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Beck M, Koll C, Dumpis U, Giske CG, Göpel S, Jørgensen SB, Kessel J, Kleppe LK, Oma DH, Raz NE, Semret M, Simonsen GS, Vehreschild MJGT, Albus K, Biehl LM, Vehreschild JJ, Classen AY. Identifying patients at high risk for antibiotic treatment following hospital admission: a predictive score to improve antimicrobial stewardship measures. Infection 2025:10.1007/s15010-025-02525-9. [PMID: 40232662 DOI: 10.1007/s15010-025-02525-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2025] [Accepted: 03/24/2025] [Indexed: 04/16/2025]
Abstract
PURPOSE Identifying patients for clinical studies evaluating strategies to reduce unnecessary antibiotic usage in hospitals is challenging. This study aimed to develop a predictive score to identify newly hospitalized patients with high likelihood of receiving antibiotics, thus improving patient inclusion in future studies focusing on antimicrobial stewardship (AMS) programs. METHODS This retrospective analysis used data from the PILGRIM study (NCT03765528), which included 1,600 patients across ten international sites. Predictive variables for antibiotic treatment during hospitalization were computed, and an additive score model was developed using logistic regression and 10-fold cross-validation. The PILGRIM score was validated in an independent cohort (validation cohort), with performance metrics assessed. RESULTS Data from 1,258 patients was included. In the development cohort 52.8% (n = 445) and in the validation cohort 42.4% (n = 134) of patients received antibiotics. Key predictors included hematologic malignancies, immunosuppressive medication, and past hospitalization. The logistic regression model demonstrated an area under the curve of 0.74 in the validation. The final additive score incorporated these predictors plus "planned elective surgery" achieving a specificity of 92%, a positive predictive value of 78%, a sensitivity of 41%, and a negative predictive value (NPV) of 69%in validation set. CONCLUSION The PILGRIM score effectively identifies newly hospitalized patients likely to receive antibiotics, demonstrating high specificity and PPV. Its application can improve future AMS programs and trial recruitment by facilitating targeted inclusion of patients, especially in the hematological and oncological setting. Further -external and prospective- validation is needed to broaden the model's applicability.
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Affiliation(s)
- Moritz Beck
- Department I of Internal Medicine, Division of Infectious Diseases, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Department of Urology, Hospital of Leverkusen, Leverkusen, Germany
| | - Carolin Koll
- Department I of Internal Medicine, Division of Infectious Diseases, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Uga Dumpis
- Faculty of Medicine, University of Latvia, Riga, Latvia
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Christian G Giske
- Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Siri Göpel
- Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany
- German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany
| | - Silje Bakken Jørgensen
- Department of Medical Microbiology and Infection Control and Department of Emergency Care, Akershus University Hospital, Lørenskog, Norway
| | - Johanna Kessel
- Department II of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt Am Main, Germany
| | - Lars Kaare Kleppe
- Department of Infection Prevention and Control, Stavanger University Hospital, Stavanger, Norway
| | - Dorthea Hagen Oma
- Section for Patient Safety, Haukeland University Hospital, Bergen, Norway
| | - Noa Eliakim Raz
- Internal medicine E, Rabin medical center Beilinson campus, Petah-Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Makeda Semret
- Infectious Diseases and Medical Microbiology, Mcgill University Health Centre, Montreal, Canada
| | - Gunnar Skov Simonsen
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
- Uit the Arctic University of Norway, Tromsø, Norway
| | - Maria J G T Vehreschild
- Department II of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt Am Main, Germany
- German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - Kerstin Albus
- Department I of Internal Medicine, Division of Infectious Diseases, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Lena M Biehl
- Department I of Internal Medicine, Division of Infectious Diseases, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - Jörg J Vehreschild
- Faculty of Medicine and University Hospital of Frankfurt, Institute for Digital Medicine and Clinical Data Sciences, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Annika Y Classen
- Department I of Internal Medicine, Division of Infectious Diseases, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
- German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany.
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Kubíčková V, Poruba M, Halačová M. Comparative analysis of antibiotic prophylaxis guidelines in cardiac surgery: a survey in Czechia and Slovakia. J Hosp Infect 2025; 156:64-71. [PMID: 39675571 DOI: 10.1016/j.jhin.2024.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 10/17/2024] [Accepted: 11/05/2024] [Indexed: 12/17/2024]
Abstract
BACKGROUND Surgical site infections (SSIs) in cardiac surgery significantly impact patient outcomes. This study examines cardiac antimicrobial prophylaxis guidelines in Czech and Slovak hospitals, crucial for reducing SSI incidence. METHODS An electronic survey was conducted across cardiac surgery departments in both countries, focusing on surgical antibiotic prophylaxis (SAP) protocols, antibiotic choices, dosages, timing and postoperative infection rates. Responses were collected over three months, ensuring a comprehensive overview. FINDINGS Most surveyed hospitals (79%) implement SAP, but guidelines exhibit notable variability. Cefazolin dominates as the primary prophylactic choice, with varying dosing regimens. Challenges include timing inconsistencies and prolonged prophylaxis durations, particularly in implant-related procedures. Regular guideline revisions are reported in 18% of hospitals within the last year, emphasizing the need for updated practices. CONCLUSIONS This study shows the importance of standardizing SAP practices, aligning them with evolving evidence, and implementing regular guideline revisions. The observed variations highlight opportunities for enhanced SSI prevention strategies in cardiac surgery, ultimately contributing to improved patient outcomes.
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Affiliation(s)
- V Kubíčková
- Department of Pharmacology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - M Poruba
- Department of Pharmacology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic.
| | - M Halačová
- Department of Clinical Pharmacy, Na Homolce Hospital, Prague, Czech Republic; Department of Anaesthesia and Intensive Care Medicine, Charles University, Third Faculty of Medicine and FNKV University Hospital, Prague, Czech Republic; Department of Pharmacology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
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Authors/Task Force Members:, Jeppsson A, (Co-Chairperson) (Sweden), Rocca B, (Co-Chairperson) (Italy), Hansson EC, (Sweden), Gudbjartsson T, (Iceland), James S, (Sweden), Kaski JC, (United Kingdom), Landmesser U, (Germany), Landoni G, (Italy), Magro P, (Portugal), Pan E, (Finland), Ravn HB, (Denmark), Sandner S, (Austria), Sandoval E, (Spain), Uva MS, (Portugal), Milojevic M, (Serbia), EACTS Scientific Document Group
. 2024 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2024; 67:ezae355. [PMID: 39385505 DOI: 10.1093/ejcts/ezae355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Collaborators] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 08/14/2024] [Accepted: 09/26/2024] [Indexed: 10/12/2024] Open
Affiliation(s)
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Bianca Rocca
- Department of Medicine and Surgery, LUM University, Casamassima, Bari, Italy
- Department of Safety and Bioethics, Catholic University School of Medicine, Rome, Italy
| | | | - Emma C Hansson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Stefan James
- Department of Medical Sciences, Uppsala University Uppsala Sweden
| | | | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George's University of London, UK
| | | | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine; Deutsches Herzzentrum Charité, Campus Benjamin Franklin, Berlin, Germany
- Charité-University Medicine Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité Berlin, Universitätsmedizin Berlin, Germany
| | | | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Pedro Magro
- Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
| | | | - Emily Pan
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | | | - Hanne Berg Ravn
- Department of Anaesthesia, Odense University Hospital, Institute of Clinical Medicine, University of Southern, Denmark
| | | | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | | | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clinic, Barcelona, Spain
| | | | - Miguel Sousa Uva
- Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
- Cardiovascular Research Centre, Department of Surgery and Physiology, Faculty of Medicine-University of Porto, Porto, Portugal
| | | | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
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Collaborators
Matthias Siepe, Vesa Anttila, Lauren Barron, Dobromir Dobrev, Fabio Guarracino, Ziad Hijazi, Andreas Koster, Tomislav Kostic, Vladimir Lomivorotov, Vojislava Neskovic, Bjorn Redfors, Lars Peter Riber, Andrea Székely, Juan Tamargo, Theis Tönnessen, Alicja Zientara,
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Cardiothoracic Interdisciplinary Research Network, Rogers LJ, Vaja R, Bleetman D, Ali JM, Rochon M, Sanders J, Tanner J, Lamagni TL, Talukder S, Quijano-Campos JC, Lai F, Loubani M, Murphy GJ. Interventions to prevent surgical site infection in adults undergoing cardiac surgery. Cochrane Database Syst Rev 2024; 12:CD013332. [PMID: 39620424 PMCID: PMC11609908 DOI: 10.1002/14651858.cd013332.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2024]
Abstract
BACKGROUND Surgical site infection (SSI) is a common type of hospital-acquired infection and affects up to a third of patients following surgical procedures. It is associated with significant mortality and morbidity. In the United Kingdom alone, it is estimated to add another £30 million to the cost of adult cardiac surgery. Although generic guidance for SSI prevention exists, this is not specific to adult cardiac surgery. Furthermore, many of the risk factors for SSI are prevalent within the cardiac surgery population. Despite this, there is currently no standard of care for SSI prevention in adults undergoing cardiac surgery throughout the preoperative, intraoperative and postoperative periods of care, with variations in practice existing throughout from risk stratification, decontamination strategies and surveillance. OBJECTIVES Primary objective: to assess the clinical effectiveness of pre-, intra-, and postoperative interventions in the prevention of cardiac SSI. SECONDARY OBJECTIVES (i) to evaluate the effects of SSI prevention interventions on morbidity, mortality, and resource use; (ii) to evaluate the effects of SSI prevention care bundles on morbidity, mortality, and resource use. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid, from inception) and Embase (Ovid, from inception) on 31 May 2021. CLINICALTRIALS gov and the WHO International Clinical Trials Registry Platform (ICTRP) were also searched for ongoing or unpublished trials on 21 May 2021. No language restrictions were imposed. SELECTION CRITERIA We included RCTs evaluating interventions to reduce SSI in adults (≥ 18 years of age) who have undergone any cardiac surgery. DATA COLLECTION AND ANALYSIS We followed the methods as per our published Cochrane protocol. Our primary outcome was surgical site infection. Our secondary outcomes were all-cause mortality, reoperation for SSI, hospital length of stay, hospital readmissions for SSI, healthcare costs and cost-effectiveness, quality of life (QoL), and adverse effects. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS A total of 118 studies involving 51,854 participants were included. Twenty-two interventions to reduce SSI in adults undergoing cardiac surgery were identified. The risk of bias was judged to be high in the majority of studies. There was heterogeneity in the study populations and interventions; consequently, meta-analysis was not appropriate for many of the comparisons and these are presented as narrative summaries. We focused our reporting of findings on four comparisons deemed to be of great clinical relevance by all review authors. Decolonisation versus no decolonisation Pooled data from three studies (n = 1564) using preoperative topical oral/nasal decontamination in all patients demonstrated an uncertain direction of treatment effect in relation to total SSI (RR 0.98, 95% CI 0.70 to 1.36; I2 = 0%; very low-certainty evidence). A single study reported that decolonisation likely results in little to no difference in superficial SSI (RR 1.35, 95% CI 0.84 to 2.15; moderate-certainty evidence) and a reduction in deep SSI (RR 0.36, 95% CI 0.17 to 0.77; high-certainty evidence). The evidence on all-cause mortality from three studies (n = 1564) is very uncertain (RR 0.66, 95% CI 0.24 to 1.84; I2 = 49%; very low-certainty evidence). A single study (n = 954) demonstrated that decolonisation may result in little to no difference in hospital readmission for SSI (RR 0.80, 95% CI 0.44 to 1.45; low-certainty evidence). A single study (n = 954) reported one case of temporary discolouration of teeth in the decolonisation arm (low-certainty-evidence. Reoperation for SSI was not reported. Tight glucose control versus standard glucose control Pooled data from seven studies (n = 880) showed that tight glucose control may reduce total SSI, but the evidence is very uncertain (RR 0.41, 95% CI 0.19 to 0.85; I2 = 29%; numbers need to treat to benefit (NNTB) = 13; very-low certainty evidence). Pooled data from seven studies (n = 3334) showed tight glucose control may reduce all-cause mortality, but the evidence is very uncertain (RR 0.61, 95% CI 0.41 to 0.91; I2 = 0%; very low-certainty evidence). Based on four studies (n = 2793), there may be little to no difference in episodes of hypoglycaemia between tight control vs. standard control, but the evidence is very uncertain (RR 2.12, 95% CI 0.51 to 8.76; I2 = 72%; very low-certainty evidence). No studies reported superficial/deep SSI, reoperation for SSI, or hospital readmission for SSI. Negative pressure wound therapy (NPWT) versus standard dressings NPWT was assessed in two studies (n = 144) and it may reduce total SSI, but the evidence is very uncertain (RR 0.17, 95% CI 0.03 to 0.97; I2 = 0%; NNTB = 10; very low-certainty evidence). A single study (n = 80) reported reoperation for SSI. The relative effect could not be estimated. The certainty of evidence was judged to be very low. No studies reported superficial/deep SSI, all-cause mortality, hospital readmission for SSI, or adverse effects. Topical antimicrobials versus no topical antimicrobials Five studies (n = 5382) evaluated topical gentamicin sponge, which may reduce total SSI (RR 0.62, 95% CI 0.46 to 0.84; I2 = 48%; NNTB = 32), superficial SSI (RR 0.60, 95% CI 0.37 to 0.98; I2 = 69%), and deep SSI (RR 0.67, 95% CI 0.47 to 0.96; I2 = 5%; low-certainty evidence. Four studies (n = 4662) demonstrated that topical gentamicin sponge may result in little to no difference in all-cause mortality, but the evidence is very uncertain (RR 0.96, 95% CI 0.65 to 1.42; I2 = 0%; very low-certainty evidence). Reoperation for SSI, hospital readmission for SSI, and adverse effects were not reported in any included studies. AUTHORS' CONCLUSIONS This review provides the broadest and most recent review of the current evidence base for interventions to reduce SSI in adults undergoing cardiac surgery. Twenty-one interventions were identified across the perioperative period. Evidence is of low to very low certainty primarily due to significant heterogeneity in how interventions were implemented and the definitions of SSI used. Knowledge gaps have been identified across a number of practices that should represent key areas for future research. Efforts to standardise SSI outcome reporting are warranted.
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Affiliation(s)
| | - Luke J Rogers
- Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Ricky Vaja
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiac Surgery, Guys and St Thomas' NHS Trust, London, UK
| | - David Bleetman
- St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Melissa Rochon
- Directorate of Infection, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Julie Sanders
- St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Judith Tanner
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Theresa L Lamagni
- Healthcare-Associated Infection & Antimicrobial Resistance Division, UK Health Security Agency, London, UK
| | - Shagorika Talukder
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Juan Carlos Quijano-Campos
- St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Florence Lai
- Leicester Clinical Trials Unit, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Righi E, Mutters NT, Guirao X, Dolores Del Toro M, Eckmann C, Friedrich AW, Giannella M, Presterl E, Christaki E, Cross ELA, Visentin A, Sganga G, Tsioutis C, Tacconelli E, Kluytmans J. European Society of Clinical Microbiology and Infectious Diseases/European Committee on infection control clinical guidelines on pre-operative decolonization and targeted prophylaxis in patients colonized by multidrug-resistant Gram-positive bacteria before surgery. Clin Microbiol Infect 2024; 30:1537-1550. [PMID: 39154859 DOI: 10.1016/j.cmi.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 07/09/2024] [Accepted: 07/13/2024] [Indexed: 08/20/2024]
Abstract
SCOPE The aim of these guidelines is to provide recommendations for decolonization and perioperative antibiotic prophylaxis (PAP) in multidrug-resistant Gram-positive bacteria (MDR-GPB) adult carriers before inpatient surgery. METHODS These European Society of Clinical Microbiology and Infectious Diseases/European Committee on Infection Control guidelines were developed following a systematic review of published studies targeting methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, methicillin-resistant coagulase-negative Staphylococci, and pan-drug-resistant-GPB. Critical outcomes were the occurrence of surgical site infections (SSIs) caused by the colonizing MDR-GPB and SSIs-attributable mortality. Important outcomes included the occurrence of SSIs caused by any pathogen, hospital-acquired infections, all-cause mortality, and adverse events associated with the interventions, including resistance development to the agents used and the incidence of Clostridioides difficile infections. The last search of all databases was performed on 1 November 2023. The level of evidence and the strength of each recommendation were defined according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Consensus of a multidisciplinary expert panel was reached for the final list of recommendations. Antimicrobial stewardship considerations were included. RECOMMENDATIONS The guideline panel reviewed the impact of decolonization, targeted PAP, and combined interventions (e.g. decolonization and targeted PAP) on the risk of SSIs and other outcomes in MDR-GPB carriers, according to the type of bacteria and type of surgery. We recommend screening for S. aureus before high-risk operations, such as cardiothoracic and orthopaedic surgery. Decolonization with intranasal mupirocin with or without a chlorhexidine bath is recommended in patients colonized with S. aureus before cardiothoracic and orthopaedic surgery and suggested in other surgeries. The addition of vancomycin to standard prophylaxis is suggested for MRSA carriers in cardiothoracic surgery, orthopaedic surgery, and neurosurgery. Combined interventions (e.g. decolonization and targeted prophylaxis) are suggested for MRSA carriers undergoing cardiothoracic and orthopaedic surgery. No recommendation could be made regarding screening, decolonization and targeted prophylaxis for vancomycin-resistant enterococci because of the lack of data. No evidence was retrieved for methicillin-resistant coagulase-negative Staphylococci and pan-drug-resistant-GPB. Careful consideration of the laboratory workload and involvement of antimicrobial stewardship and infection control teams are warranted before implementing screening procedures or performing changes in PAP policy. Future research should focus on novel decolonizing techniques, on the monitoring of resistance to decolonizing agents and PAP regimens, and on standardized combined interventions in high-quality studies.
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Affiliation(s)
- Elda Righi
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Nico T Mutters
- University Hospital Bonn, Institute for Hygiene and Public Health, Bonn, Germany
| | - Xavier Guirao
- Department of General Surgery, Surgical Endocrine Unit, Surgical Site Prevention Unit, Consorci Corporació Sanitària Parc Tauli, Sabadell, Spain
| | - Maria Dolores Del Toro
- Division of Infectious Diseases and Microbiology, University Hospital Virgen Macarena, Seville, Spain; Department of Medicine, University of Sevilla, Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Christian Eckmann
- Department of Klinikum Hannoversch-Muenden, Academic Hospital of Goettingen University, Göttingen, Germany
| | | | - Maddalena Giannella
- Department of Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elisabeth Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria (on behalf of the ESCMID Study Group on Nosocomial Infections - ESGNI), Austria
| | - Eirini Christaki
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Elizabeth L A Cross
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Alessandro Visentin
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Gabriele Sganga
- Department of Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
| | | | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Jan Kluytmans
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, The Netherlands.
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Orso D, Fodale CM, Fossati S, Venturini S, Fonda F, Cugini F, Comisso I, Crapis M, Cacciavillani L, Bove T. Do patients receiving extracorporeal membrane-oxygenation need antibiotic prophylaxis? A systematic review and meta-analysis on 7,996 patients. BMC Anesthesiol 2024; 24:410. [PMID: 39533181 PMCID: PMC11556216 DOI: 10.1186/s12871-024-02796-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Accepted: 11/01/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND Patients undergoing Extracorporeal Membrane Oxygenation (ECMO) are particularly susceptible to infections: 42% experience sepsis and 26% develop a nosocomial infection (NI). Whether antibiotic prophylaxis is effective in reducing mortality and its effects on the rate of NIs is currently unclear. RESEARCH QUESTION Can antibiotic prophylaxis decrease 30-day mortality for patients on ECMO? Can antibiotic prophylaxis prevent the occurrence of NIs in these patients? STUDY DESIGN AND METHODS A systematic review and meta-analysis was conducted. We searched PubMed, Scopus, and CINAHL libraries from inception to June 12, 2024. Two researchers were involved in abstract screening and three researchers were involved in full text selection. RESULTS A pooled population of 7,996 patients is represented by 5 retrospective studies. Reported mortality ranges between 46 and 58% and the NIs rate is between 14 and 62%. Regarding 30-day mortality, the random-effects model (I2 = 65%) indicates a non-statistically significant difference between the antibiotic prophylaxis group and the non-prophylaxis group (OR 0.76; 95%CI 0.37-1.59). For the NIs rate, a fixed-effect model (I2 = 36%) shows an OR of 0.81 (95%CI 0.71-0.92) in favor of the antibiotic prophylaxis group, with a number-needed-to-treat (NNT) of 39.7 patients. CONCLUSION According to a very low degree of certainty, antibiotic prophylaxis appears to have no impact on the 30-day mortality rate of ECMO recipients. The risk of NIs seems to decrease with antibiotic prophylaxis, even though the NNT is high. Prospective high-quality studies that address these specific clinical questions are necessary. CLINICAL TRIAL REGISTRATION PROSPERO: International prospective register of systematic reviews, 2024, CRD42024567037.
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Affiliation(s)
- Daniele Orso
- Department of Emergency, University Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale, "Santa Maria della Misericordia", Piazzale Santa Maria della Misericordia 15, Udine, 33100, Italy.
| | - Caterina Maria Fodale
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani, 2, Padua, 35128, Italy
| | - Sara Fossati
- Department of Emergency, University Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale, "Santa Maria della Misericordia", Piazzale Santa Maria della Misericordia 15, Udine, 33100, Italy
| | - Sergio Venturini
- Department of Infectious Diseases, Community Hospital of Pordenone, Azienda Sanitaria Friuli Occidentale, "Santa Maria degli Angeli", Via Montereale 34, Pordenone, 33170, Italy
| | - Federico Fonda
- Department of Emergency, University Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale, "Santa Maria della Misericordia", Piazzale Santa Maria della Misericordia 15, Udine, 33100, Italy
| | - Francesco Cugini
- Department of Emergency Medicine, Community Hospital of San Daniele del Friuli "Ospedale Sant'Antonio", Azienda Sanitaria Friuli Centrale, Viale Trento Trieste 33, San Daniele del Friuli, 33038, Italy
| | - Irene Comisso
- Department of Emergency, University Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale, "Santa Maria della Misericordia", Piazzale Santa Maria della Misericordia 15, Udine, 33100, Italy
| | - Massimo Crapis
- Department of Infectious Diseases, Community Hospital of Pordenone, Azienda Sanitaria Friuli Occidentale, "Santa Maria degli Angeli", Via Montereale 34, Pordenone, 33170, Italy
| | - Luisa Cacciavillani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University Hospital of Padua, Via Giustiniani, 2, Padua, 35128, Italy
| | - Tiziana Bove
- Department of Emergency, University Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale, "Santa Maria della Misericordia", Piazzale Santa Maria della Misericordia 15, Udine, 33100, Italy
- Department of Medicine, University of Udine, Via Colugna 51, Udine, 33100, Italy
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7
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Koudieh M, Al Saif S, Oueida F, Baradai A, Alkhamees K, Otabi A, Al Tahir H, Younis H, Al Qudaihi G, Essa M, Maharem T, Fadel M, Al Balwai D, Eskander K. Prophylactic 24 versus 48 h cephalosporins in cardiac surgery: A randomized trial. Asian Cardiovasc Thorac Ann 2024; 32:462-471. [PMID: 39523496 DOI: 10.1177/02184923241297219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
BACKGROUND Recommendations for cardiac surgery advocate for antibiotic prophylaxis for up to 48 hour after surgery. However, recent reports found a significant reduction in surgical site infection with extended duration. We evaluated the effect of the type of prophylactic antibiotics and administration durations on the postoperative surgical site infection rate following cardiac surgery in adults. METHODS An investigator-initiated randomized controlled trial was conducted from 2018 to 2022 on adult patients undergoing cardiac surgery. Patients were randomized into four groups based on antibiotic treatment type and duration: 24 h cefazolin, 24 h cefuroxime, 48 h cefazolin, and 48 h cefuroxime. The primary outcome was the rate of surgical site infections within 90 days of surgery. RESULTS A total of 568 patients were included in this study. The four groups had similar baseline characteristics, including age, sex, EuroSCORE II, and baseline HbA1c. A total of 75 patients developed infection within 90 days postoperative. The overall infection rate was not statistically different across the four groups (p = 0.193). The efficacy of cefazolin and cefuroxime in reducing infection was comparable (p = 0.901). Extended prophylaxis was associated with a significantly reduced overall infection rate within 90 days postoperatively compared to 24-h prophylaxis (10.2% vs. 16.3%; risk ratio = 0.62, 95% confidence interval: 0.40-0.96, p = 0.032). CONCLUSION Using cefazolin or cefuroxime for 48 h instead of 24 h was more effective in reducing the overall surgical site infections rate up to 90 days after surgery.
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Affiliation(s)
- Mohammed Koudieh
- Cardiac Surgery Department, Saud Al Babtain Cardiac Center, Dammam, Saudi Arabia
| | - Shukri Al Saif
- Cardiology Department, Saud Al Babtain Cardiac Center, Dammam, Saudi Arabia
| | - Farouk Oueida
- Cardiac Surgery Department, Saud Al Babtain Cardiac Center, Dammam, Saudi Arabia
| | - Abdulaziz Baradai
- Cardiac Surgery Department, Saud Al Babtain Cardiac Center, Dammam, Saudi Arabia
- Cardiac Surgery Department, King Salman Heart Center, Riyadh, Saudi Arabia
| | - Khalid Alkhamees
- Cardiac Surgery Department, Saud Al Babtain Cardiac Center, Dammam, Saudi Arabia
| | - Abdullah Otabi
- Cardiac Surgery Department, Saud Al Babtain Cardiac Center, Dammam, Saudi Arabia
| | - Hatem Al Tahir
- Anesthesia Department, Saud Al Babtain Cardiac Center, Dammam, Saudi Arabia
| | - Hesham Younis
- Intensive Care Unit, Saud Al Babtain Cardiac Center, Dammam, Saudi Arabia
| | - Ghada Al Qudaihi
- Epidemiology Department, Qatif Central Hospital, Dammam, Saudi Arabia
| | - Mostafa Essa
- Cardiac Surgery Department, Saud Al Babtain Cardiac Center, Dammam, Saudi Arabia
| | - Tarek Maharem
- Anesthesia Department, Saud Al Babtain Cardiac Center, Dammam, Saudi Arabia
| | - Mostafa Fadel
- Anesthesia Department, Saud Al Babtain Cardiac Center, Dammam, Saudi Arabia
| | - Dina Al Balwai
- Research Unit, Saud al Babtain Cardiac Center, Dammam, Saudi Arabia
| | - Khalid Eskander
- Cardiac Surgery Department, Saud Al Babtain Cardiac Center, Dammam, Saudi Arabia
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8
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Sawadogo A, Severgnini G, Bazongo M, Konaté L, Belem FP, Naré Y, Sanou A, Perlangeli S, Fénoglio L, Pilozzi A, Roberto M, Zanobini M. Right ventricle pierced by a traditional sharp hair straightener: a case report. J Cardiothorac Surg 2024; 19:333. [PMID: 38879595 PMCID: PMC11179380 DOI: 10.1186/s13019-024-02770-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 03/30/2024] [Indexed: 06/19/2024] Open
Abstract
The case presents a traumatic ventricular perforation of a girl, accidentally felt on a sharp instrument. The uniqueness of the case presented is due to the very high infrequency of injuries with this type of sharp object. The 7-year-old girl was transported to the hospital after accidentally falling on a sharp instrument. The child had no signs of heart failure. On opening the chest, it was found that the metal object was lodged in the right ventricle. Quickly proceeded to remove the object and suture the entry hole. After a short hospitalization, the child was discharged completely cured.
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Affiliation(s)
- Adama Sawadogo
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire de Tengandogo, Ouagadougou, Burkina Faso
| | - Gaia Severgnini
- Department of Cardiovascular Surgery, Centro Cardiologico Monzino IRCCS. Milan, Milano, Italia.
| | - Moussa Bazongo
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire de Tengandogo, Ouagadougou, Burkina Faso
| | - Lassina Konaté
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire de Tengandogo, Ouagadougou, Burkina Faso
| | - Farid Pingwindé Belem
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire de Tengandogo, Ouagadougou, Burkina Faso
| | - Youssouf Naré
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire de Tengandogo, Ouagadougou, Burkina Faso
| | - Alain Sanou
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire de Tengandogo, Ouagadougou, Burkina Faso
| | | | - Lorena Fénoglio
- Department of Cardiac surgery, Azienda Ospedaliera S.Croce e Carle Cuneo, Cuneo, Italia
| | - Alberto Pilozzi
- Department of Cardiac surgery, Azienda Ospedaliera S.Croce e Carle Cuneo, Cuneo, Italia
| | - Maurizio Roberto
- Department of Cardiac surgery, Azienda Ospedaliera S.Croce e Carle Cuneo, Cuneo, Italia
| | - Marco Zanobini
- Department of Cardiovascular Surgery, Centro Cardiologico Monzino IRCCS. Milan, Milano, Italia
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9
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Moja L, Zanichelli V, Mertz D, Gandra S, Cappello B, Cooke GS, Chuki P, Harbarth S, Pulcini C, Mendelson M, Tacconelli E, Ombajo LA, Chitatanga R, Zeng M, Imi M, Elias C, Ashorn P, Marata A, Paulin S, Muller A, Aidara-Kane A, Wi TE, Were WM, Tayler E, Figueras A, Da Silva CP, Van Weezenbeek C, Magrini N, Sharland M, Huttner B, Loeb M. WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections. Clin Microbiol Infect 2024; 30 Suppl 2:S1-S51. [PMID: 38342438 DOI: 10.1016/j.cmi.2024.02.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/26/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.
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Affiliation(s)
- Lorenzo Moja
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland.
| | - Veronica Zanichelli
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Dominik Mertz
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine in St. Louis, Missouri, United States
| | - Bernadette Cappello
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Graham S Cooke
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Pem Chuki
- Antimicrobial Stewardship Unit, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; World Health Organization Collaborating Centre on Infection Prevention and Control and Antimicrobial Resistance, Geneva, Switzerland
| | - Celine Pulcini
- APEMAC, and Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Evelina Tacconelli
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Loice Achieng Ombajo
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya; Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
| | - Ronald Chitatanga
- Antimicrobial Resistance National Coordinating Centre, Public Health Institute of Malawi, Blantyre, Malawi
| | - Mei Zeng
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, China
| | | | - Christelle Elias
- Service Hygiène et Epidémiologie, Hospices Civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, Centre National de la Recherche Scientifique Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | | | - Sarah Paulin
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | - Arno Muller
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | | | - Teodora Elvira Wi
- Department of Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Wilson Milton Were
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth Tayler
- WHO Regional Office for the Eastern Mediterranean (EMRO), World Health Organisation, Cairo, Egypt
| | | | - Carmem Pessoa Da Silva
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland; Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Nicola Magrini
- NHS Clinical Governance, Romagna Health Authority, Ravenna, Italy; World Health Organization Collaborating Centre for Evidence Synthesis and Guideline Development, Bologna, Italy
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infections, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Benedikt Huttner
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
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10
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Unbehaun P, Prantl L, Langer S, Spindler N. Antibiotic therapy in reconstructive surgery of deep sternal wound infections. Clin Hemorheol Microcirc 2024; 86:183-194. [PMID: 38007643 DOI: 10.3233/ch-238121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
BACKGROUND The choice of antibiotics and length of administration in the treatment of deep sternal wound infections (DSWI) is unclear. The reason for this is the lack of studies and local differences in resistance. An increase in resistance can be observed in gram-positive cocci, which are the most frequently detected in deep sternal infections. The duration of administration is often 2- 6 weeks or longer, although the benefit of prolonged antibiotic administration has not been confirmed by studies. We evaluated the antibiotic treatment during surgical treatment, consisting of surgical wound debridement and plastic chest reconstruction. METHODS Retrospective analysis of patients (n = 260) who underwent reconstructive surgery in the Department of Plastic Surgery at Leipzig University Hospital from 01.05.2012 - 31.12.2020. The duration of intake, results of microbiological swabs and resistance were investigated. RESULTS At the time of discharge, closed wound conditions were noted in 177 of 260 cases (68.1%). The largest proportion of patients (n = 238) was treated with a latissimus dorsi flap (91.5%).Antibiotic treatment was conducted in 206 of 260 cases (79.2%). The mean duration of antibiotic administration was 21.4 days (±17.6). Prolonged treatment over 14 days did not alter outcome (p = 0.226), in contrast, the number of multidrug resistances (p < 0.001). There was no prove of resistance against linezolid which is effective against the most common found infectious agents Staphylococcus epidermidis (n = 93; 24.0 %) & Staphylococcus aureus (n = 47; 12.1 %). CONCLUSION There is no evidence of benefit from antibiotic therapy over 14 days, whereas multidrug resistance increases with prolonged antibiotic use. In the absence of infectious agents or clinical signs of inflammation, surgical treatment without additional antibiotic treatment is effective.Linezolid is a suitable antibiotic in the treatment of gram-positive infections which are the most frequent in DSWI.
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Affiliation(s)
- P Unbehaun
- Department of Plastic, Hand and Reconstructive Surgery, Universitätsklinikum Regensburg, Regensburg, Germany
| | - L Prantl
- Universitätsklinikum Regensburg, Regensburg, Germany
| | - S Langer
- Universitätsklinikum Leipzig, Leipzig, Germany
| | - N Spindler
- Varisano Krankenhaus Bad Soden, Bad Soden, Germany
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11
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Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, Caselli S, Doenst T, Ederhy S, Erba PA, Foldager D, Fosbøl EL, Kovac J, Mestres CA, Miller OI, Miro JM, Pazdernik M, Pizzi MN, Quintana E, Rasmussen TB, Ristić AD, Rodés-Cabau J, Sionis A, Zühlke LJ, Borger MA. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023; 44:3948-4042. [PMID: 37622656 DOI: 10.1093/eurheartj/ehad193] [Citation(s) in RCA: 575] [Impact Index Per Article: 287.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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12
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Cooch PB, Kim MO, Swami N, Tamma PD, Tabbutt S, Steurer MA, Wattier RL. Broad- Versus Narrow-Spectrum Perioperative Antibiotics and Outcomes in Pediatric Congenital Heart Disease Surgery: Analysis of the Vizient Clinical Data Base. J Pediatric Infect Dis Soc 2023; 12:205-213. [PMID: 37018466 PMCID: PMC10146935 DOI: 10.1093/jpids/piad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 04/04/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Despite guidelines recommending narrow-spectrum perioperative antibiotics (NSPA) as prophylaxis for most children undergoing congenital heart disease (CHD) surgery, broad-spectrum perioperative antibiotics (BSPA) are variably used, and their impact on postoperative outcomes is poorly understood. METHODS We used administrative data from U.S. hospitals participating in the Vizient Clinical Data Base. Admissions from 2011 to 2018 containing a qualifying CHD surgery in children 0-17 years old were evaluated for exposure to BSPA versus NSPA. Propensity score-adjusted models were used to compare postoperative length of hospital stay (PLOS) by exposure group, while adjusting for confounders. Secondary outcomes included subsequent antimicrobial treatment and in-hospital mortality. RESULTS Among 18 088 eligible encounters from 24 U.S. hospitals, BSPA were given in 21.4% of CHD surgeries, with mean BSPA use varying from 1.7% to 96.1% between centers. PLOS was longer for BSPA-exposed cases (adjusted hazard ratio 0.79; 95% confidence interval [CI]: 0.71-0.89, P < .0001). BSPA was associated with higher adjusted odds of subsequent antimicrobial treatment (odds ratio [OR] 1.24; 95% CI: 1.06-1.48), and there was no significant difference in adjusted mortality between exposure groups (OR 2.06; 95% CI: 1.0-4.31; P = .05). Analyses of subgroups with the most BSPA exposure, including high-complexity procedures and delayed sternal closure, also did not find (but could not exclude) a measurable benefit from BSPA on PLOS. CONCLUSIONS BSPA use was common in high-risk populations, and varied substantially between centers. Standardizing perioperative antibiotic practices between centers may reduce unnecessary broad-spectrum antibiotic exposure and improve clinical outcomes.
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Affiliation(s)
- Peter B Cooch
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics, Kaiser Permanente Northern California, Oakland, California, USA
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Naveen Swami
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, University of California San Francisco, San Francisco, CaliforniaUSA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sarah Tabbutt
- Department of Pediatrics, Division of Critical Care, University of California San Francisco, San Francisco, California, USA
| | - Martina A Steurer
- Department of Pediatrics, Division of Critical Care, University of California San Francisco, San Francisco, California, USA
| | - Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California San Francisco, San Francisco, California, USA
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13
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Wang L, Yu XB, Zhou ZY, Wang J, Zheng LP, Dai Y, Wang YZ, Zhang XS, Chen C, Shi DW, Zhang CH. Modification of Vancomycin Dosing in Cardiac Surgery With Cardiopulmonary Bypass. J Clin Pharmacol 2023; 63:490-497. [PMID: 36458612 DOI: 10.1002/jcph.2190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/23/2022] [Indexed: 12/05/2022]
Abstract
This study aims to assess the risk factors for insufficient vancomycin concentrations for its prophylactic use in adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) and to modify the dosing regimen to achieve appropriate plasma concentrations. A total of 27 patients with vancomycin dosing of 1 to 1.5 g based on a weight cutoff of 67 kg were included, of which only 13 (48.15%) had vancomycin plasma concentration >15 mg/L at surgical closure. Risk factors of vancomycin concentration <15 mg/L at surgical-site closure were confirmed by multivariate logistic regression analysis, which showed that CPB duration was an independent predictor. Patients with CPB duration >4 hours had significantly lower vancomycin concentrations and lower proportion in achieving target vancomycin concentration at the end of CPB and surgical closure. For patients with CPB >4 hours, the modified dosing regimen that a second dose of 0.5 to 0.75 g added at 4 hours since the onset of CPB improved the target achievement of vancomycin concentration at surgical closure. Taken together, CPB duration >4 hours was the risk factor for insufficient vancomycin concentration at surgical closure, while our modified dosing could improve the vancomycin concentrations for its prophylactic use in patients undergoing cardiac surgery with CPB.
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Affiliation(s)
- Lei Wang
- Division of Cardiac Surgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xu-Ben Yu
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Pharmacy, Wenzhou Medical University, Wenzhou, China.,Department of Pharmacology, Chonnam National University, Gwangju, South Korea
| | - Zi-Ye Zhou
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jue Wang
- Division of Cardiac Surgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Liu-Pu Zheng
- Division of Cardiac Surgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ying Dai
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yu-Zhen Wang
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Xiao-Shan Zhang
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Chuang Chen
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Da-Wei Shi
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chun-Hong Zhang
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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14
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de Tymowski C, Sahnoun T, Provenchere S, Para M, Derre N, Mutuon P, Duval X, Grall N, Iung B, Kernéis S, Lucet JC, Montravers P. Impact of Antibiotic Prophylaxis on Surgical Site Infections in Cardiac Surgery. Antibiotics (Basel) 2023; 12:85. [PMID: 36671286 PMCID: PMC9854463 DOI: 10.3390/antibiotics12010085] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/06/2023] Open
Abstract
(1) Background: Cephalosporins (CA) are the first-line antibiotic prophylaxis recommended to prevent surgical site infection (SSI) after cardiac surgery. The combination of vancomycin/gentamicin (VGA) might represent a good alternative, but few studies have evaluated its efficacy in SSI prevention. (2) Methods: A single-centre retrospective study was conducted over a 13-year period in all consecutive adult patients undergoing elective cardiac surgery. Patients were stratified according to the type of antibiotic prophylaxis. CA served as the first-line prophylaxis, and VGA was used as the second-line prophylaxis. The primary endpoint was SSI occurrence at 90 days, which was defined as the need for reoperation due to SSI. (3) Results: In total, 14,960 adult patients treated consecutively from 2006 to 2019 were included in this study, of whom 1774 (12%) received VGA and 540 (3.7%) developed SSI. VGA patients had higher severity with increased 90-day mortality. Nevertheless, the frequency of SSI was similar between CA and VGA patients. However, the microbiological aetiologies were different, with more Gram-negative bacteria noted in the VGA group. (4) Conclusions: VGA seems to be as effective as CA in preventing SSI.
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Affiliation(s)
- Christian de Tymowski
- Department of Anaesthesiology and Surgical Intensive Care, DMU PARABOL, AP-HP, Hôpital Bichat, 75018 Paris, France
- Université Paris Cité, Centre de Recherche sur l’Inflammation, INSERM UMR 1149, CNRS ERL8252, F-75018 Paris, France
- Laboratory of Excellence, Inflamex, Université Paris Cité, F-75018 Paris, France
- Department of Immunology, DHU Fire, AP-HP, Hôpital Bichat, 75018 Paris, France
| | - Tarek Sahnoun
- Department of Anaesthesiology and Surgical Intensive Care, DMU PARABOL, AP-HP, Hôpital Bichat, 75018 Paris, France
| | - Sophie Provenchere
- Department of Anaesthesiology and Surgical Intensive Care, DMU PARABOL, AP-HP, Hôpital Bichat, 75018 Paris, France
- INSERM Clinical Investigation Center 1425, 75018 Paris, France
| | - Marylou Para
- Department of Cardiac Surgery, AP-HP, Hôpital Bichat, 75018 Paris, France
- UFR Paris Nord, Université Paris Cité, 75006 Paris, France
| | - Nicolas Derre
- Department of Anaesthesiology and Surgical Intensive Care, DMU PARABOL, AP-HP, Hôpital Bichat, 75018 Paris, France
| | - Pierre Mutuon
- Service MSI, AP-HP, Hôpital Bichat, 75018 Paris, France
| | - Xavier Duval
- INSERM Clinical Investigation Center 1425, 75018 Paris, France
- UFR Paris Nord, Université Paris Cité, 75006 Paris, France
- Université Paris Cité, INSERM, IAME, F-75018 Paris, France
| | - Nathalie Grall
- Université Paris Cité, INSERM, IAME, F-75018 Paris, France
- Service de Bactériologie, AP-HP, Hôpital Bichat, 75018 Paris, France
| | - Bernard Iung
- UFR Paris Nord, Université Paris Cité, 75006 Paris, France
- Cardiology Department, AP-HP, Bichat Hospital, Université Paris Cite, INSERM 1148, 46 Rue Henri Huchard, 75018 Paris, France
| | - Solen Kernéis
- UFR Paris Nord, Université Paris Cité, 75006 Paris, France
- Université Paris Cité, INSERM, IAME, F-75018 Paris, France
- Equipe de Prévention du Risque Infectieux (EPRI), AP-HP, Hôpital Bichat, 75018 Paris, France
| | - Jean-Christophe Lucet
- UFR Paris Nord, Université Paris Cité, 75006 Paris, France
- Université Paris Cité, INSERM, IAME, F-75018 Paris, France
- Equipe de Prévention du Risque Infectieux (EPRI), AP-HP, Hôpital Bichat, 75018 Paris, France
| | - Philippe Montravers
- Department of Anaesthesiology and Surgical Intensive Care, DMU PARABOL, AP-HP, Hôpital Bichat, 75018 Paris, France
- UFR Paris Nord, Université Paris Cité, 75006 Paris, France
- Université Paris Cité, Physiopathologie et Epidémiologie des Maladies Respiratoires, INSERM UMR 1152, F-75018 Paris, France
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15
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Chen Q, Yu J, Huang P, Huang Y, Chen Q, Zhang Z, Wang S. Incidence, Clinical Features, and Association with Prognosis of Bloodstream Infection in Pediatric Patients After Percutaneous or Surgical Treatment for Ventricular Septal Defect or Atrial Septal Defect: A Retrospective Cohort Study. Infect Dis Ther 2022; 11:2219-2232. [PMID: 36242740 PMCID: PMC9669298 DOI: 10.1007/s40121-022-00702-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/20/2022] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Bloodstream infection (BSI) may occur after cardiac procedures, but this has rarely been investigated specifically in pediatric patients after percutaneous or surgical treatment for ventricular septal defect (VSD) or atrial septal defect (ASD) with recent data. The current study aimed to investigate the incidence, clinical features, and association with prognosis of BSI in this patient population. METHODS Pediatric patients who received percutaneous or surgical procedure for VSD or ASD between 2010 and 2018 in a large children's hospital in China were retrospectively enrolled via the Pediatric Intensive Care database, but only those who had blood culture records within 24 h after the procedure and who had no prior positive blood culture records were included. BSI after the procedure was identified by reviewing blood culture records, and baseline characteristics associated with BSI were explored by univariable logistic regression. In-hospital mortality and length of hospitalization were studied as prognostic outcomes and compared between patients with and without BSI. RESULTS A total of 1340 pediatric patients were included. Among them, 46 (3.43%) patients had BSI within 24 h after the procedure, of which the majority (78.26%, 36/46) were caused by Gram-positive bacteria and 65.22% (30/46) had antibiotic-resistant organisms. Age [odds ratio (OR) 0.98 per 1-month increase, 95% confidence interval (CI) 0.97-1.00, P = 0.021] and antibiotic use within 72 h before the procedure (OR 1.81, 95% CI 1.00-3.26, P = 0.049) were statistically significantly associated with developing BSI. Compared with patients without BSI, there was no statistically significant difference in in-hospital mortality (0.00% versus 0.54%, P = 1.000), but patients with BSI had statistically significantly longer length of hospitalization (median 14.51 versus 12.94 days, P = 0.006), while the association was not statistically significant after adjustment for baseline characteristics by multivariable linear regression (β = 1.73, 95% CI -0.59 to 4.04, P = 0.144). CONCLUSION BSI is relatively uncommon in pediatric patients after procedures for VSD or ASD, but a younger age seems a risk factor. Developing BSI appears to be associated with increased length of hospitalization but not in-hospital mortality.
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Affiliation(s)
- Qinchang Chen
- Department of Pediatric Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, No. 106, Zhongshan 2nd Road, Guangzhou, China
| | - Jinjin Yu
- Department of Pediatric Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, No. 106, Zhongshan 2nd Road, Guangzhou, China
| | - Pingchuan Huang
- Department of Pediatric Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, No. 106, Zhongshan 2nd Road, Guangzhou, China
| | - Yulu Huang
- Department of Pediatric Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, No. 106, Zhongshan 2nd Road, Guangzhou, China
| | - Qingui Chen
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zhiwei Zhang
- Department of Pediatric Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, No. 106, Zhongshan 2nd Road, Guangzhou, China. .,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.
| | - Shushui Wang
- Department of Pediatric Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, No. 106, Zhongshan 2nd Road, Guangzhou, China. .,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.
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Kinn PM, Ince D. Outpatient and peri-operative antibiotic stewardship in solid organ transplantation. Transpl Infect Dis 2022; 24:e13922. [PMID: 36254519 PMCID: PMC9788159 DOI: 10.1111/tid.13922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/27/2022] [Accepted: 07/01/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The consequences of inappropriate antimicrobial use including resistance are increasingly recognized as a global public health threat and many steps have been taken over the last few decades to advance antimicrobial stewardship initiatives with most organ transplant centers currently part of institutions with active antimicrobial stewardship programs. METHODS A review of the literature was conducted and articles were categorized according to the topic and relevance in the judgment of the two authors. RESULTS A summary review of the currently available literature was created with a focus on periprocedural and outpatient antimicrobial stewardship. Limitations in the data were significant and discussed in the review. CONCLUSION The principles of antimicrobial stewardship remain important throughout all phases starting with periprocedural prophylactic antimicrobial selection all the way through to discharge and subsequent healthcare encounters. Despite the broad advances in stewardship initiatives and the rapidly progressing supportive data overall there continue to be significant opportunities for additional research within various special patient populations including recipients of solid organ transplantation (SOT). The recent white paper published in the American Journal of Transplantation called to action the transplant and stewardship communities to have an increased focus and awareness of the issues that antimicrobial overuse can present in the SOT patient population. This is an important step that will hopefully generate more data in this group of patients that arguably faces the greatest vulnerability to the consequences of increased antimicrobial resistance.
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Affiliation(s)
- Patrick Michael Kinn
- Department of Pharmaceutical CareUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | - Dilek Ince
- Department of Internal MedicineDivision of Infectious DiseasesUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
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17
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Stepin AV. [Local infectious complications in cardiac surgery: etiology and the role of antimicrobial prophylaxis]. Khirurgiia (Mosk) 2022:40-47. [PMID: 35658135 DOI: 10.17116/hirurgia202206140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate the relationship between antimicrobial prophylaxis protocol, prevalence and etiology of local infectious complications after open cardiac surgery. MATERIAL AND METHODS A retrospective cohort observational study was performed between 2010 and 2019 at the Ural Institute of Cardiology. Antimicrobial prophylaxis was performed using the main (cefuroxime 1.5 g IV every 6 hours) and alternative protocols (vancomycin 15 mg/kg IV every 12 hours). RESULTS The prevalence of local infectious complications throughout the entire follow-up period was 4.5±0.3% [95% CI 4.45-4.54]. There were 42 cases of deep infection (0.9±0.13%). Coagulase-negative staphylococci prevailed (15.9±2.5% of cases, 35 cultures). Resistant flora included coagulase-negative methicillin-resistant staphylococci (13 cultures, 37.1±8.2%) and representatives of Enterobacteriaceae family, producers of extended-spectrum beta-lactamase (8 cultures, 50.0±18.2%). Antimicrobial prophylaxis with vancomycin increases the risk of local infectious complications (OR 1.75, 95% CI 1.20, 2.55, p=0.001). Both protocols of antimicrobial prophylaxis demonstrated comparable efficacy against gram-positive and gram-negative microorganisms. CONCLUSION Coagulase-negative staphylococci are the most common cause of local infectious complications in cardiac surgery. Modern antimicrobial prophylaxis regimens are relevant despite resistant flora.
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Affiliation(s)
- A V Stepin
- Ural Institute of Cardiology, Yekaterinburg, Russia
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18
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Jannati M. The value of prophylactic antibiotics in coronary artery bypass graft surgery: A review of literature. JOURNAL OF VASCULAR NURSING 2021; 39:100-103. [PMID: 34865718 DOI: 10.1016/j.jvn.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/15/2021] [Accepted: 07/21/2021] [Indexed: 11/30/2022]
Abstract
Infections have a significant impact on increasing both the morbidity and mortality rate of patients who have undergone coronary artery bypass graft (CABG) surgery. Infection after CABG imposes a clinical and economic burden on patients and health care organizations; therefore, prevention should be on the agenda. This review will focus on the value of using prophylactic antibiotics in coronary artery bypass graft surgery (CABG). Prophylactic antibiotics like cephalosporin and vancomycin are more commonly used antibiotics and are strongly associated with reduced infection risk in patients. The results showed that using antibiotics during the perioperative period and after CABG is an effective strategy for reducing post-infection problems without compromising the patients' clinical outcomes. Diabetic patients are prone to postoperative infection after CABG, however, prophylactic antibiotics should not be the only strategy used to reduce the risk of postoperative infection in diabetic patients. Perioperative glycaemic control is essential for diabetic patients undergoing CABG. Appropriate antibiotic prophylaxis has a great impact on preventing infection after CABG but duration and selecting appropriate antibiotic is important. Standardizing the use of antibiotic prophylaxis reduces the rate of infection and unwanted bacterial resistance, which could subsequently reduce economic costs to patients and public health.
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Affiliation(s)
- Mansour Jannati
- Department of Cardiovascular Surgery, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
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19
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Kitagawa H, Shimizu H, Katayama K, Tadera K, Nomura T, Omori K, Shigemoto N, Takasaki T, Ohge H, Takahashi S. Postoperative mediastinitis after cardiac surgery caused by Mycoplasma hominis: a case report. Surg Case Rep 2021; 7:248. [PMID: 34812956 PMCID: PMC8611127 DOI: 10.1186/s40792-021-01326-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mycoplasma hominis is a human commensal bacterium of the urogenital tract, and extragenital infection caused by M. hominis has rarely been reported. The identification of M. hominis is challenging, and surgeons are generally not aware that this bacteria can cause postoperative infection. Here, we report a rare case of postoperative mediastinitis caused by M. hominis after cardiac surgery in an immunocompetent patient. CASE PRESENTATION A 54-year-old man presented with pain and purulent discharge from the wound after aortic valve replacement and patent foramen ovale closure. However, Gram staining and culture of bacteria from the purulent discharge was negative, and empiric sulbactam/ampicillin therapy was not effective. This patient developed mediastinitis and rupture of a pseudoaneurysm of the ascending aorta caused by mediastinitis, and re-operation was performed. Then, postoperative mediastinitis caused by M. hominis or Ureaplasma species was suspected and bacterial cultures targeting these pathogens were performed. M. hominis was identified from abscess and tissue obtained from the surgical site and urine. A final diagnosis of postoperative mediastinitis caused by M. hominis was determined. The patient was initially treated with levofloxacin and then with minocycline for 3 weeks. The patient's clinical condition improved; the patient was transferred to another hospital. CONCLUSION The role of M. hominis as a cause of postoperative infection might be underestimated in cardiac surgery. M. hominis should be considered when culture-negative purulent discharge is observed or there is no response to standard empiric treatment of postoperative infections.
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Affiliation(s)
- Hiroki Kitagawa
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan. .,Department of Infectious Diseases, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan. .,Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Haruna Shimizu
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Keijiro Katayama
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kayoko Tadera
- Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.,Section of Infection Diseases Laboratory, Department of Clinical Support, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.,Division of Clinical Laboratory Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Toshihito Nomura
- Department of Infectious Diseases, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kietaro Omori
- Department of Infectious Diseases, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Norifumi Shigemoto
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.,Department of Infectious Diseases, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.,Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.,Translational Research Center, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Taiichi Takasaki
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.,Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shinya Takahashi
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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20
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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Ackah JK, Neal L, Marshall NR, Panahi P, Lloyd C, Rogers LJ. Antimicrobial prophylaxis in adult cardiac surgery in the United Kingdom and Republic of Ireland. J Infect Prev 2021; 22:83-90. [PMID: 33859725 PMCID: PMC8014008 DOI: 10.1177/1757177420971850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 10/07/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Deep sternal wound infections are a financially costly complication of cardiac surgery with serious implications for patient morbidity and mortality. Prophylactic antimicrobials have been shown to reduce the incidence of infection significantly. In 2018, the European Association for CardioThoracic Surgery (EACTS) provided clear guidance advising that third-generation cephalosporins are the first-line prophylactic antimicrobial of choice for cardiac surgery via median sternotomy as a result of their broad spectrum of activity and association with reduced postoperative mortality. Despite this guidance, it was believed that UK practice differed from this as a consequence of national concerns surrounding cephalosporins use and Clostridioides difficile infection. METHODS A survey was developed and distributed to all UK and Republic of Ireland (ROI) cardiac surgery centres in January 2019 to quantify this variation. RESULTS Of the 38 centres, 34 responded. Variation existed between the antimicrobial agent used, as well as the dosage, frequency and duration of suggested regimens even among centres using the same antimicrobial agent. The most common antimicrobial prophylaxis prescribed was a combination of flucloxacillin and gentamicin (16, 47%). Followed by cefuroxime (6, 17.6%) and cefuroxime combined with a glycopeptide (4, 11.7%). In patients colonised with methicillin-resistant Staphylococcus aureus or those with penicillin allergy gentamicin combined with teicoplanin was most common (42% and 50%, respectively). DISCUSSION This variation in antimicrobial agents and regimens may well contribute to the varying incidence of surgical site infection seen across the UK and ROI.
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Affiliation(s)
- James Kofi Ackah
- Southwest Cardiothoracic Surgery Department, University Hospitals Plymouth NHS Trust, Plymouth, Devon, UK
| | - Louise Neal
- Southwest Cardiothoracic Surgery Department, University Hospitals Plymouth NHS Trust, Plymouth, Devon, UK
| | | | - Pedram Panahi
- Southwest Cardiothoracic Surgery Department, University Hospitals Plymouth NHS Trust, Plymouth, Devon, UK
| | - Clinton Lloyd
- Southwest Cardiothoracic Surgery Department, University Hospitals Plymouth NHS Trust, Plymouth, Devon, UK
| | - Luke J Rogers
- Southwest Cardiothoracic Surgery Department, University Hospitals Plymouth NHS Trust, Plymouth, Devon, UK
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22
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Majid FM, Buba FM, Barry M, Alsharani F, Alfawzan F. Incidence, types and outcomes of sternal wound infections after cardiac surgery in Saudi Arabia. A retrospective medical chart review. Saudi Med J 2021; 41:177-182. [PMID: 32020152 PMCID: PMC7841641 DOI: 10.15537/smj.2020.2.24843] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objectives: To determine the incidence, types, risk factors, identify organisms, and assess outcomes of surgical wound infections (SWIs) after cardiac surgery at a tertiary hospital in Riyadh, Saudi Arabia. Methods: This historical cohort study reviewed the chart of patients who underwent cardiac surgery at King Khalid University Hospital, Riyadh, Saudi Arabia between January 2009 and December 2014. The proforma contained personal data, comorbidities, type of surgery, microbiological analysis, and management outcomes. Results: A total of 1241 patients were enrolled in the study comprising 1,032 (83.2%) men and 209 (16.8%) women. Forty (3.2%) patients developed SWI, of which 32 (2.5%) were superficial and 8 (0.7%) were deep. Gender, obesity, diabetes mellitus, non-use of statins, and coronary artery bypass graft (CABG) surgery were not significant predictors of infection in the study. Methicillin-susceptible Staphylococcus aureus was isolated predominantly in 45%, followed by Klebsiella and Pseudomonas species. Methicillin-resistant Staphylococcus aureus, Enterococcus faecium, and extended β-lactamase-producing gram-negative organisms were pathogens isolated in last 3 years of the review. Simple and vacuum assisted closure therapies led to complete resolution in 32 (80%) patients, while 8 (20%) developed sternal osteomyelitis. All patients survived except one with a deep SWI who died of uncontrolled sepsis. Conclusion: Despite the low incidence of postoperative SWIs, the risk of sternal osteomyelitis development persists. Meticulous choice of CABG components and appropriate postoperative management, especially detecting early signs of SWI could contribute to lower its incidence and complications.
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Affiliation(s)
- Fahad M Majid
- Department of Infectious Diseases, King Saudi University, Riyadh, Kingdom of Saudi Arabia. E-mail.
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Mufti HN, Jarad M, Haider MM, Azzhary L, Namnqani S, Husain I, Albugami S, Elamin W. Impact of Pre-operative Hemoglobin A1C Level and Microbiological Pattern on Surgical Site Infection After Cardiac Surgery. Cureus 2020; 12:e11851. [PMID: 33282606 PMCID: PMC7714741 DOI: 10.7759/cureus.11851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2020] [Indexed: 01/19/2023] Open
Abstract
Background Surgical site infection (SSI) after cardiac surgery is a major concern. A limited number of studies have addressed the relationship of preoperative glycemic control on the risk of developing SSI after cardiac surgery. We aim to determine the incidence, microbiological pattern, and impact of preoperative hemoglobin A1C (Hgb A1C) on the development of SSI after cardiac surgery. Methods This is a single-center retrospective chart review that was performed on adult patients undergoing cardiac surgery from January 2017 to December 2018. Results Two hundred and twenty-nine patients underwent 233 procedures. The median age was 60 years; 71% males, 64% were diabetic, and 67% had a Hb A1C above 7% preoperatively. Around 7% of patients developed deep SSI. For patients that developed SSI, 63% had gram-negative bacteria. Hb A1C >7% was not found to be associated with an increased incidence of SSI. Conclusion Our results show that there is no apparent relationship between pre-operative Hgb A1C levels and SSI after cardiac surgery. Although we follow a comprehensive SSI perioperative bundle based on international guidelines that advocates using antibiotics to cover gram-positive organisms, it is interesting that the rate of gram-negative organisms in our patients' cohort is unexpectedly high. We believe that adjusting the perioperative antibiotic regimen based on local microbiological patterns seems to be a reasonable and easily achievable target to decrease the incidence of SSI.
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Affiliation(s)
- Hani N Mufti
- Cardiac Surgery, King Faisal Cardiac Center, King Abdullah Medical City, Jeddah, SAU
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Medicine, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Mayar Jarad
- Medicine, Ibn Sina National College, Jeddah, SAU
| | | | | | | | - Imran Husain
- Cardiothoracic Surgery, The Golden Jubilee National Hospital, Glasgow, GBR
| | - Saad Albugami
- Cardiolgy, King Faisal Cardiac Center, King Abdullah Medical City, Jeddah, SAU
| | - Wael Elamin
- Cardiac Surgery, King Faisal Cardiac Center, King Abdulaziz Medical City, Jeddah, SAU
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de la Varga-Martínez O, Gómez-Sánchez E, Muñoz MF, Lorenzo M, Gómez-Pesquera E, Poves-Álvarez R, Tamayo E, Heredia-Rodríguez M. Impact of nosocomial infections on patient mortality following cardiac surgery. J Clin Anesth 2020; 69:110104. [PMID: 33221707 DOI: 10.1016/j.jclinane.2020.110104] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/04/2020] [Accepted: 10/10/2020] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE To determine the rate of nosocomial infection among patients undergoing cardiac surgery and to identify risk factors and the impact of these infections on patient mortality. DESIGN Prospective observational study. SETTING Intensive Care Unit (ICU). PATIENTS 1097 adult patients who underwent cardiac surgery at Hospital Clínico Universitario de Valladolid between January 2011 and January 2016. INTERVENTIONS None. MEASUREMENTS Preoperative, intraoperative and postoperative medical, surgical and anaesthetic variables. MAIN RESULTS A total of 111 patients (10.1%) acquired a nosocomial infection in the postoperative period. Pneumonia was the most frequent (4.2%) nosocomial infection. Three independent risk factors for the development of a nosocomial infection were identified: cardiopulmonary bypass time, kidney failure and emergency surgery. The stay in the ICU was significantly higher in patients who developed a nosocomial infection (16.6 ± 38.8 vs. 4.4 ± 17.8, P < 0.001). The mortality rate of patients who acquired a nosocomial infection was significantly greater (18%) than that of patients who did not acquire a nosocomial infection (5%) (P < 0.001). The 90-day survival was greater in the group of patients without nosocomial infection (log rank 27.55, P < 0.001). The dynamic modelling of 90-day mortality revealed that in the first week, cardiopulmonary bypass time (HR = 1.00, 95% CI 1.00-1.02, P < 0.001) and emergency surgery (HR = 0.12, 95% CI 0.04-0.37, P < 0.001) were the most important risk factors for mortality, while after the first week, nosocomial infection (HR = 6.23, 95% CI 2.49-15.63, P < 0.001) was the main risk factor, followed by cardiopulmonary bypass time (HR = 1.01, 95% CI 1.00-1.01, P = 0.001) and EuroSCORE (HR = 1.03, 95% CI 1.00-1.06, P = 0.008). CONCLUSIONS Nosocomial infections after cardiac surgery constitute the main independent risk factor for mortality after the first week of surgery. These data suggest that its prevention following cardiac surgery must be prioritised to improve patient outcomes.
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Affiliation(s)
| | - Esther Gómez-Sánchez
- Department of Anaesthesiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain.
| | - María Fe Muñoz
- Unit of Research, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Mario Lorenzo
- Department of Anaesthesiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
| | - Estefanía Gómez-Pesquera
- Department of Anaesthesiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
| | - Rodrigo Poves-Álvarez
- Department of Anaesthesiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Eduardo Tamayo
- Department of Anaesthesiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
| | - María Heredia-Rodríguez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain; Unit of Research, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Rimmler C, Lanckohr C, Mittrup M, Welp H, Würthwein G, Horn D, Fobker M, Ellger B, Hempel G. Population pharmacokinetic evaluation of cefuroxime in perioperative antibiotic prophylaxis during and after cardiopulmonary bypass. Br J Clin Pharmacol 2020; 87:1486-1498. [PMID: 32959896 DOI: 10.1111/bcp.14556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 08/30/2020] [Accepted: 09/09/2020] [Indexed: 11/27/2022] Open
Abstract
AIMS The purpose of this study was to explore pharmacokinetic and pharmacodynamic aspects of a contemporary dosing scheme of cefuroxime as perioperative prophylaxis in cardiac surgery using cardiopulmonary bypass (CPB). METHODS Cefuroxime plasma concentrations were measured in 23 patients. A 1.5-g dose of cefuroxime was administered at start of surgery and CPB, followed by 3 additional doses every 6 hours postoperative. Drug levels were used to build a population pharmacokinetic model. Target attainment for Staphylococcus aureus (2-8 mg/L) and Escherichia coli (8-32 mg/L) were evaluated and dosing strategies for optimization were investigated. RESULTS A dosing scheme of 1.5 g cefuroxime preoperatively with a repetition at start of CPB achieves plasma unbound concentrations of 8 mg/L in almost all patients during surgery. The second administration is critical to provide this level of coverage. Simulations indicate that higher unbound concentrations up to 32 mg/L are reached by a continuous infusion rate of 1 g/h after a bolus of 1 g. In the postoperative phase, most patients do not reach unbound concentrations above 2 mg/L. To improve target attainment up to 8 mg/L, the continuous application of cefuroxime with infusion rates of 0.125-0.25 g/h is simulated and shown to be an alternative to bolus dosing. CONCLUSION Dosing recommendations for cefuroxime as perioperative antibiotic prophylaxis in cardiac surgery are sufficient to reach plasma unbound concentration to cover S. aureus during the operation. Target attainment is not achieved in the postoperative period. Continuous infusion of cefuroxime may optimize target attainment.
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Affiliation(s)
- Christer Rimmler
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Christian Lanckohr
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Miriam Mittrup
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Henryk Welp
- Department of Cardiac Surgery, University Hospital Muenster, Muenster, Germany
| | - Gudrun Würthwein
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Dagmar Horn
- Department of Pharmacy, University Hospital of Muenster, Muenster, Germany
| | - Manfred Fobker
- Center for Laboratory Medicine, University Hospital Muenster, Muenster, Germany
| | - Björn Ellger
- Department of Anesthesiology, Intensive Care and Pain Medicine, Klinikum Westfalen, Dortmund, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
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Pharmacokinetic Model for Cefuroxime Dosing during Cardiac Surgery under Cardiopulmonary Bypass. Antimicrob Agents Chemother 2020; 64:AAC.01687-20. [PMID: 33020154 DOI: 10.1128/aac.01687-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/24/2020] [Indexed: 12/17/2022] Open
Abstract
Cefuroxime (CXM) is an antibiotic recommended for surgical site infection prevention in cardiac surgery. However, the dosing regimens commonly used do not sustain therapeutic concentrations throughout surgery. The aim of this study was to conduct a population analysis of CXM pharmacokinetics (PK), and to propose an optimized dosing regimen. Adult patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) received a 1,500 mg CXM intravenous bolus followed by a 750 mg bolus at CPB priming, then every 2 h thereafter. Model-based PK simulations were used to develop an optimized dosing regimen and evaluate its efficacy in attaining various concentration thresholds, including those recommended in US and European guidelines. In total, 447 CXM measurements were acquired in 50 patients. A two-compartment model best fit the data, with total body weight and creatinine clearance determining interpatient variability in the central and peripheral volumes of distribution, and in elimination clearance, respectively. Using our optimized dosing regimen, different dosing schemes adapted to body weight and renal function were calculated to attain total concentration thresholds ranging from 12 to 96 mg/liter. Our simulations showed that the dosing regimens recommended in US and European guidelines failed to maintain concentrations above 48 mg/liter. Our individualized dosing strategy was capable of ensuring therapeutic CXM concentrations conforming to each target threshold. Our model yielded an optimized CXM dosing regimen adapted to body weight and renal function, and sustaining therapeutic concentrations consistent with each desired threshold. The optimal target concentration and necessary duration of its maintenance in cardiac surgery still remain unclear.
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28
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Segala FV, Murri R, Taddei E, Giovannenze F, Del Vecchio P, Birocchi E, Taccari F, Cauda R, Fantoni M. Antibiotic appropriateness and adherence to local guidelines in perioperative prophylaxis: results from an antimicrobial stewardship intervention. Antimicrob Resist Infect Control 2020; 9:164. [PMID: 33106190 PMCID: PMC7586646 DOI: 10.1186/s13756-020-00814-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/04/2020] [Indexed: 02/07/2023] Open
Abstract
Objectives Surgical antibiotic prophylaxis (SAP) represents a major indication of antibiotic consumption worldwide. The present study aims to report the results of an enabling, long-term AMS intervention conducted between 2013 and 2019 on an Italian University Hospital performing more than 40.000 surgical interventions per year. Methods SAP inappropriateness was defined according to the ASHP guidelines and divided in four main categories: indication, selection and dosing, duration, timing. Between 2013 and 2019, we conducted a continuative AMS intervention over 14 surgical departments that included enablement, review of selected clinical records and feedback. Results We collected a total of 789 SAP prescribed to 735 patients (mean age 56.7 ± 17.8y). Overall, guideline adherence improved from 36.6% (n = 149) at baseline to 57.9% (n = 221) post-intervention (P < 0.0001). A significant improvement (P < 0.001) was also detected for each category: indication (from 58.5 to 93.2%), selection and dosing (from 58.5 to 80.6%), timing (from 92.4 to 97.6%), duration (from 71 to 80.1%). Conclusions Though results cannot be generalized to all hospital populations, enabling AMS interventions may be effective in establishing a sustained improvement in SAP appropriateness rates. Once identified the main causes of SAP inappropriateness, tailored AMS interventions for each department may be beneficial. Further studies are needed to evaluate specific outcomes as incidence of surgical site infections and antimicrobial resistance.
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Affiliation(s)
- Francesco Vladimiro Segala
- Section of Infectious Diseases, Department of Safety and Bioethics, Catholic University of the Sacred Heart, Rome, Italy.
| | - Rita Murri
- Section of Infectious Diseases, Department of Safety and Bioethics, Catholic University of the Sacred Heart, Rome, Italy.,Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Eleonora Taddei
- Section of Infectious Diseases, Department of Safety and Bioethics, Catholic University of the Sacred Heart, Rome, Italy.,Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesca Giovannenze
- Section of Infectious Diseases, Department of Safety and Bioethics, Catholic University of the Sacred Heart, Rome, Italy
| | - Pierluigi Del Vecchio
- Section of Infectious Diseases, Department of Safety and Bioethics, Catholic University of the Sacred Heart, Rome, Italy
| | - Emanuela Birocchi
- Section of Infectious Diseases, Department of Safety and Bioethics, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Taccari
- Section of Infectious Diseases, Department of Safety and Bioethics, Catholic University of the Sacred Heart, Rome, Italy
| | - Roberto Cauda
- Section of Infectious Diseases, Department of Safety and Bioethics, Catholic University of the Sacred Heart, Rome, Italy.,Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Massimo Fantoni
- Section of Infectious Diseases, Department of Safety and Bioethics, Catholic University of the Sacred Heart, Rome, Italy.,Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Děrgel M, Voborník M, Pojar M, Karalko M, Gofus J, Radochová V, Studená Š, Maláková J, Turek Z, Chládek J, Manďák J. Lung Collapse during Mini-Thoracotomy Reduces Penetration of Cefuroxime to the Tissue: Interstitial Microdialysis Study in Animal Models. Surg Infect (Larchmt) 2020; 22:283-291. [PMID: 32633629 DOI: 10.1089/sur.2019.273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Single-lung ventilation facilitates surgical exposure during minimally invasive cardiac surgery. However, a deeper knowledge of antibiotic distribution within a collapsed lung is necessary for effective antibiotic prophylaxis of pneumonia. Patients and Methods: The pharmacokinetics/pharmacodynamics (PK/PD) of cefuroxime were compared between the plasma and interstitial fluid (ISF) of collapsed and ventilated lungs in 10 anesthetized pigs, which were ventilated through a double-lumen endotracheal cannula. Cefuroxime (20 mg/kg) was administered in single 30-minute intravenous infusion. Samples of blood and lung microdialysate were collected until six hours post-dose. Ultrafiltration, in vivo retrodialysis, and high-performance liquid chromatography-tandem mass spectrometry were used to determine plasma and ISF concentrations of free drug. The concentrations were examined with non-compartmental analysis and compartmental modeling. Results: The concentration of free cefuroxime in ISF was lower in the non-ventilated lung than the ventilated one, evidenced by a lung penetration factor of 47% versus 63% (p < 0.05), the ratio between maximum concentrations (65%, p < 0.05), and the ratio between the areas under the concentration-time curve (78%, p = 0.12). The time needed to reach a minimum inhibitory concentration (MIC) was 30%-40% longer for a collapsed lung than for a ventilated one. In addition, a delay of 10-40 minutes was observed for lung ISF compared with plasma. The mean residence time values (ISF collapsed lung > ISF ventilated lung > plasma) could explain the absence of practically important differences in the time interval with the concentration of cefuroxime exceeding the MICs of sensitive strains (≤4 mg/L). Conclusion: The concentration of cefuroxime in the ISF of a collapsed porcine lung is lower than in a ventilated one; furthermore, its equilibration with plasma is delayed. Administration of the first cefuroxime dose earlier or at a higher rate may be warranted, as well as dose intensification of the perioperative prophylaxis of pneumonia caused by pathogens with higher MICs.
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Affiliation(s)
- Martin Děrgel
- Department of Cardiac Surgery, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Martin Voborník
- Department of Cardiac Surgery, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Marek Pojar
- Department of Cardiac Surgery, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Mikita Karalko
- Department of Cardiac Surgery, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jan Gofus
- Department of Cardiac Surgery, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Věra Radochová
- Animal Research Facility, Faculty of Military Health Sciences, University of Defense, Třebešská, Králové, Czech Republic
| | - Šárka Studená
- Department of Pharmacology, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jana Maláková
- Institute of Clinical Biochemistry and Diagnoses, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Zdeněk Turek
- Department of Anesthesiology, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jaroslav Chládek
- Department of Pharmacology, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jiří Manďák
- Department of Cardiac Surgery, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
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Decreased duration of intravenous cephalosporins in intensive care unit patients with selective digestive decontamination: a retrospective before-and-after study. Eur J Clin Microbiol Infect Dis 2020; 39:2115-2120. [PMID: 32617694 PMCID: PMC7330883 DOI: 10.1007/s10096-020-03966-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/25/2020] [Indexed: 12/18/2022]
Abstract
Selective digestive decontamination (SDD) reduces the rate of infection and improves the outcomes of patients admitted to an intensive care unit (ICU). A risk associated with its use is the development of multi-drug-resistant organisms. We hypothesized that a 1-day reduction in systemic antimicrobial exposure in the SDD regimen would not affect the outcomes of our patients. In this before-and-after study design, 199 patients and 248 patients were included in a 3-day SDD group and a 2-day SDD group, respectively. The rates of hospital-acquired pneumonia and ICU infections were similar in both groups. The rates of bloodstream infection and bacteriuria were significantly lower in the 2-day SDD group than in the 3-day SDD group. Compared with the patients in the 3-day group, the patients in the 2-day SDD group received fewer antibiotics and less exposure to mechanical ventilation, and they used fewer ICU resources. The rates of ICU mortality and 28-day mortality were similar in both groups. The incidence of multi-drug-resistant organisms was similar in both groups. Within the limitations inherent to our study design, reducing the exposure of prophylactic systemic antibiotics in the SDD setting from 3 days to 2 days was not associated with impaired outcomes. Future randomized controlled trials should be conducted to test this hypothesis and investigate the effects on the development of multi-drug resistant organisms.
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31
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Phoon PHY, Hwang NC. Deep Sternal Wound Infection: Diagnosis, Treatment and Prevention. J Cardiothorac Vasc Anesth 2020; 34:1602-1613. [DOI: 10.1053/j.jvca.2019.09.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/28/2019] [Accepted: 09/12/2019] [Indexed: 12/18/2022]
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Reineke S, Carrel TP, Eigenmann V, Gahl B, Fuehrer U, Seidl C, Reineke D, Roost E, Bächli M, Marschall J, Englberger L. Adding vancomycin to perioperative prophylaxis decreases deep sternal wound infections in high-risk cardiac surgery patients. Eur J Cardiothorac Surg 2019; 53:428-434. [PMID: 29045740 DOI: 10.1093/ejcts/ezx328] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 08/03/2017] [Accepted: 08/09/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Perioperative prophylaxis with cephalosporins reduces sternal wound infections (SWIs) after cardiac surgery. However, more than 50% of coagulase-negative staphylococci, an important pathogen, are cephalosporin resistant. The aim of this study was to determine the impact of adjunctive vancomycin on SWIs in high-risk patients. METHODS We conducted a pre- and postintervention study in an academic hospital. Preintervention (2010-2011), all patients received prophylaxis with 1.5 g of cefuroxime for 48 h. During the intervention period (2012-2013), high-risk patients additionally received 1 g of vancomycin. High-risk status was defined as body mass index ≤18 or ≥ 30 kg/m2, reoperation, renal failure, diabetes mellitus, chronic obstructive pulmonary disease or immunosuppressive medication. Time series analysis was performed to study SWI trends and logistic regression to determine the effect of adding vancomycin adjusting for high-risk status. RESULTS A total of 3902 consecutive patients (n = 1915 preintervention and n = 1987 postintervention) were included, of which 1493 (38%) patients were high-risk patients. In the high-risk group, 61 of 711 (8.6%) patients had SWI before and 30 of 782 (3.8%) patients after the intervention. Focusing on deep SWI (DSWI), 33 of 711 (4.6%) patients had DSWI before and 13 of 782 (1.7%) patients afterwards; the absolute risk difference of 2.9% yielded a number-needed-to-treat of 34 to prevent 1 DSWI. Corrected for high-risk status, adding vancomycin significantly reduced the overall SWI rate (odds ratio 0.42, 95% confidence interval 0.26-0.67; P < 0.001) and the subset of DSWI (odds ratio 0.30, 95% confidence interval 0.14-0.62; P = 0.001). The rate of SWI in low-risk patients remained unchanged. CONCLUSIONS Adding vancomycin to standard antibiotic prophylaxis in high-risk patients significantly reduced DSWI after cardiac surgery.
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Affiliation(s)
- Sylvia Reineke
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Verena Eigenmann
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Brigitta Gahl
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Urs Fuehrer
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Seidl
- Department of Anesthesiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Reineke
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eva Roost
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Magi Bächli
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonas Marschall
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lars Englberger
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
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Martin C, Auboyer C, Boisson M, Dupont H, Gauzit R, Kitzis M, Leone M, Lepape A, Mimoz O, Montravers P, Pourriat JL. Antibioprophylaxie en chirurgie et médecine interventionnelle (patients adultes). Actualisation 2017. ANESTHÉSIE & RÉANIMATION 2019. [DOI: 10.1016/j.anrea.2019.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Martin C, Auboyer C, Boisson M, Dupont H, Gauzit R, Kitzis M, Leone M, Lepape A, Mimoz O, Montravers P, Pourriat J. Antibioprophylaxis in surgery and interventional medicine (adult patients). Update 2017. Anaesth Crit Care Pain Med 2019; 38:549-562. [DOI: 10.1016/j.accpm.2019.02.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Roof SA, Ferrandino RM, Villavisanis DF, Amato MV, Rubinstein BJ, Courey MS, Woo P. Infection Rates After Microlaryngeal and Open Phonosurgery: The Role of Postoperative Antibiotics. Laryngoscope 2019; 130:1128-1131. [PMID: 31424561 DOI: 10.1002/lary.28225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/26/2019] [Accepted: 07/18/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Although it is known that the airway has bacterial contamination that seeds the surgical site during microlaryngeal surgery, literature on the use of postoperative antibiotics is lacking. We performed a retrospective analysis of open phonosurgical and phonomicrosurgical cases at a single institution to assess whether use of postoperative antibiotics impacts the incidence of surgical site infections (SSI). METHODS In this retrospective cohort study, we reviewed 228 phonomicrosurgery and 53 open phonosurgery cases performed for benign diseases. Surgeries were performed by two laryngologists between February 2016 and August 2018. The surgeons differ in their postoperative antibiotic regimens: no antibiotics versus a 5- to 7-day postoperative course. Data collected include demographics, medical comorbidities, type of benign laryngeal disease, and surgical procedure. The primary outcome measure was postoperative infection, defined as the patient requiring a new prescription for antibiotics, an extended course of antibiotics, or any mention of infection at follow-up/emergency visits within the first month postoperatively. RESULTS The overall rate of SSI was 3.1% and 0% for phonomicrosurgery and open phonosurgery cases, respectively. For phonomicrosurgery, there was no difference in the rate of SSI for patients who received or did not receive antibiotics perioperatively: 2.9% versus 3.2% (P = 0.99). Similarly, there was no difference in the infection rate for open phonosurgical cases. CONCLUSION Infection rates after endoscopic and open phonosurgery are low. In this study, we found no evidence to suggest a protective effect associated with postoperative use of antibiotics. LEVEL OF EVIDENCE 4 Laryngoscope, 130:1128-1131, 2020.
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Affiliation(s)
- Scott A Roof
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Hospital, New York, New York, U.S.A
| | - Rocco M Ferrandino
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Hospital, New York, New York, U.S.A
| | | | - Michael V Amato
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Hospital, New York, New York, U.S.A
| | - Benjamin J Rubinstein
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Hospital, New York, New York, U.S.A
| | - Mark S Courey
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Hospital, New York, New York, U.S.A
| | - Peak Woo
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Hospital, New York, New York, U.S.A
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van Oostveen RB, Romero-Palacios A, Whitlock R, Lee SF, Connolly S, Carignan A, Mazer CD, Loeb M, Mertz D. Prevention of Infections in Cardiac Surgery study (PICS): study protocol for a pragmatic cluster-randomized factorial crossover pilot trial. Trials 2018; 19:688. [PMID: 30558680 PMCID: PMC6296086 DOI: 10.1186/s13063-018-3080-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/26/2018] [Indexed: 11/26/2022] Open
Abstract
Background A wide range of prophylactic antibiotic regimens are used for patients undergoing open-heart cardiac surgery. This reflects clinical equipoise in choice and duration of antibiotic agents. Although individual-level randomized control trials (RCT) are considered the gold standard when evaluating the efficacy of an intervention, this approach is highly resource intensive and a cluster RCT can be more appropriate for testing clinical effectiveness in a real-world setting. Methods/design We are conducting a factorial cluster-randomized crossover pilot trial in cardiac surgery patients to evaluate the feasibility of this design for a definite trial to evaluate the optimal duration and choice of perioperative antibiotic prophylaxis. Specifically, we will evaluate: (a) the non-inferiority of a single preoperative dose compared to prolonged prophylaxis and (b) the potential superiority of adding vancomycin to routine cefazolin in terms of preventing deep and organ/space sternal surgical site infections (s-SSIs). There are four strategies: (i) short-term cefazolin, (ii) long-term cefazolin, (iii) short-term cefazolin + vancomycin, and (iv) long-term cefazolin + vancomycin. These strategies are delivered in a different order in each health-care center participating in the trial. The centers are randomized to an order, and the current strategy becomes the standard operating procedure in that center during the study. The three feasibility outcomes include: (1) the proportion of patients receiving preoperative, intra-operative, and postoperative antibiotics according to the study protocol, (2) the proportion of completed follow-up assessments, and (3) a full and final assessment of the incidence of s-SSIs by the outcome adjudication committee. Discussion We believe that a cluster-randomized factorial crossover trial is an effective and feasible design for these research questions, allowing an evaluation of the clinical effectiveness in a real-world setting. A waiver of individual informed consent was considered appropriate by the research ethics boards in each participating site in Canada as long as an information letter with an opt-out option was provided. However, a waiver of consent was not approved at two sites in Germany and Switzerland, respectively. Trial registration Clinicaltrials.gov, NCT02285140. Registered on 15 October 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-3080-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rachel B van Oostveen
- Population Health Research Institute (PHRI), Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Richard Whitlock
- Population Health Research Institute (PHRI), Hamilton Health Sciences, Hamilton, ON, Canada.,McMaster University, Hamilton, ON, Canada
| | - Shun Fu Lee
- Population Health Research Institute (PHRI), Hamilton Health Sciences, Hamilton, ON, Canada
| | - Stuart Connolly
- Population Health Research Institute (PHRI), Hamilton Health Sciences, Hamilton, ON, Canada.,McMaster University, Hamilton, ON, Canada
| | - Alex Carignan
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - C David Mazer
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Mark Loeb
- McMaster University, Hamilton, ON, Canada
| | - Dominik Mertz
- Population Health Research Institute (PHRI), Hamilton Health Sciences, Hamilton, ON, Canada. .,McMaster University, Hamilton, ON, Canada. .,Juravinski Hospital and Cancer Center, 711 Concession Street, Section M, Level 1, Room 3, Hamilton, ON, L8V 1C3, Canada.
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37
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Asada M, Nagata M, Mizuno T, Uchida T, Kurashima N, Takahashi H, Makita K, Arai H, Echizen H, Yasuhara M. Effects of cardiopulmonary bypass on the disposition of cefazolin in patients undergoing cardiothoracic surgery. Pharmacol Res Perspect 2018; 6:e00440. [PMID: 30410768 PMCID: PMC6218359 DOI: 10.1002/prp2.440] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 09/27/2018] [Accepted: 10/02/2018] [Indexed: 11/21/2022] Open
Abstract
The aim of the study was to evaluate the disposition of plasma unbound cefazolin in patients undergoing cardiothoracic surgery with cardiopulmonary bypass (CPB). Adult patients undergoing cardiothoracic surgery with CPB were enrolled in the study. Cefazolin sodium was given intravenously before skin incision (1 g) and at the beginning of CPB (2 g). Thereafter, an additional dose (1 g) was given every 4 hours. Seven to ten blood samples were collected before and during surgery. Plasma total and unbound (ultrafiltrated) cefazolin concentrations were analyzed using an HPLC-UV method. Plasma protein binding was analyzed with the Langmuir model. Twenty-seven patients (aged 70 ± 12 years, body weight 62 ± 12 kg, mean ± SD) with GFR >30 mL min-1 completed the study. There was a significant (P < 0.001) increase in median plasma unbound fraction of cefazolin from 21% before skin incision to 45% during CPB (P < 0.001), which was accompanied by a significant (P < 0.001) reduction in median plasma albumin concentration from 36 to 27 g L-1. Plasma concentrations of unbound cefazolin exceeded the assumed target thresholds of 2 μg mL-1 in all samples and of 8 μg mL-1 in all but one of 199 samples. The increased plasma unbound fraction of cefazolin would be attributable to dilutional reduction of serum albumin at the beginning of CPB and to saturable plasma protein binding of cefazolin. These data reveal CPB may alter the plasma protein binding and possibly distribution of cefazolin. Further studies are warranted to reappraise the protocol of antimicrobial prophylaxis with cefazolin in patients undergoing surgery with CPB.
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Affiliation(s)
- Mizuho Asada
- Department of PharmacyMedical HospitalTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Masashi Nagata
- Department of PharmacyMedical HospitalTokyo Medical and Dental University (TMDU)TokyoJapan
- Department of Pharmacokinetics and PharmacodynamicsGraduate School of Medical and Dental SciencesTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Tomohiro Mizuno
- Department of Cardiovascular SurgeryGraduate School of Medical and Dental ScienceTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Tokujiro Uchida
- Department of AnesthesiologyGraduate School of Medical and Dental SciencesTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Naoki Kurashima
- Medical Engineering CenterMedical Hospital of Tokyo Medical and Dental University (TMDU)TokyoJapan
| | - Hiromitsu Takahashi
- Department of PharmacyMedical HospitalTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Koshi Makita
- Department of AnesthesiologyGraduate School of Medical and Dental SciencesTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Hirokuni Arai
- Department of Cardiovascular SurgeryGraduate School of Medical and Dental ScienceTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Hirotoshi Echizen
- Department of PharmacotherapyMeiji Pharmaceutical UniversityTokyoJapan
| | - Masato Yasuhara
- Department of Pharmacokinetics and PharmacodynamicsGraduate School of Medical and Dental SciencesTokyo Medical and Dental University (TMDU)TokyoJapan
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Cotogni P, Barbero C, Rinaldi M. Incidence and risk factors for potentially suboptimal serum concentrations of vancomycin during cardiac surgery. World J Cardiol 2018; 10:234-241. [PMID: 30510640 PMCID: PMC6259028 DOI: 10.4330/wjc.v10.i11.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 09/02/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the incidence and risk factors for vancomycin concentrations less than 10 mg/L during cardiac surgery.
METHODS In this prospective study, patients undergoing cardiac surgery received a single dose of 1000 mg of vancomycin. Multiple arterial samples were drawn during surgery. Exclusion criteria were hepatic dysfunction; renal dysfunction; ongoing infectious diseases; solid or hematologic tumors; severe insulin-dependent diabetes; body mass index of < 17 or > 40 kg/m2; pregnancy or lactation; antibiotic, corticosteroid, or other immunosuppressive therapy; vancomycin or nonsteroidal anti-inflammatory drug therapy in the previous 2 wk; chemotherapy or radiation therapy in the previous 6 mo; allergy to vancomycin or cefazolin; drug abuse; cardiac surgery in the previous 6 mo; previous or scheduled organ transplantation; preoperative stay in the intensive care unit for more than 24 h; emergency procedure or lack of adequate preparation for surgery; and participation in another trial.
RESULTS Over a 1-year period, 236 patients were enrolled, and a total of 1682 serum vancomycin concentrations (median 7/patient) were measured. No vancomycin levels under 10 mg/L were recorded in 122 out of 236 patients (52%), and 114 out of 236 patients (48%) were found to have at least 1 serum sample with a vancomycin level < 10 mg/L; 54 out of 236 patients (22.9%) had at least 5 serum samples with a vancomycin level lower than 10 mg/L. Vancomycin infusion was administered for 60 min in 97 out of 236 patients (41%). In 47 patients (20%), the duration of infusion was longer than 60 min, and in 92 patients (39%) the duration of infusion was shorter than 60 min. The maximum concentration and area under the concentration-time curve were significantly higher in patients with no vancomycin levels less than 10 mg/L (P < 0.001). The multivariate analysis identified female gender, body mass index (BMI) > 25 kg/m2, and creatinine clearance above 70 mL/min as risk factors for vancomycin levels less than 10 mg/L.
CONCLUSION Results of this study identified female gender, BMI > 25 kg/m2, and creatinine clearance above 70 mL/min as risk factors for suboptimal vancomycin serum concentration during cardiac surgery; no relationship was found between infusion duration and vancomycin levels less than 10 mg/L. These findings call attention to the risk of facilitating the emergence of vancomycin-resistant methicillin-resistant Staphylococcus aureus strains.
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Affiliation(s)
- Paolo Cotogni
- Department of Anesthesia, Intensive Care and Emergency, Molinette Hospital, University of Turin, Turin 10126, Italy
| | - Cristina Barbero
- Cardiovascular Surgery, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin 10126, Italy
| | - Mauro Rinaldi
- Cardiovascular Surgery, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin 10126, Italy
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39
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Gomes B, Geis NA, Leuschner F, Meder B, Konstandin M, Katus HA, Bekeredjian R. Periprocedural antibiotic treatment in transvascular aortic valve replacement. J Interv Cardiol 2018; 31:885-890. [DOI: 10.1111/joic.12567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/19/2018] [Accepted: 10/07/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Bruna Gomes
- Department of Internal Medicine III; University of Heidelberg; Heidelberg Germany
| | - Nicolas A. Geis
- Department of Internal Medicine III; University of Heidelberg; Heidelberg Germany
| | - Florian Leuschner
- Department of Internal Medicine III; University of Heidelberg; Heidelberg Germany
| | - Benjamin Meder
- Department of Internal Medicine III; University of Heidelberg; Heidelberg Germany
| | - Mathias Konstandin
- Department of Internal Medicine III; University of Heidelberg; Heidelberg Germany
| | - Hugo A. Katus
- Department of Internal Medicine III; University of Heidelberg; Heidelberg Germany
| | - Raffi Bekeredjian
- Department of Internal Medicine III; University of Heidelberg; Heidelberg Germany
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40
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Gurtman A, Begier E, Mohamed N, Baber J, Sabharwal C, Haupt RM, Edwards H, Cooper D, Jansen KU, Anderson AS. The development of a staphylococcus aureus four antigen vaccine for use prior to elective orthopedic surgery. Hum Vaccin Immunother 2018; 15:358-370. [PMID: 30215582 DOI: 10.1080/21645515.2018.1523093] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Staphylococcus aureus (S. aureus) is a challenging bacterial pathogen which can cause a range of diseases, from mild skin infections, to more serious and invasive disease including deep or organ space surgical site infections, life-threatening bacteremia, and sepsis. S. aureus rapidly develops resistance to antibiotic treatments. Despite current infection control measures, the burden of disease remains high. The most advanced vaccine in clinical development is a 4 antigen S. aureus vaccine (SA4Ag) candidate that is being evaluated in a phase 2b/3 efficacy study in patients undergoing elective spinal fusion surgery (STaphylococcus aureus suRgical Inpatient Vaccine Efficacy [STRIVE]). SA4Ag has been shown in early phase clinical trials to be generally safe and well tolerated, and to induce high levels of bactericidal antibodies in healthy adults. In this review we discuss the design of SA4Ag, as well as the proposed clinical development plan supporting licensure of SA4Ag for the prevention of invasive disease caused by S. aureus in elective orthopedic surgical populations. We also explore the rationale for the generalizability of the results of the STRIVE efficacy study (patients undergoing elective open posterior multilevel instrumented spinal fusion surgery) to a broad elective orthopedic surgery population due to the common pathophysiology of invasive S. aureus disease and commonalties of patient and procedural risk factors for developing postoperative S. aureus surgical site infections.
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Affiliation(s)
- A Gurtman
- a Pfizer Vaccine Research and Development , Pfizer, Inc ., Pearl River , NY , USA
| | - E Begier
- a Pfizer Vaccine Research and Development , Pfizer, Inc ., Pearl River , NY , USA
| | - N Mohamed
- a Pfizer Vaccine Research and Development , Pfizer, Inc ., Pearl River , NY , USA
| | - J Baber
- b Pfizer Vaccine Research and Development , Sydney , NSW , Australia
| | - C Sabharwal
- a Pfizer Vaccine Research and Development , Pfizer, Inc ., Pearl River , NY , USA
| | - R M Haupt
- c Medical Development, Scientific and Clinical Affairs , Pfizer, Inc ., Collegeville , PA , USA
| | - H Edwards
- d World Wide Regulatory Affairs , Pfizer Inc ., Walton Oaks , UK
| | - D Cooper
- a Pfizer Vaccine Research and Development , Pfizer, Inc ., Pearl River , NY , USA
| | - K U Jansen
- a Pfizer Vaccine Research and Development , Pfizer, Inc ., Pearl River , NY , USA
| | - A S Anderson
- a Pfizer Vaccine Research and Development , Pfizer, Inc ., Pearl River , NY , USA
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41
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Surgical antibiotic prophylaxis – The evidence and understanding its impact on consensus guidelines. Infect Dis Health 2018. [DOI: 10.1016/j.idh.2018.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Purba AKR, Setiawan D, Bathoorn E, Postma MJ, Dik JWH, Friedrich AW. Prevention of Surgical Site Infections: A Systematic Review of Cost Analyses in the Use of Prophylactic Antibiotics. Front Pharmacol 2018; 9:776. [PMID: 30072898 PMCID: PMC6060435 DOI: 10.3389/fphar.2018.00776] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/26/2018] [Indexed: 12/18/2022] Open
Abstract
Introduction: The preoperative phase is an important period in which to prevent surgical site infections (SSIs). Prophylactic antibiotic use helps to reduce SSI rates, leading to reductions in hospitalization time and cost. In clinical practice, besides effectiveness and safety, the selection of prophylactic antibiotic agents should also consider the evidence with regard to costs and microbiological results. This review assessed the current research related to the use of antibiotics for SSI prophylaxis from an economic perspective and the underlying epidemiology of microbiological findings. Methods: A literature search was carried out through PubMed and Embase databases from 1 January 2006 to 31 August 2017. The relevant studies which reported the use of prophylactic antibiotics, SSI rates, and costs were included for analysis. The causing pathogens for SSIs were categorized by sites of the surgery. The quality of reporting on each included study was assessed with the “Consensus on Health Economic Criteria” (CHEC). Results: We identified 20 eligible full-text studies that met our inclusion criteria, which were subsequently assessed, studies had in a reporting quality scored on the CHEC list averaging 13.03 (8–18.5). Of the included studies, 14 were trial-based studies, and the others were model-based studies. The SSI rates ranged from 0 to 71.1% with costs amounting to US$480-22,130. Twenty-four bacteria were identified as causative agents of SSIs. Gram negatives were the dominant causes of SSIs especially in general surgery, neurosurgery, cardiothoracic surgery, and obstetric cesarean sections. Conclusions: Varying results were reported in the studies reviewed. Yet, information from both trial-based and model-based costing studies could be considered in the clinical implementation of proper and efficient use of prophylactic antibiotics to prevent SSIs and antimicrobial resistance.
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Affiliation(s)
- Abdul K R Purba
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.,Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Didik Setiawan
- Unit of PharmacoEpidemiology & Pharmacoeconomics (PE2), Department of Pharmacy, University of Groningen, Groningen, Netherlands.,Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Muhammadiyah Purwokerto, Purwokerto, Indonesia
| | - Erik Bathoorn
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Maarten J Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.,Unit of PharmacoEpidemiology & Pharmacoeconomics (PE2), Department of Pharmacy, University of Groningen, Groningen, Netherlands.,Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Groningen, Netherlands
| | - Jan-Willem H Dik
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Alex W Friedrich
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Gertler R, Gruber M, Wiesner G, Grassin-Delyle S, Urien S, Tassani-Prell P, Martin K. Pharmacokinetics of cefuroxime in infants and neonates undergoing cardiac surgery. Br J Clin Pharmacol 2018; 84:2020-2028. [PMID: 29761538 DOI: 10.1111/bcp.13632] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/22/2018] [Accepted: 04/26/2018] [Indexed: 12/29/2022] Open
Abstract
AIMS Very little data exist regarding the effect of cardiopulmonary bypass (CPB) on cefuroxime (CXM) pharmacokinetics in children less than one year of age. METHODS 50 mg kg-1 CXM i.v. after induction were followed by 75 mg kg-1 into the CPB circuit. In 42 patients undergoing cardiac surgery, 15-20 samples were obtained between 5 and 360 min after the first dose. Total CXM concentrations were measured by high-performance liquid chromatography and a pharmacokinetic/pharmacodynamic (PK/PD) modelling was performed. RESULTS Using a fixed protein binding of 15.6% for CXM, peak plasma concentrations of unbound CXM were 229 ± 52 μg ml-1 after the first bolus and 341 ± 86 μg ml-1 on CPB. Nadir concentrations before CPB were 69 ± 20 μg ml-1 and six hours later decreased to 41 ± 19 μg ml-1 with and 24 ± 14 μg ml-1 without CPB. A two-compartment model was fitted with the main covariates body weight, CPB and postmenstrual age (PMA). PK parameters were as follows: systemic clearance, 5.15 [95% CI 4.5-5.8] l h-1 ; central volume of distribution, 11.25 [9.41-13.09] l; intercompartmental clearance, 18.19 [14.79-21.58] l h-1 ; and peripheral volume, 17.07 [15.7-18.5] L. ƒT > MIC of 32 μg ml-1 for an 8-h time period was between 70 and 100% (2.5-10 kg BW). According to our simulation, 25 mg ml-1 CXM as a primary bolus and into the prime plus a 5 mg kg-1 h-1 infusion maintain CXM concentrations continuously above 32 μg ml-1 . CONCLUSIONS The routine dosing regimen provided was sufficient for prophylaxis, but continuous dosing can provide a higher percentage of ƒT > MIC.
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Affiliation(s)
- Ralph Gertler
- Klinik für Anaesthesie, operative und allgemeine Intensivmedizin, Notfallmedizin, Klinikum Links der Weser, University Medical Center Hamburg-Eppendorf, Bremen, Germany
| | - Michael Gruber
- Department of Anesthesia, University Hospital Regensburg, Germany
| | - Gunther Wiesner
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Germany
| | - Stanislas Grassin-Delyle
- Département des Maladies des Voies Respiratoires, Hôpital Foch, Université Versailles Saint Quentin en Yvelines, Université Paris Saclay, F-92150, Suresnes, France.,Plateforme de spectrométrie de masse et INSERM UMR1173, UFR Sciences de la Santé Simone Veil, Université Versailles Saint Quentin en Yvelines, Université Paris Saclay, F-78180, Montigny-le-Bretonneux, France
| | - Saïk Urien
- CIC1419 Inserm Necker-Cochin, URC Paris Descartes Necker Cochin, AP-HP, Paris, France; EAU7323, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Peter Tassani-Prell
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Germany
| | - Klaus Martin
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Germany
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O'Hara LM, Thom KA, Preas MA. Update to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infection (2017): A summary, review, and strategies for implementation. Am J Infect Control 2018. [PMID: 29525367 DOI: 10.1016/j.ajic.2018.01.018] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Surgical site infections remain a common cause of morbidity, mortality, and increased length of stay and cost amongst hospitalized patients in the United States. This article summarizes the evidence used to inform the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infection (2017), and highlights key updates and new recommendations. We also present specific suggestions for how infection preventionists can play a central role in guideline implementation by translating these recommendations into evidence-based policies and practices in their facility.
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Affiliation(s)
| | - Kerri A Thom
- University of Maryland School of Medicine, Baltimore, MD
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Population Pharmacokinetic Model-Based Evaluation of Standard Dosing Regimens for Cefuroxime Used in Coronary Artery Bypass Graft Surgery with Cardiopulmonary Bypass. Antimicrob Agents Chemother 2018; 62:AAC.02241-17. [PMID: 29358296 DOI: 10.1128/aac.02241-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/09/2018] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study was to investigate the population pharmacokinetics (PK) of cefuroxime in patients undergoing coronary artery bypass graft (CABG) surgery. In this observational pharmacokinetic study, multiple blood samples were collected over a 48-h interval of intravenous cefuroxime administration. The samples were analyzed by using a validated high-performance liquid chromatography (HPLC) method. Population pharmacokinetic models were developed using Monolix (version 4.4) software. Pharmacokinetic-pharmacodynamic (PD) simulations were performed to explore the ability of different dosage regimens to achieve the pharmacodynamic targets. A total of 468 blood samples from 78 patients were analyzed. The PK for cefuroxime were best described by a two-compartment model with between-subject variability on clearance, the volume of distribution of the central compartment, and the volume of distribution of the peripheral compartment. The clearance of cefuroxime was related to creatinine clearance (CLCR). Dosing simulations showed that standard dosing regimens of 1.5 g could achieve the PK-PD target of the percentage of the time that the free concentration is maintained above the MIC during a dosing interval (fTMIC) of 65% for an MIC of 8 mg/liter in patients with a CLCR of 30, 60, or 90 ml/min, whereas this dosing regimen failed to achieve the PK-PD target in patients with a CLCR of ≥125 ml/min. In conclusion, administration of standard doses of 1.5 g three times daily provided adequate antibiotic prophylaxis in patients undergoing CABG surgery. Lower doses failed to achieve the PK-PD target. Patients with high CLCR values required either higher doses or shorter intervals of cefuroxime dosing. On the other hand, lower doses (1 g three times daily) produced adequate target attainment for patients with low CLCR values (≤30 ml/min).
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Tarchini G, Liau KH, Solomkin JS. Antimicrobial Stewardship in Surgery: Challenges and Opportunities. Clin Infect Dis 2018; 64:S112-S114. [PMID: 28475788 DOI: 10.1093/cid/cix087] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Antibiotic stewardship programs have been playing an increasingly important role in patient care and hospital policies. The role of these programs in surgical care presents several unique challenges and opportunities, most notably in the perioperative setting. Controversy remains regarding optimal antibiotic choice, dosage, and length of prophylaxis. Here, we review current best practices and suggest areas for further research specific to antibiotic stewardship in surgical care.
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Affiliation(s)
- Giorgio Tarchini
- Department of Infectious Diseases, Cleveland Clinic Florida, Weston
| | - Kui Hin Liau
- Yong Loo Lin School of Medicine, National University of Singapore and Liau KH Consulting, Mount Elizabeth Novena Hospital, Mount Elizabeth Novena Specialist Centre, Singapore; and
| | - Joseph S Solomkin
- Department of Surgery, Division of Trauma/Critical Care, University of Cincinnati College of Medicine, Ohio
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47
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Ierano C, Nankervis JAM, James R, Rajkhowa A, Peel T, Thursky K. Surgical antimicrobial prophylaxis. Aust Prescr 2017; 40:225-229. [PMID: 29377021 DOI: 10.18773/austprescr.2017.073] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Courtney Ierano
- National Centre for Antimicrobial Stewardship, Doherty Institute, Royal Melbourne Hospital/University of Melbourne
| | | | - Rod James
- National Centre for Antimicrobial Stewardship, Doherty Institute, Royal Melbourne Hospital/University of Melbourne
| | - Arjun Rajkhowa
- National Centre for Antimicrobial Stewardship, Doherty Institute, Royal Melbourne Hospital/University of Melbourne
| | - Trisha Peel
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne
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Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:5-33. [PMID: 29029110 DOI: 10.1093/ejcts/ezx314] [Citation(s) in RCA: 263] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Järvelä KM, Khan NK, Loisa EL, Sutinen JA, Laurikka JO, Khan JA. Hyperglycemic Episodes Are Associated With Postoperative Infections After Cardiac Surgery. Scand J Surg 2017; 107:138-144. [PMID: 28934890 DOI: 10.1177/1457496917731190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS To describe the incidence of and risk factors for postoperative infections and the correlation between postoperative hyperglycemia despite tight blood glucose control with infectious and other complications after contemporary cardiac surgery. MATERIAL AND METHODS The study comprised 1356 consecutive adult patients who underwent cardiac surgery between January 2013 and December 2014 and were followed up for 6 months. Patients surviving the first 2 days were included in the analysis. Preoperative demographic information, medical history, procedural details, and the postoperative course were recorded. The target range for blood glucose levels was 4-7 mmol/L and repeated arterial blood samples were obtained during the intensive care unit stay. The associations of blood glucose levels during the first postoperative day and the occurrence of postoperative infections and other significant complications were analyzed. RESULTS Of the study cohort, 9.8% developed infectious complications which were classified as major surgical site infections in 2.2%, minor surgical site infections in 1.1%, lung infections in 2.0%, unclear fever or bacteremia in 0.3%, cannula or catheter related in 2.6%, multiple in 1.5%, and other in 0.2%. The incidence of deep sternal wound infection was 2.0%. Repeated hyperglycemia occurred in 39.7% of patients and was associated with increased rates of postoperative infections, 12.1% versus 8.2%, p = 0.019; stroke, 4.9% versus 1.5%, p < 0.001; and mortality, 6.1% versus 2.1%, p < 0.001, when compared to patients with single or no hyperglycemia. CONCLUSION Every 10th patient develops infectious complications after cardiac surgery. Repeated hyperglycemia is associated with increased rates of infectious complications, stroke, and mortality.
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Affiliation(s)
- K M Järvelä
- 1 Department of Cardiothoracic Surgery, TAYS Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - N K Khan
- 2 Department of Vascular Surgery, Tampere University Hospital, Tampere, Finland
| | - E L Loisa
- 3 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - J A Sutinen
- 3 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - J O Laurikka
- 1 Department of Cardiothoracic Surgery, TAYS Heart Hospital, Tampere University Hospital, Tampere, Finland.,3 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - J A Khan
- 1 Department of Cardiothoracic Surgery, TAYS Heart Hospital, Tampere University Hospital, Tampere, Finland
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Valkenet K, Trappenburg J, Hulzebos E, van Meeteren N, Backx F. Effects of a pre-operative home-based inspiratory muscle training programme on perceived health-related quality of life in patients undergoing coronary artery bypass graft surgery. Physiotherapy 2017; 103:276-282. [DOI: 10.1016/j.physio.2016.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 02/21/2016] [Indexed: 01/22/2023]
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