Adherence to international antimicrobial prophylaxis guidelines in cardiac surgery: a Jordanian study demonstrates need for quality improvement. Antibiotic prophylaxis for cardiac surgery in Australia. Comparative study of single-dose and 24-hour multiple-dose antibiotic prophylaxis for cardiac surgery. Short-term versus long-term cefuroxime prophylaxis in patients undergoing emergency cesarean section. Metronidazole in Head and Neck Surgery—The Effect of Lengthened Prophylaxis Cefotaxime prophylaxis in major non-contaminated head and neck surgery: one-day vs. seven-day therapy. Antibiotic Prophylaxis in High-Risk Head and Neck Surgery: One-Day vs. Five-Day Therapy Cefotaxime in the Prophylaxis of Otorhinolaryngological Cancer Surgery Antibiotic prophylaxis in cardiac operations. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Card Preoperative Oral Antibiotics and Intravenous Antimicrobial Prophylaxis Reduce the Incidence of Surgical Site Infections in Patients With Ulcerative Colitis Undergoing IPAA Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. Our patients do not need endocarditis prophylaxis for genitourinary tract procedures: insights from the 2007 American Heart Association guidelines. Efficacy of two third-generation cephalosporins in prophylaxis for head and neck surgery.
BACKGROUND Antimicrobial prophylaxis in cardiac surgery has been demonstrated to lower the incidence of surgical site infection ( SSI ) . Inappropriate antimicrobial prophylaxis , such as inappropriate selection of the antimicrobial agent or inappropriate dosing regimen , can increase the prevalence of antibiotic resistant strains , prolong hospital stay , cause adverse reactions , and negatively affect an institution 's pharmacy budget for antibiotics . In developing countries such as Jordan , where the role of clinical pharmacists is still in its primary stages , the first step in establishing an organized clinical pharmacy service is the evaluation of current practice to determine the need for improvement . OBJECTIVE To assess the degree of adherence to international guidelines for antimicrobial prophylaxis practice in cardiac surgery performed at Queen Alia Heart Institute ( QAHI ) in Amman , Jordan , as part of an attempt to determine opportunities for clinical pharmacist intervention . METHODS For a total of 236 patients who were admitted for cardiac surgery to QAHI - the only official referral hospital for cardiac patients in Jordan - between November 19 , 2006 , and January 22 , 2007 , the antimicrobial prophylaxis indication , choice , duration , dose , dosing interval , and timing appropriateness were assessed against 3 international guidelines using a pre-tested , structured clinical data collection form that was completed by 2 of the authors who work at QAHI . The study design was prospect i ve . All patients who were scheduled for surgery were monitored daily during their inpatient stay until discharge and then were tracked in the outpatient clinic for 2 months following surgery . Data regarding antimicrobial prophylaxis indication , choice , duration , dose , dosing interval , and timing appropriateness were collected during the patient 's inpatient stay ; data collection was performed periodically thereafter as data became available until the end of the 2-month follow-up . The 3 guidelines agreed that ( a ) antimicrobial prophylaxis should be given to all patients undergoing cardiac surgeries ; ( b ) the first- or second-generation cephalosporins ( cefazolin or cefuroxime ) are the antibiotics of choice , and vancomycin use is reserved for cases of allergy to beta-lactams or if presumed or known methicillin-resistant Staphylococcus aureus ( MRSA ) colonization is present ; ( c ) the timing of the first dose should be within 60 minutes prior to the skin incision ; and ( d ) the duration of antimicrobial prophylaxis should not be longer than 48 hours . RESULTS Adherence to all antimicrobial prophylaxis guidelines was not achieved for any study patients . For the 6 evaluated criteria , ( 1 ) indication : in 100 % of patients the appropriate decision was made to use antimicrobial prophylaxis in concordance with guidelines ; ( 2 ) choice : only 1.7 % of patients received the antibiotic of choice ; ( 3 ) duration : 39.4 % of patents received antimicrobial prophylaxis for a total duration of 48 hours or less in concordance with guidelines , and for 58.9 % of patients , duration was longer than recommended ; ( 4 ) dose : 27.9 % of patients received an appropriate dose ; ( 5 ) dosing interval : only 13.0 % of patients received an appropriate dosing interval , and none of the doses of antimicrobial prophylaxis used at induction of anesthesia was repeated in operations that lasted longer than the half-life of the antibiotic used ; and ( 6 ) timing : 99.1 % of patients received antimicrobial prophylaxis dose within 60 minutes prior to skin incision as recommended by guidelines , but 97.0 % of patients received an unnecessary midnight dose of intravenous antibiotic the night before surgery . CONCLUSION Study findings indicate that adherence to international guidelines for antimicrobial prophylaxis is far from optimal in QAHI , leading to the inappropriate administration of many antibiotics . Developing local hospital guidelines , as well as giving the clinical pharmacist a central role in the administration , monitoring , and intervention of antimicrobial prophylaxis may improve the current practice OBJECTIVE To evaluate national practice for antibiotic prophylaxis in cardiac surgery with respect to the use of protocol s , agent selection and duration of administration . DESIGN , SETTING AND PARTICIPANTS Two point-prevalence surveys of intensive care units in 24 public and 27 private hospitals performing cardiac surgery in Australia , conducted in 2004 and 2008 , using a structured telephone question naire of the attending senior intensive care clinician in each unit . MAIN OUTCOME MEASURES Existence of a protocol in the unit for antibiotic prophylaxis , specific antibiotic agents used and their duration of administration . RESULTS Between 2004 and 2008 , reported protocol use increased from 58 % to 80 % ( P = 0.02 ) , while concordance with version 13 of the Australian Therapeutic guidelines : antibiotic for both choice of agent and timing ( duration of administration ) remained around 10 % . Use of multiple agents was common , as was continued antibiotic administration after completion of surgery . Over 4 years , the proportion of cardiac surgical units reporting  vancomycin administration  for routine valve surgery prophylaxis doubled to 62 % ( P < 0.001 ) . CONCLUSION Despite an increase in reported protocol use for antibiotic prophylaxis in cardiac surgery , concordance with national antibiotic guidelines remained low , with duration of antibiotic administration deviating most from recommendations . Prophylactic  vancomycin  use appears to have increased substantially in recent years . Clinical implementation of recommended perioperative cardiac surgical antibiotic prophylaxis may not occur until supported by evidence from either a large prospect i ve r and omised study or st and ardised national surveillance of cardiac surgical site infection rates OBJECTIVE Use of single-dose antibiotic prophylaxis is associated with reduced antibiotic resistance , lower costs , and fewer problems with drug toxicity and superinfections . We tested the hypothesis that single doses of cefazolin are as effective as a 24-hour regimen of cefazolin in preventing surgical site infections in adults undergoing cardiac procedures . METHODS This r and om , prospect i ve , clinical study included 838 adult patients undergoing elective coronary artery bypass grafting , valve operations , or both . These patients were r and omly given a single dose of cefazolin ( 2 g ) or a 24-hour treatment ( 2-g initial dose , followed by 1 g every 8 hours ) . Investigators blinded to the drug regimen diagnosed wound infections according to Centers for Disease Control and Prevention criteria . Patient clinical and demographic characteristics were noted , with follow-up for 12 postoperative months . The primary objective was to compare the incidence of surgical infections between groups up to 12 months postoperatively . RESULTS A total of 419 patients received single-dose cefazolin , and another 419 received the 24-hour treatment . Surgical site infection occurred in 35 ( 8.3 % ) patients receiving single doses and 15 ( 3.6 % ) patients administered the 24-hour treatment ( P = .004 ) . We identified no differences between groups for mortality or duration of hospitalization ( preoperative hospitalization , intensive care unit stay , and hospitalization after surgical intervention ) . The microorganisms isolated showed a similar distribution in both groups . The germs isolated were gram-positive cocci in 86 % of the surgical site infections . CONCLUSIONS Single-dose cefazolin used as antibiotic prophylaxis in cardiac surgery is associated with a higher surgical site infection rate than the 24-hour , multiple-dose cefazolin regimen A prospect i ve r and omized clinical trial was conducted to test the effectiveness of long-term and short-term prophylaxis with cefuroxime in preventing morbidity after cesarean section .  Sixty patients who required emergency cesarean section were r and omly assigned to one of three treatment groups : a control group of 20 patients receiving no prophylactic antibiotics ; a group of 20 patients receiving 24 hours of cefuroxime prophylaxis ( 0.75 gm 30 to 60 minutes before surgery and at 8 hours and 16 hours after surgery ) ; and a group of 20 patients receiving five days of cefuroxime prophylaxis ( 0.75 gm three times a day , the first dose being given postoperatively ) . The short-term and long-term prophylaxes were equally effective in reducing morbidity , assessed by postoperative temperatures , presence or absence of endometritis , and duration of postoperative hospital stay Previous studies of antibiotic prophylaxis have shown that treatment for 24 hours has been beneficial for head and neck surgery and that longer periods of antibiotic therapy have not improved results . Metronidazole ( Flagyl ) , unlike other antibiotics tested , has been shown to be effective in an experimental abscess , even if treatment is begun up to 120 hours after administration of inoculum . This article presents a prospect i ve , r and omized , multifactorial study comparing a brief vs. a prolonged duration of metronidazole and cefazolin prophylaxis in 50 consecutive patients with a head and neck cancer undergoing operation . Patients receiving 2 days vs. 7 or more days of antibiotic prophylaxis were compared . Statistical analysis of data demonstrated a striking reduction in severity of wound complications and a reduced incidence of wound infections in the group treated with 7 or more days of antibiotic prophylaxis Patients who undergo major surgery of head and neck benefit from perioperative antibiotic prophylaxis . This study was developed to determine if seven days of antibiotic administration would be more effective than one day . A prospect i ve r and omized double blind study was design ed . Patients were r and omly assigned to receive cefotaxime sodium for either 24 hours or seven days . In each case , the drug was administered intramuscularly , beginning one to two hours pre-operatively and continued for the prescribed period . Sixty patients were included in the trial . Of 30 patients assigned to one day of perioperative prophylaxis , wound infection developed in four ( 13 per cent ) . Of 30 patients assigned to seven days of perioperative antibiotic prophylaxis , wound infection developed in three ( 10 per cent ) ( P > 0.05 ) . These data suggest that no beneficial effect from administration of antibiotics for longer than 24 hours post-operatively can be achieved in patients who undergo major head and neck surgery Patients who undergo major contaminated surgery of the head and neck benefit from perioperative antibiotic prophylaxis . This study was developed to determine if 5 days of antibiotic administration would be more effective than 1 day . A multi-institutional prospect i ve r and omized double-blind study was design ed . Patients who were identified as requiring pedicled flap reconstruction were potential c and i date s for the study . Later , patients were r and omly assigned to receive cefoperazone sodium for either 24 hours or 120 hours . In each case , the drug was administered intravenously , beginning 1 to 2 hours preoperatively and continued for the prescribed period . One hundred nine patients were evaluable . Fifty-three patients were assigned to 1 day of perioperative prophylaxis .  Wound Infection developed in ten patients ( 18.9 % ) . Fifty-six patients were assigned to 5 days of perioperative antibiotic prophylaxis .  Wound infection developed in 14 ( 25 % ) of these patients ( P > .05 ) . These data suggest that no beneficial effect from administration of antibiotics for longer than 24 hours postoperatively can be achieved in patients who undergo myocutaneous flap reconstruction The problem of which antibiotic to choose and the optimal duration of its administration in the prophylaxis of otorhinolaryngological surgery for cancer has not been satisfactorily resolved . Subjects suffering from cancer of the upper airways or digestive tract , who are often smokers and drinkers , have a population of Gram-positive or Gram-negative anaerobes and Gram-negative aerobes ( predominantly Pseudomonas , Proteus and Escherichia coli ) in addition to their usual oropharyngeal flora .  Antibacterial monotherapy has little chance of success against all of these organisms , which are liable to become pathogenic in the event of surgery . Drug combinations would be costly and could result in selection of resistant strains . Accordingly , it is generally recommended that either monotherapy with a newer 13-lactam or a combination of a penicillin and imidazole be used , knowing that not all of the potential pathogens will be covered , but that the most resistant anaerobes in the postoperative period will be effectivelyerased and that a second antibiotic can be used in the event of the sudden occurrence of a specific infection . The optimum duration of antibiotic administration has not been determined for this area of surgery ; 8 days ' treatment is excessively long and 24 hours ( the usual duration of st and ard prophylaxis ) is insufficient because one is dealing with a highly infectious type of surgery in a very septic medium . Tumours are often necrosed in an environment which already has an abundance of potentially pathogenic organisms ; surgery is long ( average duration is 4 hours ) and exposes a large operation area to contamination : i.e. the neck and frontal thorax if a musculo-cutaneous flap has been prepared . Third generation cephalosporins similar to cefotaxime have already been the subject of studies as antibiotic prophylaxis in this indication ( Gehanno & Moisy in press ; Johnson et al. 1983 ) . The aim of the present multicentre study was to determine the optimum duration of administration of cefotaxime This clinical trial , which was composed of 1,031 adults undergoing cardiac operations , compared the efficacy of a single dose of 1 g of ceftriaxone with a 48-our regimen consisting of flucloxacillin and gentamicin . There was no significant difference ( p = 0.89 ) in the overall incidence of major infections : 30 of 515 patients ( 5.8 % ; 95 % confidence interval , 5.4 % to 6.2 % ) taking ceftriaxone and 29 of 516 patients ( 5.6 % ; 95 % confidence interval , 5.2 % to 6.0 % ) taking flucloxacillin and gentamicin . Subgroup analyses , with a lower statistical power , failed to show a significant difference between patients who received ceftriaxone and those who received flucloxacillin/gentamicin :  major sternal wound infections arose in 2.7 % of the patients taking ceftriaxone versus 1.6 % in those on the 48-hour regimen ( p = 0.20 ) and major limb wound infections arose in 4.2 % and 5.4 % , respectively ( p = 0.44 ) . Single-dose prophylaxis was associated with fewer intravenous administrations ( 864 doses versus 9,570 doses ) and cost less ( A$ 17,248 versus A$ 78,510 ) . Although the regimen that included gentamicin was associated with the greatest biochemical impairment of renal function , the overall toxicity for both groups was low . We conclude that a single dose of ceftriaxone provided cost-efficient prophylaxis for adults undergoing cardiac operations when compared with a 48-hour regimen of gentamicin and flucloxacillin . The general principle revealed by our data is that the short-term administration of an appropriate antibiotic regimen represents optimal prophylaxis for patients undergoing cardiac procedures BACKGROUND The purpose of this statement is to up date the recommendations by the American Heart Association ( AHA ) for the prevention of infective endocarditis that were last published in 1997 . METHODS AND RESULTS A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis , with liaison members representing the American Dental Association , the Infectious Diseases Society of America , and the American Academy of Pediatrics . The writing group review ed input from national and international experts on infective endocarditis . The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis , in vitro susceptibility data of the most common microorganisms that cause infective endocarditis , results of prophylactic studies in animal models of experimental endocarditis , and retrospective and prospect i ve studies of prevention of infective endocarditis . MEDLINE data base search es from 1950 to 2006 were done for English- language papers using the following search terms : endocarditis , infective endocarditis , prophylaxis , prevention , antibiotic , antimicrobial , pathogens , organisms , dental , gastrointestinal , genitourinary , streptococcus , enterococcus , staphylococcus , respiratory , dental surgery , pathogenesis , vaccine , immunization , and bacteremia . The reference lists of the identified papers were also search ed . We also search ed the AHA online library . The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used . The paper was subsequently review ed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee . CONCLUSIONS The major changes in the up date d recommendations include the following : ( 1 ) The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 % effective . ( 2 ) Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis . ( 3 ) For patients with these underlying cardiac conditions , prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa . ( 4 ) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis . ( 5 ) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure . These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations BACKGROUND : The usefulness of preoperative oral antibiotics for the prevention of surgical site infection in elective colorectal surgery remains controversial . OBJECTIVE : This study aim ed to investigate the effects of oral antimicrobial prophylaxis in addition to intravenous antimicrobial prophylaxis on patients with ulcerative colitis undergoing restorative proctocolectomy . DESIGN : This study was a r and omized , nonblinded , single-center clinical trial . SETTING : This study was conducted between July 1 , 2006 , and April 30 , 2009 , at Hyogo College of Medicine . PATIENTS : Two hundred patients with ulcerative colitis scheduled to undergo restorative proctocolectomy with IPAA with an open approach were r and omly assigned to either group A or B ( n = 100 ) . Combined use of preoperative oral antibiotics and intravenous antimicrobial prophylaxis were given to group A , and intravenous antimicrobial prophylaxis alone was given to group B. INTERVENTIONS : Patients in group A received oral antibiotics the day before surgery ( 500 mg of kanamycin and 500 mg of metronidazole at 2:00 P.M. , 3:00 P.M. , and 9:00 P.M. ) , whereas those in group B did not . All patients underwent preoperative mechanical bowel preparation , and intravenous antimicrobial prophylaxis with second-generation cephalosporin was given for 24 hours . MAIN OUTCOME MEASURES : The primary end point of this study was the incidence of overall surgical site infection according to intention-to-treat analysis . RESULTS : The incidence of overall surgical site infection was significantly lower in group A ( 6/97 patients , 6.1 % ) than in group B ( 22/98 patients , 22.4 % ) ( p = 0.0024 ) . In multivariate analysis , the administration of oral antibiotics ( OR , 0.178 ; 95 % CI , 0.057–0.552 ; p = 0.003 ) and ASA score ≥3 ( OR , 5.343 ; 95 % CI , 1.595–17.891 ; p = 0.007 ) were independent risk factors for surgical site infection . LIMITATIONS : This study is limited because of its open-label nature . CONCLUSIONS : Combined oral and intravenous antimicrobial prophylaxis in patients with ulcerative colitis undergoing restorative proctocolectomy with IPAA contributed to the prevention of surgical site infection HYPOTHESIS  Surgical site infections ( SSIs ) are a major contributor to patient injury , mortality , and health care costs . Despite evidence of effectiveness of antimicrobials to prevent SSIs , previous studies have demonstrated inappropriate timing , selection , and excess duration of administration of antimicrobial prophylaxis . We herein describe the use of antimicrobial prophylaxis for Medicare patients undergoing major surgery . DESIGN National retrospective cohort study with medical record review . SETTING Two thous and nine hundred sixty-five acute-care US hospitals . PATIENTS A systematic r and om sample of 34,133 Medicare in patients undergoing coronary artery bypass grafting ; other open-chest cardiac surgery ( excluding transplantation ) ; vascular surgery , including aneurysm repair , thromboendarterectomy , and vein bypass operations ; general abdominal colorectal surgery ; hip and knee total joint arthroplasty ( excluding revision surgery ) ; and abdominal and vaginal hysterectomy from January 1 through November 30 , 2001 . MAIN OUTCOME MEASURES The proportion of patients who had parenteral antimicrobial prophylaxis  initiated within 1 hour before the surgical incision ; the proportion of patients who were given a prophylactic antimicrobial agent  that was consistent with currently published guidelines ; and the proportion of patients whose antimicrobial prophylaxis was discontinued within 24 hours after surgery . RESULTS An antimicrobial dose was administered to 55.7 % ( 95 % confidence interval [ CI ] , 54.8%-56.6 % ) of patients within 1 hour before incision .  Antimicrobial agents consistent with published guidelines were administered to 92.6 % ( 95 % CI , 92.3%-92.8 % ) of the patients .  Antimicrobial prophylaxis was discontinued within 24 hours of surgery end time for only 40.7 % ( 95 % CI , 40.2%-41.2 % ) of patients . CONCLUSION Substantial opportunities exist to improve the use of prophylactic antimicrobials for patients undergoing major surgery The 2007 American Heart Association guidelines for the prevention of infective endocarditis have dramatically reduced both the types of eligible procedures and the types of eligible cardiac lesions that require prophylaxis . Antibiotic prophylaxis to prevent infective endocarditis is not indicated for any patient undergoing obstetric and /or gynaecological procedures , not even for patients with underlying cardiac lesions with the highest risk of developing complications from endocarditis . This sharp departure from previously published guidelines relies on the recognition that endocarditis is more likely to develop from " r and omly occurring " bacteremia ( e.g. , from brushing teeth ) than from invasive procedures and that antibiotic prophylaxis has not been proven to be effective . A short discussion on enterococcal infections associated to obstetric and gynaecological procedures and therapeutic implication s is presented Optimal antimicrobial prophylaxis during head and neck surgery is as yet unclear . The semisynthetic third-generation cephalosporin antibiotics would appear to have potential usefulness because of their broad antibacterial spectrum , favorable pharmacokinetic properties , and record of safety . Eighty patients were prospect ively r and omized into this placebo-controlled , double-blind study to receive either placebo , cefoperazone sodium , or cefotaxime sodium preoperatively and for 24 hours postoperatively . Infection rates were 78 % for the placebo group and 10 % for the group receiving the cephalosporin antibiotics .  Infections were polymicrobial . Anaerobic bacteria constituted 42 % of the pathogens isolated . Wound and serum antibiotic concentrations exceeded the minimal inhibitory concentration of the bacterial flora . This study establishes the necessity of antimicrobial prophylaxis for contaminated oncologic procedures of the head and neck . Our experience indicates that cefoperazone and cefotaxime are particularly useful
There were no statistically significant differences in mortality , infections overall and adverse events .
Perioperative antibiotic prophylaxis of ≥24 hours may be more efficacious in preventing sternal SSIs in patients undergoing cardiac surgery compared to shorter regimens .
OBJECTIVE We aim ed to compare the efficacy of short-term ( < 24 hours ) versus longer-term antibiotic prophylaxis ( ≥24 hours ) in open heart surgery .
BACKGROUND The optimal duration of antibiotic prophylaxis for adults undergoing cardiac surgery is unknown and guideline recommendations are inconsistent .