Effectiveness of antibiotic prophylaxis for acute esophageal variceal bleeding in patients with band ligation: A large observational study

BACKGROUND Esophageal variceal bleeding is a severe complication associated with liver cirrhosis and typically necessitates endoscopic hemostasis.The current standard treatment is endoscopic variceal ligation(EVL),and Western guidelines recom-mend antibiotic prophylaxis following hemostasis.However,given the impro-vements in prognosis for variceal bleeding due to advancements in the management of bleeding and treatments of liver cirrhosis and the global concerns regarding the emergence of multidrug-resistant bacteria,there is a need to reassess the use of routine antibiotic prophylaxis after hemostasis.AIM To evaluate the effectiveness of antibiotic prophylaxis in patients treated for EVL.METHODS We conducted a 13-year observational study using the Tokushukai medical database across 46 hospitals.Patients were divided into the prophylaxis group(received antibiotics on admission or the next day)and the non-prophylaxis group(did not receive antibiotics within one day of admission).The primary outcome was composed of 6-wk mortality,4-wk rebleeding,and 4-wk spontaneous bacterial peritonitis(SBP).The secondary outcomes were each individual result and in-hospital mortality.A logistic regression with inverse probability of treatment weighting was used.A subgroup analysis was conducted based on the Child-Pugh classification to determine its influence on the primary outcome measures,while sensitivity analyses for antibiotic type and duration were also performed.RESULTS Among 980 patients,790 were included(prophylaxis:232,non-prophylaxis:558).Most patients were males under the age of 65 years with a median Child-Pugh score of 8.The composite primary outcomes occurred in 11.2%of patients in the prophylaxis group and 9.5%in the non-prophylaxis group.No significant differences in outcomes were observed between the groups(adjusted odds ratio,1.11;95%confidence interval,0.61-1.99;P=0.74).Individual outcomes such as 6-wk mortality,4-wk rebleeding,4-wk onset of SBP,and in-hospital mortality were not significantly different between the groups.The primary outcome did not differ between the Child-Pugh subgroups.Similar results were observed in the sensitivity analyses.CONCLUSION No significant benefit to antibiotic prophylaxis for esophageal variceal bleeding treated with EVL was detected in this study.Global reassessment of routine antibiotic prophylaxis is imperative.

Navigating the controversy regarding antibiotic prophylaxis in acute variceal bleeding

Antibiotic prophylaxis in patients with cirrhosis and acute variceal bleeding is part of the standard of care according to most clinical guidelines.However,with recent evidence arguing against antibiotic prophylaxis,the role of this intervention has become less clear.

Impact of clinical pharmacist intervention on rational use of surgical antibiotic prophylaxis in thyroid surgery

In the present study, we aimed to evaluate the intervention effect of prophylactic antibiotic use in thyroid surgery in a large hospital. From 2004 to 2012, 70 patients who underwent thyroid surgery were randomly selected each year. The quality of surgical antibiotic prophylaxis （SAP） was assessed each year in terms of antibiotic ratio, choice, duration, timing, combination, route of administration and so on. The result showed that the SAP ratio was 100% from 2004 to 2010. With our intervention, this SAP ratio was decreased to 45.7% in 2011, and it reached 2.9% in 2012. The AUD was consistently greater than 38 before 2010, while it rapidly declined to 1 in 2012. The number of DDDs per 100 operations was decreased from 431 to 3 after the intervention. The average cost of antibiotic drugs per patient was RMB 350.65 in 2010, whereas it was decreased to RMB 18.51 in 2012. The average duration of hospitalization showed no difference during the intervention. This study indicated that implementation of a multi-disciplinary protocol and clinical pharmacist interventions could improve the rational use of SAP.

Dual antibiotic loaded bone cement in patients at high infection risks in arthroplasty: Rationale of use for prophylaxis and scientific evidence

In view of the demographic changes and projected increase of arthroplasty procedures worldwide,the number of prosthetic joint infection cases will naturally grow.Therefore,in order to counteract this trend more rigid rules and a stricter implementation of effective preventive strategies is of highest importance.In the absence of a"miracle weapon"priorities should lie in evidence-based measures including preoperative optimization of patients at higher infection risks,the fulfilment of strict hygiene rules in the operating theatre and an effective antibiotic prophylaxis regimen.Instead of a"one size fits all"philosophy,it has been proposed to adjust the antibiotic prophylaxis protocol to major infection risks taking into account important patient-and procedure-related risk factors.A stronger focus on the local application mode via use of high dose dual antibioticloaded bone cement in such risk situations may have its advantages and is easy to apply in the theatre.The more potent antimicrobial growth inhibition in vitro and the strong reduction of the prosthetic joint infection rate in risk for infection patients with aid of dual antibiotic-loaded bone cement in clinical studies align with this hypothesis.

Challenges and recommendations when selecting empirical antibiotics in patients with cirrhosis

There is abundant evidence that bacterial infections are severe complications in patients with cirrhosis,being the most frequent trigger of acute-on-chronic liver failure and causing death in one of every four patients during hospitalization.For these reasons,early diagnosis and effective treatment of infections are mandatory to improve patient outcomes.However,treating physicians are challenged in daily practice since diagnosing bacterial infections is not always straightforward.This situation might lead to delayed antibiotic initiation or prescription of ineffective regimens,which are associated with poor outcomes.On the other hand,prescribing broad-spectrum antibiotics to all patients suspected of bacterial infections might favor bacterial resistance development.This is a significant concern given the alarming number of infections caused by multidrug-resistant microorganisms worldwide.Therefore,it is paramount to know the local epidemiology to propose tailored guidelines for empirical antibiotic selection in patients with cirrhosis in whom bacterial infections are suspected or confirmed.In this article,we will revise current knowledge in this area and highlight the importance of surveillance programs.

Inhibitory Effect of Short-Term Palpebral Margin Cleaning with Antibiotic Eye Drops on Ocular Surface Flora before Cataract Extraction:A New Preoperative Antibacterial Method

Objective To explore the clinical significance of the combined application of palpebral margin cleaning and antibiotic eye drops in inhibiting bacterial growth in the palpebral margin and conjunctival sacs before cataract extraction.Methods In this study,61 patients(97 eyes)with age-related cataract who underwent phacoemulsification and intraocular lens implantation were selected,and randomly grouped.In the experimental group,the combined application of palpebral margin cleaning with cotton pads and levofloxacin eye drops was given for three days before the surgery.In the control group,levofloxacin eye drops alone were applied for three consecutive days.Bacteria samples from the conjunctival sac and eyelid margins were cultivated and identified before and three days after taking antimicrobial measures,respectively.Results In the experimental group,the positive rates of the two bacteria samples were 100%(50/50)and 40%(20/50)before and 10%(5/50)and 0%(0/50)after the treatment.In the control group,the positive rates of the two bacteria samples were 97.9%(46/47)and 29.8%(14/47)before and 40.4%(19/47)and 10.6%(5/47)after the treatment.The positive rates between the two groups were not significantly different before taking antimicrobial measures(P=0.485 and 0.395),while they were significantly different after taking antimicrobial measures(P=0.001 and 0.024).Conclusion Combined application of eyelid and palpebral margin cleaning with cotton pads and antibiotic eye drops before cataract extraction imparted excellent antibacterial effects.

Assessment of Cardiovascular Surgical Infection Prophylaxis in a Lebanese Hospital

The appropriate use of antibiotics prophylaxis reduces the incidence of surgical site infections. Despite advances in antiseptic measures, antibiotics, and preoperative precautions, infections are common complications from surgeries. This study was conducted to assess the appropriateness of the prescription of antibiotics prophylaxis prior to cardiac surgery among hospitalized patients in the geographic area of Lebanon. This was a retrospective, observational, single center study conducted at a public Lebanese teaching hospital from February till April 2014. Data were collected from computerized data bases for hospitalized patients who did cardiac surgeries from January 2010 till December 2013. Patients above eighteen years old undergoing CABG （coronary artery by-pass graft）, valve surgery, or both were eligible for study enrollment. Excluded were patients younger than eighteen years of age, prior intake of antibiotics, or had another concomitant surgery with the cardiac. Consistency with the guidelines was evaluated for appropriate route of administration, choice, preoperative timing, duration, dosing, and redosing of antibiotics. The IRB （Institutional Review Board） approved the study design. Data were analyzed by the SPSS version 20.0 and presented as frequency/percentage and mean ± SD （standard deviation）. A total of 3,000 patients were initially screened where only 245 patients met the inclusion criteria. Baseline age of the participants was 58.91± 13.65 years （mean ± standard deviation SD）, and a body mass index of 28.19 ± 5.19 Kg/m2. The enrolled participants were on different intravenous antibiotic regimens, where 188 （76.7%） patients were on vancomycin and ceftriaxone, 15 （6.1%） on vancomycin and cefuroxime, 13 （5.3%） on ceftriaxone, 12 （4.9%） on vancomycin, 6 （2.4%） on cefuroxime, 2 （0.8%） on clindamycin）, and the others were on combination of gentamicin and a cephalosporin. Only twelve （4.9%） from the enrolled patients were consistent with the treatment guidelines regarding the choice of the antibiotic. For those patients who were given the appropriate antibiotics, proper dose was found in only seven patients （58.7%）. Five patients out of 254 （2%） required redosing where four were given the appropriate doses. As for preoperative timing it was appropriate for all of those cases （i.e. within 120 minutes of incision for vancomycin and within 60 minutes for cefuroxime and clindamycin）. Prophylaxis was extended beyond one day in 173 patients （70.61%） and the average duration was 2.8531 days ± 2.07514. This study demonstrates that in cardiac surgery, the optimal choice of antibiotics is seldom administered, duration of prophylaxis is excessively long, and the preoperative dose timing is rarely employed. More education and communication are required to improve these practices to reduce risks of surgical site infection, prevent resistance, and limit costs potentially associated with antibiotic misuse. The role of clinical pharmacist may facilitate this process across all surgical disciplines through interventions that should be implemented to optimize the perioperative antibiotic prophylaxis in procedures.

Knowledge and attitudes of orthopedic surgeons regarding prosthesis joint infection

BACKGROUND Periprosthetic joint infection(PJI)is a critical complication after joint arthroplasty and is accompanied by increasing rates of morbidity and mortality.Several studies have aimed at preventing PJI.AIM To research the knowledge level and attitudes of orthopedic surgeons,who play a key role in both preventing and managing PJI.METHODS We conducted a web-based survey to evaluate orthopedic surgeons'knowledge level and attitudes regarding PJI.The Likert scale survey utilized consisted of 30 questions which were prepared based on the"Proceedings of the International Consensus on Periprosthetic Joint Infection".RESULTS A total of 264 surgeons participated in the survey.Their average age was 44.8,and 173 participants(65.5%)had more than 10 years of experience.No statistically significant relationship was found between the PJI knowledge of the surgeons and their years of experience.However,participants who worked in training and research hospitals demonstrated higher levels of knowledge than the ones in the state hospitals.It was also noticed that surgeons'knowledge concerning the duration of antibiotic therapy and urinary infections was not consistent with their attitudes.CONCLUSION Even though orthopedic surgeons have adequate knowledge about preventing and managing PJI,their attitudes might contradict their knowledge.Future studies are required to examine the causes and solutions of the contradictions between orthopedic surgeons'knowledge and attitudes.

Older age, longer procedures and tandem endoscopic-ultrasound as risk factors for post-endoscopic retrograde cholangiopancreatography bacteremia

BACKGROUND Clinically significant post-endoscopic retrograde cholangiopancreatography(ERCP) bacteremia(PEB) occurs in up to 5% of cases, while antibiotic prophylaxis is recommended only when an ERCP is unlikely to achieve complete biliary drainage. However, the current recommendations may not cover all potential risk factors for PEB.AIM To identify novel risk factors for PEB and evaluate appropriateness of antibiotic prophylaxis.METHODS A retrospective study of 1082 ERCP procedures performed between January 2012-December 2013 in a single tertiary medical center. Data collection included: Demographic and clinical characteristics such as pre and post procedure antibiotic treatment and bacterial blood cultures. Exclusion criteria were:(1) Age < 18 years;(2) Positive bacterial blood culture before ERCP;(3) Scheduled antibiotic treatment prior to ERCP;(4) Hospitalization longer than 14 d before ERCP;and(5) missing critical data. Stepwise Logistic Regression analysis and Decision Tree algorithms were used for prediction modeling of PEB.RESULTS A total of 626 ERCPs performed in 434 patients were included. Mean age 66.49 ± 15.4 years and 46.5% were males. PEB prevalence was 3.7%. Antibiotic prophylaxis was administrated in 139/626(22.2%) cases but was indicated according to the guidelines only in 44/626(7%) cases. In all the PEB cases, prophylaxis was deemed not indicated. A stepwise logistic regression [receiver operating characteristic(ROC), 0.766], identified 3 variables as independent risk factors for PEB: Age at ERCP ≥ 75 years(OR, 3.780, 95%CI: 1.519-9.408, P = 0.004);Tandem EUS/ERCP with fine needle aspiration(FNA)(OR, 14.528, 95%CI: 3.571-59.095, P < 0.001);ERCP duration longer than 60 min(OR, 5.396, 95%CI: 1.86-15.656, P = 0.002). In a decision tree model(ROC, 0.778) the probability for PEB without any risk factors was 1% regardless of prophylaxis administration.CONCLUSION The prevalence of PEB in our study is similar to previous reports, despite the fact that antibiotic prophylaxis was administrated more readily than recommended. ERCP duration longer than 60 min, tandem EUS-ERCP with FNA and age above 75 years are significant risk factors for PEB. These factors should be further evaluated as indications for prophylactic antibiotic treatment before ERCP.

Intraoperative vs 24-Hour Administration of Cefamandole to Prevent Deep Sternal Wound Infection and Endocarditis after Adult Cardiac Surgery

Background and Objectives: Duration of antibiotic prophylaxis for cardiac surgery is still debated and controversial. International guidelines are vague: French guidelines recommend an intraoperative administration, while the Society of Thoracic Surgeons’ guidelines suggest that optimal postoperative prophylactic antibiotics be given for 48 hours or less. Very few studies have compared the same antibiotic with 2 different administration durations. The study was designed to compare the efficacy of 24-hour administration of cefamandole vs intraoperative cefamandole to prevent deep sternal wound infection and endocarditis after cardiac surgery. Methods: This retrospective and observational study compared the rates of severe surgical site infections (deep sternal wound infection, endocarditis) after cardiac surgery between period 1, 01/01/2008-31/08/2008, with 24-hour administration of cefamandole, and period 2, 01/09/2008-30/04/2009 with intraoperative cefamandole. Results: Among 933 patients, 14 patients (1.5%) developed surgical site infection during the 16-month study: 1.3% during the first period and 1.7% during the second (ns). The populations (470 patients in period 1 and 463 in period 2) were homogeneous and comparable for pre-, intra- and postoperative characteristics. Surgical site infection characteristics (pathogens involved, time to diagnosis) and consequences (longer hospital stay, outcomes) were comparable in the 2 groups. Conclusions: Intraoperative cefamandole was as safe as its 24-hour administration to prevent deep sternal wound infection and endocarditis after adult cardiac surgery.

Probiotics prophylaxis in pyelonephritis infants with normal urinary tracts

Background:Pyelonephritis in infants is considered as a major factor for the formation of renal scar.To prevent recurrent pyelonephritis and renal damage,prophylaxis is extremely important.The aim of this study was to compare the effectiveness of probiotic and antibiotic prophylaxis or no-prophylaxis in infants with pyelonephritis and normal urinary tract.Methods:Altogether 191 infants,who were diagnosed with acute pyelonephritis,proven to have normal urinary tracts and followed up for 6 months on prophylaxis,were retrospectively evaluated.According to the types of prophylaxis,the infants were divided into three groups[probiotics(Lactobacillus species),antibiotics(trimethoprim/sulfamethoxazole,TMP/SMX),and noprophylaxis].The incidence of recurrent urinary tract infection(UTI)during 6 months after the development of pyelonephritis,main causative uropathogens,and its antimicrobial sensitivities were compared.Results:The incidence of recurrent UTI in the probiotic group was 8.2%,which was significantly lower than 20.6%in the no-prophylaxis group(P=0.035)and was not significantly different from 10.0%of the antibiotic group(P=0.532).The significant difference between the probiotic and no-prophylaxis groups was seen only in male infants(P=0.032).The main causative organism of recurrent UTI was Escherichia coli(E.coli),which was not different among the three groups(P=0.305).The resistance rate of E.coli to TMP/SMX was 100%in the antibiotic group,which was significantly higher than 25.0%in the probiotic group and 41.7%in the no-prophylaxis group(P=0.008).Conclusion:Probiotic prophylaxis was more effective in infants with pyelonephritis and normal urinary tract than in those with no-prophylaxis.It could be used as a natural alternative to antibiotic prophylaxis.

A Multipathogen Bile Sample-based PCR Assay Can Guide Empirical Antimicrobial Strategies in Cholestatic Liver Diseases

Background and objectives:Polymerase chain reaction(PCR)techniques provide rapid detection of pathogens.This pilot study evaluated the diagnostic utility and clinical impact of multiplex real-time PCR(mRT-PCR,SeptiFast)vs.conventional microbial culture(CMC)in bile samples of patients with chronic cholestatic liver diseases(cCLDs),endoscopic retrograde cholangio-pancreatography(ERCP),and peri-interventional-antimicrobial-prophylaxis(pAP).Methods:We prospectively collected bile samples from 26 patients for microbiological analysis by CMC and mRT-PCR.Concordance of the results of both methods was determined by Krippendorff's alpha(α)for inter-rater reliability and the Jaccard index of similarity.Results:mRT-PCR_(bile)and CMC_(bile)results were concordant for only Candida albicans(α=0.8406;Jaccard index=0.8181).mRT-PCR_(bile)detected pathogens in 8/8 cases(100%),CMC_(bile)in 7/8(87.5%),and CMCblood in 5/8(62.5%)with clinical signs of infection.mRTPCR_(bile),CMC_(bile),and CMCblood had identical detection results in 3/8(37.5%)with clinical signs of infection(two Klebsiella spp.and one Enterococcus faecium).The total pathogen count was significantly higher with mRT-PCR_(bile)than with CMC_(bile)(62 vs.31;χ^(2)=30.031,p<0.001).However,pathogens detected by mRT-PCR_(bile)were more often susceptible to pAP according to the patient infection/colonization history(PI/CH)and surveillance data for antibiotic resistance in our clinic(DARC).Pathogens identified by mRT-PC_(Rbile)and resistant to pAP by PI/CH and DARC were likely to be clinically relevant.Conclusions:mRT-PCR in conjunction with CMCs for bile analysis increased diagnostic sensitivity and may benefit infection management in patients with cholestatic diseases.Implementation of mRT-PCR in a bile sample-based diagnostic routine can support more rapid and targeted use of antimicrobial agents in cCLD-patients undergoing ERCP and reduce the rate/length of unnecessary administration of broad-spectrum antibiotics.

Prevention of Perinatal Group B Streptococcus Infections

Group B streptococcus(GBS)is a leading cause of neonatal infection.Maternal vaginal-rectal colonization with GBS during the intrapartum period is a prerequisite for GBS early-onset disease(EOD).The obstetric measures for effective prevention of GBS EOD include universal prenatal screening by vaginal-rectal culture,correct specimen collection and processing,appropriate implementation of intrapartum antibiotic prophylaxis,and coordination with pediatric care providers.It is now recommended to universal screen GBS between 36^(0/7)and 37^(6/7)weeks of gestation and to identify groups of women who are eligible for intravenous intrapartum antibiotic prophylaxis as a means of preventing GBS EOD.