患者间停用抗生素后14天后全身感染复发率以及28天病死率无明显统计学差异(P0.05)。但PCT组患者总住ICU时间明显少于常规组,差异有统计学意义(P0.05)。结论:动态监测血清PCT水平在优化全身性感染患者抗菌治疗策略中具有重要价值。     

Advanced techniques in abdominal surgery.

Almost every abdominal organ is now amenable to laparoscopic surgery. Laparoscopic appendicectomy is a routine procedure which also permits identification of other conditions initially confused with an inflamed appendix. However, assessment of appendiceal inflammation is more difficult. Almost all colonic procedures can be performed laparoscopically, at least partly, though resection for colonic cancer is still controversial. For simple patch repair of perforated duodenal ulcers laparoscopy is ideal, and inguinal groin hernia can be repaired satisfactorily with a patch of synthetic mesh. Many upper abdominal procedures, however, still take more time than the open operations. These techniques reduce postoperative pain and the incidence of wound infections and allow a much earlier return to normal activity compared with open surgery. They have also brought new disciplines: surgeons must learn different hand-eye coordination, meticulous haemostasis is needed to maintain picture quality, and delivery of specimens may be problematic. The widespread introduction of laparoscopic techniques has emphasised the need for adequate training (operations that were straight-forward open procedures may require considerable laparoscopic expertise) and has raised questions about trainee surgeons acquiring adequate experience of open procedures.     

PYOGENIC INFECTIONS IN ORTHOPEDIC SURGERY—Prevention and Management

A problem that confronts surgeons in clinical practice is that a patient may acquire new infections while in the hospital. When such infections occur they are predominantly staphylococcal and these bacteria are often, but not always resistant to penicillin, streptomycin and the tetracycline antibiotics. They are often but neither completely nor uniformly sensitive to the newer or less frequently used antimicrobial agents.The extension of antibiotic usage from proven situations to “routine” prophylaxis has been a widespread practice. There are many reasons to discourage and to reexamine the validity and purpose, as well as the safety of this practice. We now have sufficient background and experience to revert from widespread and indiscriminate use to a practice of discriminate prophylactic therapy.In general, soft tissue lacerations and clean wounds do not require operation under an “antibiotic umbrella.” Similarly, elective orthopedic surgical procedures of soft tissues such as muscle biopsy, tenorrhaphy and muscle and tendon transplants as well as plastic surgical procedures can be safely performed without antibiotic therapy if technique is good and operation not prolonged. Operations of major magnitude on the motor-skeletal system, such as open fractures, internal fixation of fractures with bone grafts, and major operations of joints are indication for antibiotic therapy for impending infection postoperatively for five days. Reliance is mainly on antistaphylococcal drugs to which hospital organisms are predominantly sensitive. The two remaining indications for antibiotic therapy against impending infection are: (1) major crush injury—for example, to the thigh—and (2) the need for a patient with a healing fracture to have other surgical procedures such as tooth extraction or excision of an infected area which might predispose to transient bacteremia and embolic infection in bone or joint.     

Antibiotic use: present and future

Antibiotics were initially viewed as "wonder drugs" primarily because they were introduced at a time when only surgical drainage or spontaneous cures were available to treat serious bacterial infections. During the five or six decades since their introduction, several classes of these drugs became available including sulfonamides and trimethoprim, penicillins, cephalosporins, chloramphenicol, tetracyclines, colimycins, macrolides, lincosamides, streptogramins, rifamycins, glycopeptides, aminoglycosides, fluoroquinolones, oxazolidinones, glycylglycines, lipoglycopeptides, and variations on these themes. Unfortunately, through a variety of mechanisms and perhaps as a result of their profligate use, many bacterial groups are exhibiting resistance to these antibiotics. At present, most bacterial infections can still be treated with available antibiotics used alone or in combination, but increasing numbers of clinical failures with the current armamentarium can be expected. Optimizing drug dosing and duration might help minimize the emergence of resistance in some situations. However, the future could look dim, as there are relatively few new agents on the horizon. A bold new look for antibacterial targets is needed. Surely our scientific abilities are up to this challenge. New approaches to antimicrobial chemotherapy are needed if we are to survive the increasing rates of antibiotic resistance predicted for the future.     

Pharmaceutically active secondary metabolites of microorganisms

The antibiotics have been useful in our battles against infectious bacteria and fungi for over 50 years. However, many antibiotics are used commercially, or are potentially useful, in medicine for activities other than their antibiotic action. They are used as antitumor agents, immunosuppressive agents, hypocholesterolemic agents, enzyme inhibitors, antimigraine agents, and antiparasitic agents. A number of these products were first discovered as antibiotics which failed in their development as such, or as mycotoxins. In addition to the above alternative applications, new powerful antibiotics have been discovered and commercialized in recent years and others are in clinical testing at the moment. A few successful secondary metabolites appear to have no antibiotic activity. The recently increased development of resistance to older antibacterial and antifungal drugs is being met with the use or clinical testing of older, underutilized or previously nondeveloped narrow-spectrum antibacterial products as well as powerful semisynthetic antifungal agents. Received: 28 December 1998 / Received revision: 26 April 1999 / Accepted: 1 May 1999     

Novel strategies for inhibition of bacterial biofilm in chronic rhinosinusitis

An important role has been recently reported for bacterial biofilm in the pathophysiology of chronic diseases, such as chronic rhinosinusitis (CRS). CRS, affecting sinonasal mucosa, is a persistent inflammatory condition with a high prevalence around the world. Although the exact pathological mechanism of this disease has not been elicited yet, biofilm formation is known to lead to a more significant symptom burden and major objective clinical indicators. The high prevalence of multidrug-resistant bacteria has severely restricted the application of antibiotics in recent years. Furthermore, systemic antibiotic therapy, on top of its insufficient concentration to eradicate bacteria in the sinonasal biofilm, often causes toxicity, antibiotic resistance, and an effect on the natural microbiota, in patients. Thus, coming up with alternative therapeutic options instead of systemic antibiotic therapy is emphasized in the treatment of bacterial biofilm in CRS patients. The use of topical antibiotic therapy and antibiotic eluting sinus stents that induce higher antibiotic concentration, and decrease side effects could be helpful. Besides, recent research recognized that various natural products, nitric oxide, and bacteriophage therapy, in addition to the hindered biofilm formation, could degrade the established bacterial biofilm. However, despite these improvements, new antibacterial agents and CRS biofilm interactions are complicated and need extensive research. Finally, most studies were performed in vitro, and more preclinical animal models and human studies are required to confirm the collected data. The present review is specifically discussing potential therapeutic strategies for the treatment of bacterial biofilm in CRS patients.