Neues in der perioperativen antibiotischen Prophylaxe

Perioperative antimicrobial prophylaxis (PAP) leads to a reduction in surgical site infections. The aim of PAP is adequate serum and tissue concentrations of the antimicrobial drug in the field of operation. The antibiotic must be effective against the expected pathogens during the operation, safe, and have the fewest possible side effects. The indication for PAP should take into account the risks of the operative procedure and especially the individual risk factors of the patient. Depending on pharmacokinetics, the antibiotic should be administered within 60 min before incision. After closure of the wound, further applications of the antibiotic drug have no influence on the infection rate of the wound but do increase the side effects (resistance, CDT colitis, allergy). Operation-specific recommendations according to guidelines of the Paul Ehrlich Society are given.     

Antibiotic choices in surgical intensive care unit patients.

Antibiotics have dramatically changed the care of the critically ill patient over the last 60 years. Patients with complex physiological conditions present with infectious processes requiring the effective use of antimicrobial drugs. In many situations, the inability to eradicate the infectious process is complicated by the progressive development of resistance among the causative organisms. Systemic antibiotic prophylaxis is warranted only for the prevention of wound infections. Regimens in these cases should use large doses of nontoxic antibiotics covering the spectrum of organisms likely to contaminate the wound. The duration of wound prophylaxis should be short, essentially covering only the period of active wound closure; this is usually less than 24 hours. Prevention of most other infections in the ICU depends on the recognition and correction of the various disturbances of host defenses. Topical antibiotic therapy may reduce the level of colonization for a few specific types of infection. Initial empiric antibiotic therapy should be started for clear indications. The antibiotics chosen should be those most likely to be effective against the probable organisms, those which have the lowest toxicity, and those with the smallest likelihood of inducing multiresistance. They must be adjusted promptly based on the microbiologic sensitivities observed. The realization that the physiology of critical illness may alter the normal relations between drug dosages and the tissue antibiotic levels obtained mandates a different approach to the treatment of these patients. The drug volumes of distribution are generally markedly expanded in these patients. Furthermore, these patients require high tissue antibiotic concentrations to improve the chances for successful therapy. Thus, the antibiotics selected must be capable of providing these levels without significant toxicity to the host. Therapy should be continued based on the clinical response observed. Premature cessation of effective therapy often results in relapse.     

Prophylactic antibiotics in surgery and surgical wound infections

Wound infection remains a considerable cause of morbidity and mortality among surgical patients, despite the relative success of prophylactic antibiotics. In modern efforts to control healthcare costs while improving the quality of patient care, we must not overlook the basic principles of wound infections and their appropriate treatment. Predisposing factors for the development of surgical wound infection include the creation of a surgical wound, the presence of bacteria, and a susceptible host. The selection of an appropriate antimicrobial drug depends on the identification of the most likely pathogens associated with a given procedure, as well as the expected antibiotic susceptibility of those pathogens. Ideally, a prophylactic antibiotic should achieve high peak tissue concentration at the site of the wound before the first incision and should be maintained until the time of closure. Currently, the administration of prophylactic antibiotics is indicated for contaminated and clean-contaminated wounds. Despite the proven effectiveness of antibiotic prophylaxis, many researchers would argue that contemporary dosing regimens should be reevaluated. The debates concerning the dosage and timing of ideal prophylactic administration are likely to continue.     

The role of antibiotic prophylaxis in the new era of immunosuppression

Despite significant improvements in renal transplantation (RTX), certain basic issues remain unresolved such as the routine use of perioperative antibiotic prophylaxis (PAP). To address the need for PAP, we retrospectively evaluated the clinical course of 349 consecutive RTX patients who did not receive any PAP except for Bactrim. Of the 349 transplant recipients, 77% received induction therapy with low-dose rabbit antithymocyte globulin (rATG) and the others were treated with basiliximab. All patients received triple immunosuppression with tacrolimus, mycophenolic acid, and prednisone. Seven patients (2%) developed wound infections. Wound infections were more common in obese and older patients. All wound infections were superficial and responded well to wound drainage and outpatient antibiotic therapy. Six patients (1.7%) experienced a urinary tract infection (UTI) within the first postoperative month. UTIs were more common in the patient with ureteral stent compared to nonstented patients (11.4% vs 0.3%, P < .001). No patient or graft was lost due to perioperative bacterial infections (PBI). Our study shows that despite many predisposing factors, PBI are rare following RTX even in the absence of PAP. Therefore, in order to avoid emergence of multiantibiotic-resistant pathogens, excessive costs, and antibiotic-related adverse events, we suggest that PAP should be used only in selected circumstances such as in recipients older than 60 or when the body mass index is greater than 35.     

Antibiotic treatment for prevention of infectious complications in joint replacement

Prophylactic antibiotic treatment is mandatory in every operation involving an orthopedic implant. Carefully selected and correctly administered antibiotics can provide effective protection of the implant from bacterial colonization. The prevention of deep wound infection in joint replacement includes several procedures and measures which constitute three basic groups: 1) Promotion of patient's ability to resist infection (careful pre-operative preparation, elimination of potential infectious loci, good nutritional status, etc). 2) Optimal conditions for the operative wound (surgical technique, prophylactic antibiotics). 3) Reduction of the number of bacteria brought in the wound (control measures, super-sterile operating theatres). Clear rules for the system of prophylactic antibiotic treatment should be adopted. A program in which responsibility for antibiotic administration was shifted from the nursing staff to the anesthesiologist in the operating theatre showed improved outcomes and reduced costs. Poor timing of prophylactic antibiotic administration is one of the basic mistakes. If the wound happened to be contaminated during surgery, the first three post-operative hours would be most decisive for the development of infection. An effective bactericidal concentration of antibiotic should be present in tissues and serum immediately after surgery has begun. Therefore the appropriate time for antibiotic application is before a skin incision is made, and not after the operation has started; the highest serum and bone tissue levels appear 20 to 30 min. after intravenous antibiotic injection. To allow antibiotics to reach target tissues, they should be introduced at least 10 min. before tourniquet application. For long surgical procedures or when blood loss is high, an additional dose of antibiotics is recommended during the operation. If a sample for bacterial cultivation is required, antibiotic administration is postponed until during surgery. However, this is used only in indicated cases when deep infection is suspected and no assessment of the causative agent is available. Otherwise this approach carries a high risk of infectious complications in aseptic revision arthroplasty. Long-term, unjustified administration of antibiotics leads to an increase in resistance to the antibiotic involved. Some studies show that a day's course is as effective as a seven-day one. A shorter antibiotic course decreases the costs, reduces side-effects and minimizes the development of resistance. An optimal duration of antibiotic treatment has not been defined yet, and is still a hot issue for discussion. Many authors recommend one pre-operative antibiotic dose and, according to the kind of antibiotic, agree to its 24-hour administration in order to lower the toxic effect of antibiotic and to prevent selection of resistant microorganisms. The choice of suitable antibiotics for prophylactic treatment should be based on the range of agents causing joint replacement infections and the pharmacological properties of the drug. This should have minimal toxicity, should be well tolerated by the patient and, from the epidemiological point of view, should have a low risk of inducing resistance because of frequent use. Naturally, it is not possible to include all antibiotics against all causative agents and therefore attention should be paid, in the first place, to Gram-positive bacteria, i. e., staphylococci and streptococci, which are the most common causes of infectious complications associated with joint replacement. Because of difficulties related to the right choice of antibiotic, it is recommended to keep a record of complications in each patient in order to provide feedback and to facilitate the establishment of reliable antibiotic-based prevention. The prevention of infection in orthopedics is a comprehensive issue. It cannot be expected that prophylactic antibiotic treatment will compensate for mistakes made in operative protocols, for inadequate operative techniques, for shortcomings in operating theatre equipment or insufficient preparation of patients.     

The use of prophylactic antimicrobial agents during and after hip arthroplasty

An intravenous antibiotic, administered just before skin incision, effectively reduces the prevalence of deep wound infection. The optimal antimicrobial agent has not been determined definitively; however, a short duration of prophylaxis is recommended. Institutional compliance strategies are cost-effective and improve the timing of antibiotic administration. Also, published antimicrobial restriction recommendations are warranted because of the concern of emerging antibiotic-resistant bacteria. Specifically, restriction of vancomycin in orthopaedic surgery should be targeted critically. Supplemental antibiotic administration includes additional intra-operative antibiotic dosing, use of antibiotic-irrigant solutions, and admixture of antibiotics into acrylic bone cement or bone graft. There are no established standards or clinical guidelines for these supplemental antibiotic applications. Post-operatively, antimicrobial agents frequently are overused for various clinical scenarios and this pattern of antibiotic usage is potentially detrimental. A prophylaxis strategy for prevention of early and late hematogenous infection requires consideration of host risk factors, wound environment variables, and sources of potential bacteremia. This strategy should include deliberation of the cost-effectiveness, efficacy, and complications associated with routine use of antibiotics. Advisory statements for elective procedures, which potentially may cause bacteremia, are being developed and additional research is required for this area of antimicrobial agent prophylaxis.     

Prospective,randomized, controlled trial of ticarcillin and cephalothin as prophylactic antibiotics for gastrointestinal operations

The effectiveness of ticarcillin (one 6 g dose at the start of the operation) and cephalothin (three 2 g doses given at 4 hour intervals from the start of the operation) as prophylactic antibiotics in operations on the colon, stomach, small bowel or obstructed biliary tract was determined in a prospective, randomized, blind study of 190 patients. Data from the 152 patients forming the definitive study revealed a significant reduction in the rate of wound and peritoneal infections with the use of ticarcillin (3.4 percent) and cephalothin (5.3 percent) over that with the use of a placebo (27.8 percent). Cultures showed no evidence of antibiotic resistance in the contaminant organisms of patients who later developed infections. Both antibiotic regimens offered excellent protection against infection after gastrointestinal operations; neither produced untoward side effects. The very short duration of treatment, particularly with ticarcillin, conferred the additional benefits of low cost, simplicity of drug administration, and negligible risk of the emergence of resistant bacterial strains.     

Randomized placebo-controlled trial of single-dose antibiotic prophylaxis with fusidic acid in neurosurgery

Summary In neurosurgery, the antibiotic prophylaxis of choice has not yet been determined. The ideal drug should have an appropriate antimicrobial spectrum and favourable pharmacokinetic properties. In addition it should be nontoxic and easy to apply. We therefore conducted in 90 patients a prospective, randomized, placebo-controlled, double-blind trial in clean neurosurgery at increased risk of wound infection using a single pre-operative dose of 500 mg fusidic acid. Fusidic acid is a steroid-like antibiotic with a serum half-life of about 10 hours and excellent activity against grampositive bacteria, including methicillin-resistant staphylococci. The neurosurgical infection rates for craniotomies, posterior fossa surgery and implantation of foreign bodies were 2.4% in the treatment group and 9.1% in the placebo group, respectively. This difference is statistically significant at a 95% confidence level.     

Antibiotic prophylaxis

Surgical site infection (SSI) is a common postoperative complication which leads to significant morbidity and mortality. The aim of antibiotic prophylaxis is to reduce the incidence of SSI by preventing the development of infection due to colonizing or contaminating organisms at the operative site. It is used as an adjunct to, rather than a replacement for, other evidence-based interventions to prevent wound infection, such as the use of skin antiseptics. The choice of antimicrobial agent(s) used is dependent on how ‘clean’ the operation is, the operative site (which determines the likely organisms), and a variety of patient factors including the presence of allergies and colonization with resistant organisms such as meticillin-resistant Staphylococcus aureus (MRSA). The practicalities of antibiotic prophylaxis administration are discussed. Not all operations require antibiotic prophylaxis; use of antibiotics in any context, including as prophylaxis, can be associated with adverse effects, specifically an increased risk of Clostridium difficile-associated diarrhoea (CDAD) and resistance development; prophylaxis should therefore be used responsibly. This article will address some of the common misconceptions about its use and special patient circumstances requiring deviation from the usual guidance.     

Wound and serum levels of tobramycin with the prophylactic use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures

Antibiotic-impregnated polymethylmethacrylate (PMMA) beads have been useful in treating orthopedic infections. Local delivery has been reported to establish wound antibiotic levels well above the therapeutic range while avoiding serum levels associated with increased incidence of side effects. After operative debridement, 70 patients with compound fractures were treated prophylactically with tobramycin-impregnated PMMA beads. Observations of antibiotic levels in 27 patients demonstrated antibiotic levels in the wound drainage and clot that were significantly in excess of the usual therapeutic range for tobramycin and simultaneous nontoxic serum levels. Significant levels of tobramycin can be achieved in the extracellular fluid at the fracture site when tobramycin-impregnated PMMA beads are placed in the wound after irrigation and debridement.     

Antibiotics-why so many and when should we use them?

Antibiotic prophylaxis in vascular surgery has been proven beneficial to reduce surgical site infections after reconstruction of the aorta, procedures on the leg that involve a groin incision, any procedure that implants a vascular prosthesis or endoluminal stent, and lower extremity amputation for ischemia. Bactericidal antibiotics administered before induction-cefazolin or cefuroxime for 1 to 2 days alone or in combination with vancomycin if a hospital wound surveillance program indicates a high incidence of methicillin-resistant Staphylococcus aureus infection-is recommended. If a patient is felt to be at increased risk for infection and require prosthetic grafting, the use of a rifampin-soaked (1 mg/mL) gelatin- or collagen-impregnated graft may decrease the incidence of wound and graft infection. Antibiotic treatment of established vascular graft infections should begin with broad-spectrum coverage for expected pathogens (S aureus, Staphylococcus epidermidis, Gram-negative bacteria) followed by culture-specific therapy based on antibiotic susceptibility testing. Specific antibiotic usage involves a decision regarding efficacy to expected or isolated pathogens versus its potential side effects and the drug costs. New applications for antibiotics in vascular surgery include the use of specific tetracyclines (doxycycline, azithromycin) as an inhibitor of matrix metalloproteinases to retard aortic aneurysm growth or for their antiinflammatory properties to retard atherogenesis related to Chylamydia pneumoniae.     

Effects of antibiotics on prevention of infection in contaminated abdominal operations.

A prospective study was undertaken on 102 patients with massice intraperitoneal contamination from traumatic or spontaneous perforation of intestinal or pancreaticobiliary tract to determine the effects of combined systemic and intraperitoneal antibiotic administration on the prevention of the postoperative sepsis, intra-abdominal abscess formation and wound infection. Large doses of gentamicin and clindamycin were given parenterally before, during, and after the operation for five days. In addition, the peritoneal cavity and the abdominal incision were irrigated intraoperatively with antibiotic solution containing the same antibiotics. The drugs were given so as to provide a potent level of antibiotics during the operation and in the immediate postoperative period. The postoperative wound infection rate was 4 per cent, intra-abdominal abscess 2.9 per cent, sepsis 1 per cent, resulting in a total infectious complication rate of 7.9 per cent. This is a marked reduction in the incidence of infectious complications and compares favorably with the results from either parenteral or intraperitoneal therapy alone. Furthermore, no complications were encountered due to this method of therapy. These results do not indicate that antimicrobial drugs be given prophylactically to all surgical patients, but they strongly suggest the advantages of combined systemic and intraperitoneal antibiotics in the management of patients with massive intraperitoneal contamination.     

Essential oils and metal ions as alternative antimicrobial agents: a focus on tea tree oil and silver

The increasing occurrence of hospital‐acquired infections and the emerging problems posed by antibiotic‐resistant microbial strains have both contributed to the escalating cost of treatment. The presence of infection at the wound site can potentially stall the healing process at the inflammatory stage, leading to the development of a chronic wound. Traditional wound treatment regimes can no longer cope with the complications posed by antibiotic‐resistant strains; hence, there is a need to explore the use of alternative antimicrobial agents. Pre‐antibiotic compounds, including heavy metal ions and essential oils, have been re‐investigated for their potential use as effective antimicrobial agents. Essential oils have potent antimicrobial, antifungal, antiviral, anti‐inflammatory, antioxidant and other beneficial therapeutic properties. Similarly, heavy metal ions have also been used as disinfecting agents because of their broad spectrum activities. Both of these alternative antimicrobials interact with many different intracellular components, thereby resulting in the disruption of vital cell functions and eventually cell death. This review will discuss the application of essential oils and heavy metal ions, particularly tea tree oil and silver ions, as alternative antimicrobial agents for the treatment of chronic, infected wounds.     

Management of the patient reporting an allergy to penicillin

Recent emphasis on the prevention of surgical wound infection has highlighted the role of the anesthesiologist as the physician responsible for administering appropriate antibiotic prophylaxis. Patients often report a distant or unclear history of penicillin allergy. Administering an antibiotic to which the patient has a true allergy can provoke a life threatening reaction. The anesthesiologist should be aware of the prevalence, severity, and manifestations of allergies to antibiotics, as well as the available alternatives. Unnecessary administration of more powerful broad-spectrum antibiotics leads to the development of antimicrobial resistance and should be avoided. It is the anesthesiologists' duty to balance these issues when selecting appropriate antibiosis.     

Sirolimus-Induced Pulmonary Alveolar Proteinosis in the Context of Hematopoietic Stem Cells Transplant Rejection: A Case Report

Pulmonary alveolar proteinosis (PAP) is a rare parenchymal pulmonary disease, characterized by the accumulation of surfactant material in alveoli. Rare cases of pulmonary alveolar proteinosis have been reported following the use of sirolimus. All published cases have been described following solid organ transplantation, and symptoms improved quickly after treatment's cessation.We describe a case of PAP secondary to sirolimus treating graft-versus-host reaction in a patient who received a stem cell transplant for chronic lymphocytic leukemia. Pulmonary alveolar proteinosis was cured after stopping sirolimus without any other therapeutic management.PAP can be a rare but serious side effect of sirolimus. It is important to rule out other causes of primary or secondary PAP before suggesting a toxic drug cause.The main challenge is to quickly diagnose this side effect to stop exposure to the toxic agent.     

Antibiotikaprophylaxe und endolumin?re Sonden

Surgical site infections are one of the most common complications after surgical procedures. The use of perioperative antibiotic prophylaxis can successfully reduce the number of wound infections. The indications, timing and choice of antibiotics are discussed critically. Taken together antibiotic prophylaxis should be evaluated depending on wound contamination, the type of operation and patient-specific risk factors. In the second part of this work the current literature on the effectiveness of endoluminal tubes in abdominal surgery is analyzed. While many surgeons use these tubes regularly in elective abdominal surgery, only few data are available on this topic. The use of nasogastric tubes in elective surgery should be avoided.     

The prevention of wound infections with the use of local antibiotics.

The local use of kanamycin, a broad spectrum antibiotic, has been successful in preventing primary wound infections. There have been no instances of drug reaction or sensitivity when kanamycin is used as a dilute topical irrigating solution. Secondary wound infections, which occurred in two cases, responded to local and systemic antibiotic therapy. Kanamycin can be recommended as an effective and safe topical antibiotic to prevent wound infections in foot surgery.     

Akute Maßnahmen beim „limb salvage“-Prozedere Teil 2

The quality of the primary care of Gustilo–Anderson (GA) type IIIB and IIIC extremity injuries is crucial to the success of the limb salvage procedure. This article provides a compilation of consistent, but often controversially discussed aspects of initial debridement, modern techniques of lavage and wound closure, in addition to current issues on the application of antibiotics and antiseptics, based on our own experiences and the latest literature. The following points should be stressed. Severe extremity injuries with gross contamination (GA IIIA, B, and C) will still be associated with an infection rate of up to 60?%. The initial debridement should be performed as soon as an experienced trauma surgeon is available. Tissue that is definitely avital will have to be removed, whereas traumatized but potentially surviving tissue will have to be re-evaluated during a second-look operation after 36–48 h. Given a high enough level of contamination, biofilms will form after as few as 6 h. The perioperative antibiotic prophylaxis has to be initiated early and should be continued for at least 24 h (GA I/II) or up to 5 days (GA III). In cases of bacterial contamination, wound irrigation will be useful with additives such as polyhexanide, octenidine or superoxidized water. Rinsing of the wound should be performed with 3–9 L and only slight manual pressure (no jet lavage). The definitive primary closure of a wound should be achieved in the initial operation, but only in the case of certain “decontamination” and overall vitality of the wound (GA I and II). In the presence of high-grade injuries, a temporary vacuum sealing technique can be used until the earliest possible definitive plastic surgical wound closure.     

损伤控制在急性胆管炎治疗中的应用

目的探讨损伤控制在急性胆管炎患者治疗中的应用。对急性胆管炎的早期复苏、手术时机及手术方法、鼻胆管引流的指征、细菌培养和减少围手术期并发症的重要性进行讨论。方法回顾分析1995年1月至2005年12月收治的急性胆管炎非保守治疗患者88例,其中手术治疗72例,经十二指肠镜鼻胆管引流术(ENBD)15例和B超引导下经皮经肝胆囊穿刺引流(PTGD)1例。并对术中胆汁细菌学培养和抗生素治疗等情况进行总结分析。结果术后死亡5例,胆道残余结石9例,29例出现并发症。ENBD治疗15例,均一期治愈。术中胆汁细菌学培养60例,39例培养阳性,培养出细菌51株。结论急性胆管炎患者诊断一旦明确,在创伤控制理论的指导下,尽早进行复苏,抗感染,纠正休克、水电解质及酸碱平衡紊乱和凝血功能异常。首要目的在于抢救患者生命,治疗及手术力求简单有效。ENBD创伤小,胆道减压效果确实,亦为择期手术创造了条件。胆汁细菌学培养和药敏试验应列为常规,对调整抗生素用药有指导意义。