Internist (Berl) . 2005 Jan 18; {Epub ahead of print} {Diagnosis and therapy of acute pancreatitis.}; Adler G et al.; In acute pancreatitis the evaluation of severity is as important as the diagnosis . If there is evidence for severe pancreatitis, an immediate intensive care of all organ systems is needed, to avoid complications . Besides clinical signs, serum CRP is the most valuable parameter to define severity . According to present knowledge, a CT-scan is only needed in sepsis or multiorgan failure . Non-invasive ventilation should be started early in case of hypoxia . Up to now, no general benefit was detected for antibiotic prophylaxis or enteral nutrition . No consensus exists whether and when endoscopic interventions are superior to surgery in the treatment of infected necrosis. Inflamm Res, 2004 Dec 1, 53(12), 697 - 705 Sickness behavior of rats with abdominal sepsis can be improved by antibiotic and G-CSF prophylaxis in clinic modeling randomized trials; Bauhofer A et al.; BACKGROUND AND AIM: In clinical sepsis research nearly all immune-modulators have demonstrated no benefit in regard to the 28-day mortality rate . Other endpoints such as quality of life have become more attractive, but clinically relevant animal models analyzing an equivalent to quality of life by measurement of sickness behavior are extremely rare . The concept of clinic modeling randomized trials was used in an animal trial to model clinical complexity and conditions of a randomized clinical trial . METHODS: 80 adult male Wistar rats were randomly assigned to (1) control: anesthesia and sham operation, (2) sepsis: laparotomy and peritoneal infection with human stool bacteria, (3) sepsis with antibiotic prophylaxis: cefuroxime/metronidazole and (4) sepsis with antibiotic plus a cytokine prophylaxis with granulocyte-colony stimulating factor (GCSF) . Endpoints were physiological and behavioral parameters . RESULTS: The combination of antibiotics plus G-CSF was most effective in reducing mortality . All infected animals showed reduced open field activity acutely after infection, and recovery was improved during the 9 day follow-up in rats with prophylactic treatments . In the social interaction test, but not in the elevated plus-maze anxiety test, prophylaxis was also efficient, especially with antibiotics and G-CSF . CONCLUSIONS: The results show that improving sickness behavior in septic rats with G-CSF plus antibiotics may be a promising approach. Dig Liver Dis, 2004 Dec, 36(12), 787 - 98 Diagnosis and treatment of portal hypertension; de Franchis R et al.; Prevention of the first variceal haemorrhage should start when the patients have developed medium-sized to large varices . Non-selective beta-blockers and band ligation are equally effective in preventing the first bleeding episode . Rubber band ligation is the first choice for patients with contraindications or intolerance to beta-blockers . Treatment of acute bleeding should aim at controlling bleeding and preventing early rebleeding and complications, especially infections . Combined endoscopic (band ligation or sclerotherapy) and pharmacological treatment with vasoactive drugs can control bleeding in up to 90% of patients . Antibiotic prophylaxis is an integral part of the treatment of acute variceal haemorrhage, and must be started as soon as possible . Emergency transjugular intrahepatic portosystemic stent shunt (TIPS) is the standard rescue therapy for patients failing combined endoscopic and pharmacological treatment . All patients who survive a variceal bleed should be treated with beta-blockers or band ligation to prevent rebleeding . All patients in whom bleeding cannot be controlled or who continue to rebleed can be treated with salvage TIPS or, in selected cases, with surgical shunts . Liver transplantation should be considered for patients with severe liver insufficiency in which first-line treatments fail. J Pediatr Endocrinol Metab, 2004 Dec, 17(12), 1583 - 90 Hypoparathyroidism-retardation-Dysmorphism (HRD) syndrome--a review; Hershkovitz E et al.; Hypoparathyroidism, retardation, and dysmorphism (HRD) is a newly recognized genetic syndrome, described in patients of Arab origin . The syndrome consists of permanent congenital hypoparathyroidism, severe prenatal and postnatal growth retardation, and profound global developmental delay . The patients are susceptible to severe infections including life-threatening pneumococcal infections especially during infancy . The main dysmorphic features are microcephaly, deep-set eyes or microphthalmia, ear abnormalities, depressed nasal bridge, thin upper lip, hooked small nose, micrognathia, and small hands and feet . A single 12-bp deletion (del52-55) in the second coding exon of the tubulin cofactor E (TCFE) gene, located on the long arm of chromosome 1, is the cause of HRD among Arab patients . Early recognition and therapy of hypocalcemia is important as is daily antibiotic prophylaxis against pneumococcal infections. Rev Esp Enferm Dig, 2004 Dec, 96(12), 856 - 863 Open lateral internal anal sphincterotomy under local anesthesia as the gold standard in the treatment of chronic anal fissures . A prospective clinical and manometric study; Sanchez Romero A et al.; Background: chronic anal fissure is one of the most frequent proctological disorders in Western populations . Open lateral internal sphincterotomy is one of the therapeutic options accepted as the treatment of choice for chronic anal fissure, since it reduces the hypertonia of the internal anal sphincter (the main etiopathogenic mechanism of fissures), decreases anal pain, and allows the fissure to heal . Material and methods: we carried out a prospective study of 120 patients operated on for chronic anal fissure with open sphincterotomy under local anesthesia at our Proctology Outpatient Unit from 1998 to 2001 . No preoperative studies, bowel preparation, or antibiotic prophylaxis were carried out . All patients were followed up after 1 week, 2 months, 6 months, and 1 year, and underwent an anal manometry before and after surgery . Results: early complications: 3 hematoma-ecchymosis of the wound (2.5%), 3 self-limited hemorrhage events (2.5%) . No hemorrhoidal thrombosis, fistulas, or perianal abscesses occurred . Fissures recurred in nine patients (7.5%) within one year . The initial rate of incontinence of 7.5% at two months dropped down to 5% at six months . The mean resting pressure (MRP) in incontinent patients was lower than in continent patients (55+/-7 mmHg versus 80.7 +/- 21 mmHg) . The difference in mean squeeze pressure (MSP) between incontinent patients and continent patients was not statistically significant . Conclusions: open sphincterotomy under local anesthesia has a long-term rate of healing and a morbidity rate similar to other techniques . It may therefore be considered an effective treatment for chronic anal fissure. J Orthop Surg (Hong Kong), 2004 Dec, 12(2), 184 - 90 Musculoskeletal tissue banking in Singapore: 15 years of experience (1988-2003); Nather A; PURPOSE . To report 15 years' experience of musculoskeletal tissue banking by the National University Hospital Tissue Bank . METHODS . This study describes the development of Singapore's national bone bank since its establishment in 1988 . The bone bank's protocol follows guidelines recommended by the American Association of Tissue Banks and the European Association of Tissue Banks using strict donor selection criteria . Informed consent is obtained from all potential donors for tissue procurement and laboratory tests . Detailed medical history, thorough clinical examination, and chart review is performed for consenting donors . Suitable donors are subjected to tests for hepatitis B, hepatitis C, syphilis, and culture/sensitivity test of tissue for aerobic and anaerobic organisms . For living donors, repeat testing for AIDS and hepatitis C is performed at least 180 days after procurement . Tissue procurement is performed under sterile conditions . Small tissues are procured using the 'sterile double jar technique' and long bones using the 'sterile triple wrap technique', both developed by the author . Deep-frozen bones are gamma irradiated at 25 kilograys . Morsellised bones are lyophilised and gamma irradiated . Meticulous preparation for grafts is performed during transplantation . Antibiotic prophylaxis is used for 2 weeks . RESULTS . The bank maintains a good quality control . In January 2003, it was accredited ISO 9001 status . Up to June 2003, it has procured 440 bones from 440 living donors and 1055 allografts from 63 deceased donors . 854 musculoskeletal transplantations have been performed using tissues processed by the bank . Complication rate encountered was only 2.2% . CONCLUSION . The tissue bank provides high-quality allografts for safe tissue transplantations. Kyobu Geka, 2004 Dec, 57(13), 1171 - 4; discussion 1175-6 {Feasibility of short-term antibiotic prophylaxis after pulmonary resection}; Otani S et al.; How long to administer antibiotics after lung surgery is controversial . We investigated the feasibility of short-duration cefmetazole sodium administration as antibiotic prophylaxis after lung cancer surgery . A total of 40 patients were randomized into either a short-duration prophylaxis group (n=20) that was given 4 g of cefmetazole sodium for 2 days or a long-duration patients group (n=20) that was given 14 g of cefmetazole sodium for 7 days . Daily changes in body temperature, WBC, and plasma CRP concentration were determined for 9 days after surgery . The data were compared statistically between the 2 groups . Postoperative infection occurred in 20% of patients in the short-duration group and in 30% of patients in the long-duration group . The mean hospital stay after surgery was 15.5 days in the short-duration group and 18.6 days in the long-duration group . All variables did not differ significantly between the 2 groups . Our results indicate that short-duration antibiotic administration is an effective prophylactic treatment after surgery for lung cancer. Cad Saude Publica, 2004, 20 Suppl 2, 175 - 89 Epub 2004 Dec 15. {Systematic review and meta-analysis of antibiotic prophylaxis in abdominal hysterectomy.}; Costa RJ et al.; The objective of the present study was to assess the available evidence regarding antibiotic prophylaxis taking the case of abdominal hysterectomy, as an aid to decisions related to coverage and to the development of evidence-based clinical guidelines . Using a previously elaborated protocol, the pertinence and quality of double-blind, randomized, placebo-controlled trials were examined . Clinical heterogeneity among studies was also analyzed . The studies were found to be homogeneous, considering p > 0.10 as the significance level for rejecting heterogeneity . Combination of the 16 selected studies resulted in a summary rate ratio of 0.49 (95%CI: 0.41-0.59), i.e., efficacy of 51%, and in a summary rate difference of 11% (95%CI: 8-14), utilizing the fixed effects model . Results according to the random effects model were very similar . Exploratory analysis of subgroups of single versus multiple doses did not indicate more benefit for multiple dose interventions . Evidence from comparative trials is insufficient to consider third-generation cephalosporins more efficacious than first-generation ones. Acta Otorrinolaringol Esp, 2004 Nov, 55(9), 443 - 5 {Sepsis, arthritis and acute renal failure following adenoidectomy and insertion of drainage tubes}; Gundin Rivas G et al.; We present a six year-old patient suffering of adenoiditis and serous otitis . After surgical intervention, she developed septicemia with arthritis and acute renal failure . We discuss the need to carry out antibiotic prophylaxis in patients without previous risk factors. J Can Dent Assoc, 2004 Dec, 70(11), 769 - 73 Unusual post-extraction hemorrhage in a cardiac patient: a case report; Auluck A et al.; In patients with cyanotic congenital heart disease (CCHD), the need for antibiotic prophylaxis for infective endocarditis is well known among dentists, but not many dentists are aware of the associated hemorrhagic tendencies in such patients . We report a case of post-extraction hemorrhage in a patient with Eisenmenger's syndrome and discuss the importance of more elaborate hematologic evaluation in patients with CCHD before oral surgery. Rev Gastroenterol Disord, 2004 Fall, 4(4), 175 - 85 Management of ascites in patients with end-stage liver disease; Saadeh S et al.; Ascites is the most common complication in patients with decompensated cirrhosis . Approximately 50% of patients with compensated cirrhosis will develop ascites over a 10-year period . This occurrence is an important milestone in the natural history of end-stage liver disease because only 50% of patients survive 2 to 5 years (depending on the cause of cirrhosis) after its onset . Salt restriction and diuretics are the mainstays of therapy, and these measures are effective in approximately 90% of patients . Large-volume paracentesis or transjugular intrahepatic portosystemic shunt can be used in patients with refractory ascites as either a bridge to transplant or as palliation . Cirrhotic patients with ascites should be carefully monitored for the development of bacterial peritonitis, and those at greatest risk should receive antibiotic prophylaxis . When spontaneous bacterial peritonitis is suspected, prompt diagnostic paracentesis followed by broad-spectrum antibiotics and albumin infusion can be life saving . Orthotopic liver transplantation should be considered in all patients with decompensated liver disease with or without ascites. Ann Surg, 2004 Dec, 240(6), 955 - 60; discussion 960-1 The role of antibiotic prophylaxis in prevention of wound infection after Lichtenstein open mesh repair of primary inguinal hernia: a multicenter double-blind randomized controlled trial; Aufenacker TJ et al.; OBJECTIVE: To determine whether the use of prophylactic antibiotics is effective in the prevention of postoperative wound infection after Lichtenstein open mesh inguinal hernia repair . SUMMARY BACKGROUND DATA: A recent Cochrane meta-analysis (2003) concluded that "antibiotic prophylaxis for elective inguinal hernia repair cannot be firmly recommended or discarded." METHODS: Patients with a primary inguinal hernia scheduled for Lichtenstein repair were randomized to a preoperative single dose of 1.5 g intravenous cephalosporin or a placebo . Patients with recurrent hernias, immunosuppressive diseases, or allergies for the given antibiotic were excluded . Infection was defined using the Centers for Disease Control and Prevention criteria . RESULTS: We included 1040 patients in the study between November 1998 and May 2003 . According to the intention-to-treat principle, 1008 patients were analyzed . There were 8 infections (1.6%) in the antibiotic prophylaxis group and 9 (1.8%) in the placebo group (P = 0.82) . There was 1 deep infection in the antibiotic prophylaxis group and 2 in the placebo group (P = 0.57) . Statistical analysis showed an absolute risk reduction of 0.19% (95% confidence interval, -1.78%-1.40%) and a number needed to treat of 520 for the total number of infections . For deep infection, the absolute risk reduction is 0.20% (95% confidence interval, -0.87%-0.48%) with a number needed to treat of 508 . CONCLUSIONS: A low percentage (1.7%) of wound infection after Lichtenstein open mesh inguinal (primary) hernia repair was found, and there was no difference between the antibiotic prophylaxis or placebo group . The results show that, in Lichtenstein inguinal primary hernia repair, antibiotic prophylaxis is not indicated in low-risk patients. Crit Care, 2004 Dec, 8(6), 430 - 2 Epub 2004 Dec. Risk management in patients with severe acute pancreatitis; Gerlach H; Primary or secondary infection of necrotized areas by enteral bacteria is considered a primary cause of mortality in patients with severe acute pancreatitis (SAP) . Indeed, 20-30% of patients die during the course of the disease from multiple organ dysfunction after infection . This is why strategies such as antibiotic prophylaxis and early surgical intervention are appealing, but the controlled data that support these measures are insufficient . On the other hand, environmental risk factors (e.g . smoking, alcohol) and genetic predisposition have been identified; together, these led to SAP being considered a 'multifactorial' disease . However, this description does not help the intensivist to assess risk in the individual patient . A number of prognostic factors in SAP have been identified, and different scoring systems have been developed that include therapy-associated and patient-related factors . Nevertheless, at present no prognostic model is available that takes into account all of these predictors . Moreover, despite several attempts to create guideline-based strategies, SAP is still characterized by rapidly progressive multiple organ failure and high mortality, and both surgical and conservative therapies yield poor outcomes . This brief commentary highlights the most recent developments in risk management for patients with SAP. Chir Ital, 2004 Sep-Oct, 56(5), 705 - 10 Femoral hernia repair with Bard Mesh Dart Plug; Licheri S et al.; Several tension-free femoral hernia repair techniques are currently available with different approaches and prosthetic devices, all of which, however, largely yielding excellent results . The aim of this report was to describe the technical aspects of femoral hernia repair via an infrainguinal approach using the Bard Mesh Dart Plug, and to evaluate the short- and medium-term results in our experience . From May 2000 to December 2003, 25 patients (F/M ratio 2.1:1; mean age 66.4 years) underwent femoral hernia repair with the Bard Mesh Dart Plug . Fourteen patients (56%) were operated on as emergency cases for irreducible hernias and in 3 cases a bowel resection under general anaesthesia was necessary . The other 11 patients underwent surgery on an outpatient day surgery basis under local or spinal anaesthesia . Topical antibiotic prophylaxis was administered in all cases, while short-term prophylaxis with ceftazidime was limited to emergency patients . The main phases of the operation are described . The mean operative time was 40 minutes and the patients were mostly discharged within 2 hours of surgical treatment . No general or local intraoperative complications were registered . Postoperative mortality occurred in a single case (a 98-year-old woman, ASA IV, affected by strangulated hernia) . Postoperative morbidity included 4 seromas and 1 haematoma . No recurrences were observed over a mean follow-up period of 24 months (range: 5-46 months) . The femoral hernia repair with the Bard Mesh Dart Plug is a simple, safe, fast and effective procedure which can often be carried out in the day surgery setting . It can therefore be regarded as a valid alternative to other tension-free techniques. Br J Oral Maxillofac Surg, 2004 Dec, 42(6), 506 - 10 Antibiotic prophylaxis for orthognathic surgery: a prospective, randomised clinical trial; Baqain ZH et al.; A prospective, randomised, placebo-controlled double-blind clinical trial, compared short-term (1 day) and long-term (5 days) antibiotic prophylaxis after orthognathic surgery . Thirty four patients had single jaw or bimaxillary osteotomies and were given two perioperative doses of amoxycillin . Patients were then randomised to receive either placebo or amoxycillin for 5 days in a double-blind manner . Postoperatively the patients were monitored for infection by scoring a series of validated measurements of infection . In the postoperative period four patients required additional antibiotics in the short-term group and two in the long-term group (P = 0.67) . Morbidity scores were higher in the short-term group, at 406 to 264 (P = 0.04), and when individual variables were compared there was a significant difference in the degree of swelling (P = 0.04) . Although a 5-day regimen of antibiotic prophylaxis in orthognathic surgery did not decrease the incidence of postoperative infection significantly, it may decrease the morbidity of the operation. Eur J Heart Fail, 2004 Oct, 6(6), 787 - 91 Clinical trials update from the European Society of Cardiology: SENIORS, ACES, PROVE-IT, ACTION, and the HF-ACTION trial; Cleland JG et al.; This article provides information and a commentary on landmark trials presented at the European Society of Cardiology Congress in August 2004, relevant to the pathophysiology, prevention or treatment of heart failure . The SENIORS trial suggests that nebivolol is well tolerated and effective in older patients with heart failure, even if left ventricular systolic function is not markedly depressed . However, patients aged >75 years appeared to gain less benefit . Further data on the effects of nebivolol on symptoms and quality of life are awaited . Two new trials of long-term antibiotic prophylaxis after myocardial infarction (ACES and PROVE-IT) showed no benefit . The ACTION trial showed no reduction in serious cardiovascular events with nifedipine GITS in patients with chronic stable angina, despite a substantial reduction in blood pressure . The HF-ACTION trial announced that the first 700 patients of a projected 3000 had been randomised to either an exercise program or encouragement to exercise but without a formal program . The primary outcome measure is death or hospitalisation for any reason. Inflammopharmacology, 2004, 12(3), 271 - 5 Anti-inflammatory therapy with a COX-2 inhibitor in Tourette's syndrome; Muller N; An infectious/inflammatory process plays a role in at least a subgroup of patients with tics and Tourette's syndrome (TS) . Successful antibiotic therapy and prophylaxis was described repeatedly . We report the case of a patient suffering from chronic TS who was treated with celecoxib additionally to the antibiotic prophylaxis . This treatment was associated with a continuous improvement of tics and disturbed behaviour, such as aggression and social withdrawal . The withdrawal of celecoxib led to a marked deterioration in TS symptoms while the re-exposition had advantageous therapeutic effects . This result of the treatment with a COX-2 inhibitor supports the view that COX-2 inhibitors show therapeutic benefit in patients suffering from psychiatric disorders in which an inflammatory process is involved in the pathophysiology. Harefuah, 2004 Sep, 143(9), 664 - 8, 694, 693 {Endoscopic treatment of vesicoureteral reflux}; Chertin B et al.; OBJECTIVES: Endoscopic subureteral injection of tissue-augmenting substances, a 15-minute outpatient procedure has become an alternative to long-term antibiotic prophylaxis and surgical intervention in the treatment of vesicoureteral reflux (VUR) in children . MATERIALS AND METHODS: We searched MEDLINE using the words: vesicoureteral reflux, treatment, the long-term results of endoscopic treatment of reflux . We summarized the worldwide data regarding endoscopic treatment of VUR using various tissue-augmenting substances presently available . RESULTS: In terms of effectiveness and long-term successful results, polytetrafluoroethylene is still the most reliable injectable material for the endoscopic treatment of VUR . However, Dextranomer/hyaluronic acid copolymer (Deflux) is a new promising tissue augmenting substance which might be able to replace Teflon in the endoscopic treatment of reflux in terms of a similar to Teflon reflux cessation rate and exhibiting no evidence of migration . CONCLUSION: Endoscopic subureteral polytetrafluoroethylene injection is a simple and effective outpatient procedure for in the treatment of vesicoureteral reflux . No long-term morbidity was observed in our patients with small amounts of injectable polytetrafluoroethylene. J Obstet Gynaecol, 2000, 20(6), 584 - 8 Improving the standards of care for women having caesarean sections; Muthukumarappan Claire Rigby R Johanson P Jones K; Improvement in the uptake of prophylactic antibiotics at caesarean section was chosen as a priority at the 1994 ASQUAM (Achieving Sustainable Quality in Maternity) meeting . The interventions used were guidelines, cyclical audit of cases and a patient-specific reminder stamp in the notes . A more detailed qualitative assessment of standards of communication and outcome was undertaken on a smaller cohort of women . Data on antibiotic prophylaxis were obtained from an audit record completed for every caesarean section undertaken at North Staffordshire Hospital from 1996 to 1998 . Information on morbidity following caesarean section and on counselling was obtained from a review of the case records of a consecutive series of 75 caesarean sections and from a telephone call . In the baseline audit, 75% of women had received antibiotics; this increased to 92% in the remainder of 1996, 95% in 1997 and 98% in 1998 . Fifty-eight of the 75 women were contactable by telephone (77%); of these 16 (28%) had a 'wound infection', 12 of which developed after discharge from hospital . Only 25 women (43%) remembered being counselled about the caesarean section . It is possible to achieve significant improvements in the quality of care for women having caesarean sections through the use of local guidelines, cyclical audit and reminder stamps . However, this audit, with community follow-up, raises questions about the adequacy of single dose prophylaxis . It also suggests the need for improved compliance with RCOG communication following caesarean section guidelines. J Obstet Gynaecol, 1997, 17(5), 439 - 43 Audit of infective morbidity following caesarean section at a district general hospital; R Pirwany And T Mahmood I; This paper sets out to audit infectious morbidity before and after introduction of a policy of antibiotic prophylaxis following emergency and elective caesarean section in a district general hospital in Scotland with approximately 3800 deliveries a year . In the first 'loop of audit', case notes of 200 consecutive patients managed during 1992 were studied . Audit loop was completed by studying 224 patients prospectively in 1993-94 following the introduction of new guidelines, which required the intraoperative administration of a single dose of intravenous antibiotic, following delivery of the baby . A significantly greater proportion of women received prophylactic antibiotics in 1993 compared with 1992 (81% vs . 14%; Diff= 67%; 95% CI 60%, 74%) . The incidence of infection related morbidity was significantly reduced after routine antibiotic prophylaxis (28,5% vs . 16%; Diff= 12.5%, 95% CI=(4.60%,20.4%) . The incidence of wound infection was halved in 1993 (9% vs . 17.5% in 1992) . None of the patients in 1993 had a serious postoperative infection . Postnatal stay was significantly shorter in 1993 compared with 1992 ( P 0.0001) . Although the target of adherence to the guidelines of 90% coverage was not met, this audit demonstrates the benefits of antibiotic prophylaxis for emergency and elective caesarean sections . Further reduction in morbidity may be obtained by strictly implementing the guidelines, and also by considering the use of multiple doses of antibiotics. Obstet Gynecol Surv, 2004 Nov, 59(11), 761 - 763 Higher Rates of Post-partum Complications in HIV-Infected Than in -Uninfected Women Irrespective of Mode of Delivery: European HIV in Obstetrics Group; European HIV in Obstetrics Group; Elective cesarean section (CS) before labor and before membrane rupture substantially lowers the risk of transmitting HIV to the child . The advent of highly active antiretroviral therapy, however, has raised the question of whether CS still is indicated even if the viral load is low or absent . This investigation collected data prospectively on HIV-infected women who delivered at 14 European HIV reference centers . In 2 matched case-control studies, vaginal delivery and elective CS were compared in both HIV-infected and uninfected control women . Matched pairs of women delivering vaginally totalled 250, whereas 158 women had elective CS . The overall rate of complications was 29% in HIV-infected women and 19% in uninfected control women, for an odds ratio (OR) of 1.7 . Complication rates were 43% for uninfected women having CS and 13% for women who delivered vaginally (OR, 5.1) . Women delivering vaginally had no major complications, but HIV-infected women had an OR for puerperal fever of 4.5 . The risk was greatest after mediolateral episiotomy . Five of 6 major complications in the CS group occurred in case women and 1 in an uninfected woman (OR, 5.1) . The OR for minor complications in case women was 1.5 compared with control women . These mostly involved anemia that did not require transfusion . HIV-infected women were at significantly greater risk of minor complications (OR, 1.5), but their increased risk of major complications was not statistically significant . Hospital stays were longer after CS, regardless of infection status . HIV-infected pregnant women ae at an increased risk of postpartum complications after either vaginal delivery or CS . They should be aware of the risk of both complications and vertical transmission of infection so that they may participate in deciding on vaginal delivery or CS . Antibiotic prophylaxis should be considered for these women. Cochrane Database Syst Rev . 2004 Oct 18;(4):CD003769. Antibiotic prophylaxis for hernia repair; Sanchez-Manuel FJ et al.; BACKGROUND: The use of antibiotic prophylaxis for hernia repair is currently a controversial issue given the disparity among study results in this area . OBJECTIVES: The objective of this systematic review was to clarify the effectiveness of antibiotic prophylaxis in reducing postoperative wound infection rates in elective open inguinal hernia repair . SEARCH STRATEGY: Searches in the Cochrane Colorectal Cancer Group specialized register were conducted crossing the terms herni* and inguinal or groin and the terms antimicr* or antibiot* , as free text and MeSH terms . A similar search in Medline (WebSPIRS from Silver Platter, January/1966 to March/2004) and Embase (1976 to December/2003) was conducted using the following terms: #1 antibiotic* or antimicrob* or anti infecti* or antiinfecti*; #2 prophyla* or prevent*; #3 #1 and #2; #4 clean and (surgery or tech* or proced*); #5 herni*; #6 (wound infection) and #4; #7 #3 and (#4 or #5 or #6) . Reference lists of the included studies were checked to identify additional studies . SELECTION CRITERIA: Only randomized clinical trials were included . DATA COLLECTION AND ANALYSIS: Eight randomized clinical trials were identified . Three of them used prosthetic material for hernia repair (hernioplasty) whereas the remaining studies did not (herniorraphy) . Pooled and subgroup analysis were conducted depending on whether prosthetic material was or not used . A random effects model was used in the analysis . MAIN RESULTS: The total number of patients included was 2907 (treatment group: 1421, control group: 1486) . Overall infection rates were 2.88% and 4.3% in the prophylaxis and control groups, respectively (OR 0.65, 95%CI 0.35 - 1.21) . The subgroup of patients with herniorrhaphy had infection rates of 3.78% and 4.87% in the prophylaxis and control groups, respectively (OR 0.84, 95%CI 0.53 - 1.34) . The subgroup of patients with hernioplasty had infection rates of 1.2% and 3,3% in the prophylaxis and control groups, respectively (OR 0.28, 95%CI 0.02 - 3.14) . REVIEWERS' CONCLUSIONS: Based on the results of this meta-analysis, there was no clear evidence that routine administration of antibiotic prophylaxis for elective inguinal hernia repair reduced infection rates. Heart, 2004 Nov, 90(11), 1321 - 5 Prevalence and development of additional cardiac abnormalities in 1448 patients with congenital ventricular septal defects; Glen S et al.; OBJECTIVE: To determine by modern echocardiographic techniques the prevalence and development of cardiac abnormalities associated with ventricular septal defect (VSD) . METHODS: Consecutive patients referred to a tertiary centre for paediatric cardiology and attenders at an adult congenital heart disease clinic had details of clinical outcome prospectively recorded . Patients with VSD in association with conotruncal abnormalities, atrioventricular septal defects, and univentricular heart were not included in the study . RESULTS: 1448 patients with VSD were assessed between 1991 and 1998 . 1127 (78%) patients had isolated defects; of these 862 (76%) were perimembranous and 265 (24%) were muscular . Of the remainder, 284 (19.6% of the total population) patients had VSD associated with one other significant cardiac abnormality: 35 (2.4%) with two and two (0.1%) with three other abnormalities . The most common associated cardiac abnormalities were infundibular pulmonary stenosis (5.8%), aortic valve prolapse (3.6%), pulmonary valvar stenosis (2.7%), osteum secundum atrial septal defect (2.2%), persistent ductus arteriosus (1.9%), and coarctation of the aorta (1.5%) . In the cohort of 743 patients followed up from birth, cumulative mortality was 4% by the age of 8 years and most deaths occurred within the first year of life in infants with associated genetic abnormalities such as trisomy 13 or 18 . Of the 594 patients attending the adult congenital clinic with VSD, aortic regurgitation due to aortic root prolapse developed in 45 (7.6%) patients . Most of these cases were detected before the patient was 30 years old . CONCLUSIONS: In 22% of patients with congenital VSD there were significant associated cardiac abnormalities . Some of these abnormalities, such as aortic prolapse and regurgitation or infundibular pulmonary stenosis, may develop or progress subsequently and therefore should be sought during the initial assessment and monitored during follow up . Follow up to the age of 30 years allows the detection of most cases of aortic regurgitation . The prognosis from VSD is excellent and the risk of endocarditis in a population informed of the need for antibiotic prophylaxis is small. Fertil Steril, 2004 Oct, 82(4), 793 - 4 Endometrial endotoxin, assisted reproductive technology, and preterm birth; Iams JD; The failure of antibiotic prophylaxis to reduce preterm birth in women at risk and the increased rate of preterm birth in singleton pregnancy after ART may have a common explanation: persistent bacterial endotoxin in the endometrium, reported by Kamiyama et al . as an explanation for reduced fertility. Surgery, 2004 Oct, 136(4), 833 - 41 Mutual reporting of process and outcomes enhances quality outcomes for colon and rectal resections; Galandiuk S et al.; BACKGROUND: This report describes the favorable results of mutual reporting of process and outcome of care for major resections of the colon and rectum, one of six focal points for the Center for Medicare Services studies seeking to broadly reduce death and complications and enhance consistency of care . METHODS: A group of 66 surgical specialists in 9 cities in Kentucky reported cases to a quality improvement network over the past 5 years, and these data were supplemented by chart verification and patient satisfaction surveys . Consecutive colon and rectal resections (N=309) were reported by 23 general and colorectal surgeons . Eighty percent of the operations were performed by 4 surgeons . RESULTS: Forty-four percent of the patients had colorectal cancer, and 27% had diverticulitis; 84% of colon resections were performed by general surgeons whereas 77% of rectal resections were performed by colorectal specialists . Audit showed 6 leaks/fistulas and 16 patients who required unscheduled readmissions . Eleven patients had prolonged ileus . Only 2 patients died . Consensus among network surgeons included the following: 1 . Mutual reporting led to a narrowing of choices and improved timing for antibiotic prophylaxis . 2 . Standard order sets in one hospital led to a shortened duration of stay . 3 . Surgeon participation in a quality improvement network led to a safe reduction in preoperative cardiology consultation . 4 . More patients arrive with all evaluations complete due to increased utilization of preoperative anesthesiology clinics . 5 . Enhanced operating room throughput has been achieved by joint anesthesia/surgery reporting and includes reduced time to induction of anesthesia and in the Post-Anesthesia Care Unit and lessened use of expensive postoperative antiemetics . 6 . Reported medication errors were reduced by standard order sets, as were other reported adverse events . CONCLUSIONS: Practicing surgeons meet and/or exceed published benchmarks for colorectal resections and can further improve their outcomes by standardization and refinement of orders and procedures and improved collaboration with anesthesiologists. Qual Saf Health Care, 2004 Oct, 13(5), 384 - 7 Use of a preprinted sticker to improve the prescribing of prophylactic antibiotics for hip fracture surgery; Ritchie S et al.; PROBLEM: Antibiotic prophylaxis has been shown to reduce the number of postoperative infections following surgery for hip fracture . At Auckland Hospital the policy for antibiotic prophylaxis for hip fracture surgery is for the patient to receive the first dose of antibiotic at the induction of anaesthesia followed by two more doses at 8 hour intervals . A previous audit found that patients often received too many doses of antibiotic . A retrospective audit was performed of 100 patients undergoing surgery for a hip fracture . The primary problem was over-prescribing; 68 patients (68%) received more than three doses . The number of patients who received three doses according to the guidelines was 29 (29%, 95% CI 21 to 40) . SETTING: Auckland Hospital which provides acute orthopaedic services for a population of 500,000 . STRATEGY FOR CHANGE: A sticker was introduced with the prescription printed on it . The sticker was applied to the medication chart by the anaesthetist when the initial dose of antibiotic was given . Charts of a further 100 patients were reviewed after the introduction of the sticker and compared with those from another hospital in Auckland where the sticker was not used . EFFECTS OF CHANGE: The number of patients who received three doses, in accordance with the guidelines, improved to 74 (74%, 95% CI 64 to 82, p<0.001) . These changes were observed even though the sticker was only used in 44 patients (44%, 95% CI 34 to 54) . At the other hospital the number of patients who received three doses was 10 (20%, 95% CI 10 to 42) and 13 (26%, 95% CI 15 to 40, p = 0.37) for the same two periods . LESSONS LEARNT: The use of a preprinted sticker is a simple intervention which improves the use of antibiotic prophylaxis at the time of surgery . This improvement occurred even though the sticker was used in slightly fewer than half the cases. Oral Oncol, 2004 Oct, 40(9), 862 - 71 The use of implant retained mandibular prostheses in the oral rehabilitation of head and neck cancer patients . A review and rationale for treatment planning; Schoen PJ et al.; Surgical treatment of malignancies in the oral cavity (tongue, floor of the mouth, alveolus, buccal sulcus, oropharynx) often results in an unfavourable anatomic situation for prosthodontic rehabilitation . The outcome is a severe disturbance of oral functioning despite the improved surgical techniques for reconstruction that are currently available . Radiotherapy, which often is applied postsurgically, worsens oral functioning in many cases . Main problems that may hamper proper prosthodontic rehabilitation of these patients include a severe reduction of the neutral zone, an impaired function of the tongue, and a very poor load-bearing capacity of the remaining soft tissues and mandibular bone . Many of these problems can, at least in part, be diminished by the use of endosseous oral implants . These implants can contribute to the stabilisation of the prostheses and intercept the main part of the occlusal loading . Surgical interventions after radiotherapy are preferably avoided because of compromised healing, which may lead to development of radionecrosis of soft tissues and bone as well as to increased implant loss . If surgical treatment after radiotherapy is indicated, measures to prevent implant loss and development of radionecrosis have to be considered e.g . antibiotic prophylaxis and/or pre-treatment with hyperbaric oxygen (HBO) . To avoid this problem, implant insertion during ablative surgery has to be taken into consideration if postoperative radiotherapy is scheduled or possibly will be applied . This approach is in need of a thorough pre-surgical examination and multidisciplinary consultation for a well-established treatment planning . The primary curative intent of the oncological treatment and the prognosis for later prosthodontic rehabilitation have to be taken into account too. Can J Urol, 2004 Aug, 11(4), 2352 - 3 Septic shock after transrectal ultrasound guided prostate biopsy . Is ciprofloxacin prophylaxis always protecting? Binsaleh S, Al-Assiri M, Aronson S, Steinberg A. We report a case of septic shock complicating transrectal ultrasound guided prostate biopsy despite antibiotic prophylaxis with ciprofloxacin . Patient was recently treated with the same agent for other infectious illnesses. Pediatr Nephrol . 2004 Sep 17; {Epub ahead of print} Catheter-related infections in children treated with hemodialysis; Paglialonga F et al.; Infectious complications of the central venous catheter (CVC) are a major source of morbidity among children treated with hemodialysis (HD), with catheter-related bloodstream infections (CRBSI) being the most important clinical manifestations . As only a few studies of children on HD have been published, the management of CVC-related infections in this population is mainly based on data derived from adults or occasionally from children not affected by end-stage renal disease (ESRD) . The aim of this review is to discuss current knowledge concerning the epidemiology, prevention, and treatment of catheter-related infections in children on HD . Catheters impregnated with antibiotics/antiseptics, lock antibiotic prophylaxis, nasal mupirocin, and the application of ointments at the exit-site have all been proposed as means of reducing the risk of CVC infections, but their real efficacy in the pediatric population has not yet been demonstrated . Furthermore, it is not clear how long antibiotic therapy should be continued, and there is still debate as to whether the catheter has to be removed . We propose some practical guidelines for the management of CRBSI in children with percutaneously inserted and surgically implanted HD catheters, but a number of unresolved clinical issues still remain, which will require prospective clinical trials specifically performed in pediatric patients with ESRD. J Chin Med Assoc, 2004 Jun, 67(6), 275 - 80 Effectiveness of short-term antibiotic prophylaxis on postoperative recovery course after pulmonary lobectomies; Lin CS et al.; BACKGROUND: Postoperative pneumonia is a major cause of mortality and morbidity after lung surgery . The effectiveness of prophylactic antibiotics for preventing postoperative pneumonia and the recovery course after pulmonary lobectomy is still not clarified yet . We conducted this study to evaluate the effectiveness of prophylactic antibiotics on the post-operative recovery course after pulmonary lobectomies . METHODS: Forty-five cases undergoing pulmonary lobectomies between June 2002 and January 2003 were enrolled in this prospective study . Each patient received prophylactic antibiotics of cefuroxime and sisomicin . Sputum culture upon admission and swab culture from the bronchus cut-end during operation were obtained . The clinical vital signs including heart rates, respiratory rates and core body temperature in the postoperative recovery courses were analyzed . RESULTS: Four (8.9%) patients developed pneumonia after lobectomies, and pneumonia occurred only in patients who had positive culture results from bronchial cut-end . The organisms cultured from the sputum seemed to be controlled by prophylactic antibiotics . All the organisms cultured in the bronchus cut-end differed from those in the sputum; it denoted these pathogens were inoculated during anesthesia for surgical operation . The postoperative vital signs including tachycardia and fever improved gradually in the initial 3 days . Patients with pneumonia sustained significant higher fever than the non-pneumonic patients during postoperative course . CONCLUSIONS: The short-term combination of cefuroxime and sisomicin offers sufficient effectiveness in prophylaxis of pneumonia after pulmonary surgery . Positive bronchial cut-end cultures were related to the post-lobectomy pneumonia significantly . Body temperature was the most useful presenting vital sign for early detection of the postoperative pneumonia. Eur J Orthod, 2004 Aug, 26(4), 443 - 7 The prevalence of bacteraemia on removal of fixed orthodontic appliances; Burden DJ et al.; This study investigated the prevalence of bacteraemia on removal of fixed appliances . Venous blood samples were taken before and after debonding and debanding for 30 patients (mean age 17 years 8 months) who had worn fixed appliances for an average of 19 months . Before removal of the fixed appliances, bacteraemia was detected in one of the 30 subjects (3%) and in four subjects (13%) following removal of their fixed appliances . The 95 per cent confidence intervals for the prevalence of post-debanding bacteraemia were 3.8 and 30.7 per cent . No significant relationship was detected between the mean plaque scores (t = -0.65, P = 0.52) or the mean gingival scores (t = 0.75, P = 0.46) and the occurrence of bacteraemia . The prevalence of bacteraemia detected following debanding in this study is considerably lower than reported for dental procedures traditionally covered by antibiotic prophylaxis guidelines. Leuk Lymphoma, 2004 Jun, 45(6), 1141 - 7 Fludarabine, cyclophosphamide and mitoxantrone for untreated follicular lymphoma: a report from the non-Hodgkin's lymphoma co-operative study group; Santini G et al.; The aim of the study was to determine the safety and efficacy of the combination of fludarabine (FLU), cyclophosphamide (CY) and mitoxantrone (FLU/CY/MITO) in untreated follicular lymphomas (FL), Sixty patients with newly diagnosed stage II bulky to IV FL, median age 59 years (range 36-70), received FLU/CY/MITO regimen (FLU 25 mg/m2 days 1-3, CY 300 mg/m2 days 1-3, Mito 10 mg/m2 day 1) . Patients received antibiotic oral prophylaxis during all treatments, and growth factors (G-CSF) when grade III granulocytopenia (WHO) occurred . The overall response rate was 87%: 46 patients achieved complete response (CR) (77%), 6 a partial response (10%) and 8 were non-responders . Fifty patients are surviving with a median observation time of 31 months . The 4-year estimated probability of overall survival and failure-free survival were 78.2% and 45% respectively . Thirty-five patients (58%) are still in CR . Sixty percent of patients experienced grade III-IV granulocytopenia . Two patients suffered grade III pulmonary infection and one grade III liver toxicity . In a subset of 46 patients, bcl-2 translocation was positive in bone marrow (BM) and/or peripheral blood (PB) of 36 patients . At the end of treatment, 25 of these patients had CR and 19 (76%) converted to polymerase chain reaction (PCR) negativity . FLU/CY/MITO regimen showed a high level of activity in follicular lymphoma . Toxicity, mainly hematological, was acceptable and the treatment was made feasible by the use of antibiotic prophylaxis and G-CSF . Significant non-hematological toxicities were seen, but no patients died . The conversion of bcl-2 from positive to negative by PCR in BM and/or PB suggests a possible role for this treatment in clearing minimal residual disease and improving patients' outcome. Otol Neurotol, 2004 Sep, 25(5), 720 - 2 Short-term versus long-term antibiotic prophylaxis in cochlear implant surgery; Basavaraj S et al.; OBJECTIVE: The objective of this study to evaluate antibiotic prophylaxis options for cochlear implant surgery . Does long-term antibiotic prophylaxis have any advantage over a single perioperative dose in preventing postoperative infection? STUDY DESIGN: We conducted a retrospective case review . PATIENTS: A total of 292 adult and pediatric patients who underwent cochlear implantation during a 15-year period (1988-2003) were reviewed . MAIN OUTCOME MEASURE: Minor and major postoperative wound infections in first 4 weeks . RESULTS: There were four major and eight minor complication among 292 patients (complication rate 4.1%) . The infection rate was higher in patients who had either C incision (11.1%) or extended endaural incision (7.5%) and in patients with a preexisting medical condition . The infection rate was also higher in patients who had long-term antibiotics (5.6% and 13% in the 5-d and 7-d regimes) compared with short-term (single-dose) group . CONCLUSION: Long-term antibiotic prophylaxis did not have any advantage over single perioperative dose . Predisposing medical conditions and extensive surgical incisions were associated with a greater severity of infections and higher risk of wound complications. Hepatology, 2004 Sep, 40(3), 652 - 9 Improved survival after variceal bleeding in patients with cirrhosis over the past two decades; Carbonell N et al.; Over the past two decades, new treatment modalities have been introduced for the management of variceal bleeding . The aim of this retrospective study in a single center was to assess whether these treatments have improved the prognosis for cirrhotic patients with variceal bleeding . We reviewed the clinical records of all patients with cirrhosis admitted to our Liver Intensive Care Unit due to variceal bleeding during the years 1980, 1985, 1990, 1995, and 2000 . Whereas balloon tamponade was still the first-line treatment in 1980, patients treated in 2000 received a vasoactive agent, an endoscopic treatment, and an antibiotic prophylaxis in, respectively, 90%, 100%, and 94% of cases . The in-hospital mortality rate steadily decreased over the study period: 42.6%, 29.9%, 25%, 16.2%, and 14.5% in 1980, 1985, 1990, 1995, and 2000, respectively (P < .05) . Mortality decreased from 9% in 1980 to 0% in 2000 in Child-Turcotte-Pugh class A patients, from 46% to 0% in class B patients, and from 70% to 32% in class C patients . This improved survival was associated with a decrease of rebleeding (from 47% in 1980 to 13% in 2000) and bacterial infection rates (from 38% to 14%) . On multivariable analysis, endoscopic therapy and antibiotic prophylaxis were independent predictors of survival . In conclusion, in-hospital mortality of patients with cirrhosis and variceal bleeding decreased threefold over the past two decades, in concurrence with an early and combined use of pharmacological and endoscopic therapies and short-term antibiotic prophylaxis . J Cataract Refract Surg, 2004 Sep, 30(9), 1960 - 5 Investigation into postoperative endophthalmitis and lessons learned; Mandal K et al.; PURPOSE: To describe an approach to the investigation of a series of endophthalmitis cases to determine whether there was a true outbreak . SETTING: Outpatient facility, Sunderland, England . METHODS: Different approaches to statistical analysis of the probability of infrequent events being due to chance occurrence are described . Potential factors leading to an outbreak were reviewed . RESULTS: Bayesian statistical analysis was shown to be appropriate in the determination of an endophthalmitis outbreak . The only factor found to account for the outbreak was the operating surgeon's recent abandonment of subconjunctival antibiotic prophylaxis . This decision was based on the absence of good evidence that subconjunctival antibiotic injection is effective in prophylaxis . These endophthalmitis cases demonstrate that the absence of evidence for effect is not the same as there being no effect . CONCLUSIONS: Bayesian statistical analysis has a place in determining whether an outbreak has occurred . Withdrawing treatment simply on the basis of a lack of good evidence can lead to undesirable outcomes. Inflamm Res, 2004 Aug, 53 Suppl 2, S126 - 9 Epub 2004 Aug 10. Effects of G-CSF and antibiotic prophylaxis in a 2 x 2 factorial design on outcome in septic rats; Bauhofer A et al.; OBJECTIVE: In a recently completed randomised clinical trial in patients with colorectal cancer resections the combination of the granulocyte-colony stimulating factor (G-CSF) + cefuroxime/ metronidazole (cef/met) was superior to ofloxacin/metronidazole (ofl/met) . These combinations were used to confirm the clinical data and to validate the concept of clinic modelling randomised trials (CMRTs) in a rat model of intra-abdominal sepsis . SUBJECTS: 80 male Wistar rats were randomised in a 2 x 2 factorial study design . TREATMENT: All animals (n = 20/group) received anaesthesia, antihistamines, antibiotic prophylaxis, peritoneal contamination and infection . Groups were: 1) G-CSF + cef/met; 2) placebo + cef/ met; 3) G-CSF+ofl/met; 4) placebo + ofl/met . G-CSF (20 g/kg) prophylaxis was applied three times . METHODS: Survival at 120 h was analysed with the Kaplan Meier method . RESULTS: Survival rate was best in the G-CSF + cef/met group with 75% and was significantly improved compared to the cef/met placebo group, in which only 42% survived (P < 0.05) . Survival rate between both G-CSF groups was similar being 75% in the cef/met and 72% in the ofl/met group . P = 0.10) . Ozone increased TNF-alpha and MIP-2 after infection: 127 +/- 23 pg/ml and 94 +/- 19 pg/ml (control group: 398 pg/ml and 369 pg/ml; P < 0.002 and P < 0.01) . IL-6 levels were similar in both groups . CONCLUSIONS: The results of this CMRT confirmed the result of our clinical G-CSF trial in that G-CSF prophylaxis was most efficacious in combination with cef/met to improve the outcome . Inflamm Res, 2004 Aug, 53 Suppl 2, S116 - 21 Epub 2004 Aug 10. Antibiotic prophylaxis influences cardiovascular stability in complicated surgery; Celik I et al.; OBJECTIVE: Antibiotic prophylaxis is used in many surgical procedures but there are frequent cardiovascular instabilities following antibiotics in perioperative period . A clinic modelling randomised trial (CMRT) in pigs was developed to compare the effects of 2 commonly used antibiotic combinations on cardiovascular stability during major surgery . MATERIALS AND METHODS: Thirty pigs (both sexes) were randomised into 3 groups, receiving either saline (placebo), co-amoxiclav or cefuroxime/metronidazole in clinically relevant doses as antibiotic prophylaxis . A laparotomy was performed and the abdomen remained open . Surgical complications were simulated by removing one third of the blood volume . For fluid resuscitation, 500 ml hetastarch (HAES(TM)) were infused rapidly (therapy of complication) and polymyxin B (15 mg/kg bodyweight) was applied for induction of histamine release reactions (complication of therapy) . The main end points were histamine release reactions, these were classified by 2 blinded investigators . RESULTS: Neither cardiovascular changes nor histamine release reactions were detected immediately after the administration of antibiotics or placebo alone . Plasma histamine concentrations increased after bleeding in the co-amoxiclav group (p < 0.05) . After fluid resuscitation and induction of anaphylactoid reactions, the median histamine release and cardiovascular changes were not significantly different between the groups . However, the incidence of typical histamine release related reactions differed significantly between the groups: 8/10 for the controls, 6/10 in the co-amoxiclav and 2/10 in the cefuroxime/metronidazole group (p < 0.05) . CONCLUSIONS: The stability and reproducibility of this model clearly demonstrated the concept of a 'clinic modelling randomised trial' as a useful tool . Antibiotic prophylaxis influences the organism's capability to cope with intraoperative bleeding and fluid resuscitation problems . Indeed antibiotic prophylaxis may be beneficial . These effects of antibiotics could only be demonstrated in complex surgical models . Thus new antibiotics should be investigated in complex animal models prior to prospective randomised clinical trials or usage in clinical practice . Infez Med, 2004 Mar, 12(1), 65 - 8 Pneumococcal bacterial peritonitis in aids patient following esophageal endoscopic variceal sclerotherapy . Case report and recommendations for antibiotic prophylaxis; Ferretto R et al.; Chronic viral hepatitis is a common co-morbidity in Italian HIV-infected patients . It represents an important emergent associated risk of mortality in patients with HIV infection whose survival has increasingly improved by highly active antiretroviral therapy . In such patients further infectious predisposing factors, related to hepatic failure and esophageal haemorrage, worsen the immunodeficiency due to HIV infection . Bacterial peritonitis has been reported in 3% of patients after esophageal endoscopic injection sclerotherapy emergency and in 0,5% of elective procedure . Combined antibiotic prophylaxis with aminopenicillins beta-lactamase inhibitor and fluoroquinolone should be regularly given to AIDS patients with decompensated liver cirrhosis who have esophageal variceal bleeding . A case of a pneumococcal bacterial peritonitis following emergency esophageal endoscopic sclerotherapy for variceal bleeding in patient with AIDS and liver cirrhosis with ascites is reported. Schweiz Monatsschr Zahnmed, 2004, 114(6), 601 - 13 {Antibiotic prophylaxis and therapy in dental surgery}; Lambrecht JT; Antibiotics are used for prophylactic and therapeutic indications . Since the conditions caused by bacteria resistance are in constant modification the regime has to be verified at regular intervals and adapted to the new conditions . The prescription of antibiotics in oral surgery and medicine should be administrated with reservation . The use of antibiotic prophylaxis is imperatively required during treatment of high-risk patients, especially in cases of endocarditis . An antibiotic therapy is absolutely indicated in acute osteomyelitis as well as in spreading and multispacial abscesses. Int J Clin Pract, 2004 Jun, 58(6), 632 - 4 An audit of antibiotics usage and their effect on MRSA infection or colonisation following percutaneous endoscopic gastrostomy in a district general hospital; Ogundipe OA et al.; Percutaneous endoscopic gastrostomy (PEG) has become a widely practised procedure to maintain long-term nutrition in patients with a variety of medical conditions . Incidence of infection and the usage of prophylactic antibiotic continue to remain an area of debate . Guidelines in gastroenterology on antibiotic prophylaxis published by the British Society of Gastroenterology recommend the use of prophylactic antibiotic prior to placement of PEG tube (1) . There has been an alarming rise in the incidence of MRSA, which has jumped from a reported 2% in 1992 to about 42% in 2001 in England & Wales . Use of antibiotic may lead to emergence of MRSA in debilitated patients requiring PEG feeding . This audit addresses some of the problems encountered in a small district general hospital. J Occup Environ Med, 2004 Aug, 46(8), 801 - 11 Experience in the medical management of potential laboratory exposures to agents of bioterrorism on the basis of risk assessment at the United States Army Medical Research Institute of Infectious Diseases (USAMRIID); Rusnak JM et al.; Experience in managing laboratory exposures to potential agents of bioterrorism is limited . The United States Army Medical Research Institute of Infectious Diseases reviewed laboratory exposures involving these agents (1989 to 2002) to assess the effectiveness of medical management . The evaluation of 234 persons (78% vaccinated) for exposure to 289 infectious agents revealed 5 confirmed infections (glanders, Q fever, vaccinia, chikungunya, and Venezuelan equine encephalitis) . Postexposure antibiotic prophylaxis was given for most moderate- or high-risk bacterial exposures (41/46; 89%); most unvaccinated minimal-risk (7/10; 70%), and subsets of vaccinated minimal-risk exposures (18/53; 34%) but generally not negligible-risk exposures (6/38; 16%) . Vaccine "breakthroughs" were not unexpected (enzootic Venezuelan equine encephalitis, localized vaccinia) or presented with mild symptoms (Q fever) . A multifaceted policy of personal protective measures, vaccination, early assessment, and postexposure antibiotic prophylaxis was effective in minimizing morbidity and mortality in at-risk laboratory workers. Chir Ital, 2004 May-Jun, 56(3), 397 - 402 Surgical infections after laparoscopic cholecystectomy: ceftriaxone vs ceftazidime antibiotic prophylaxis . A prospective study; Colizza S et al.; The incidence of surgical infections after laparoscopic cholecystectomy is reported to be <2%, because of the minimal trauma due to this approach . We report the results of a prospective study of antibiotic prophylaxis in laparoscopic cholecystectomy, comparing ceftriaxone vs ceftazidime . From Jan 1 to Dec 31 2002 a consecutive series of 242 cholecystectomies were performed, consisting in 18 open cholecystectomies and 224 laparoscopic cholecystectomies, 7 of which (3.1%) were converted to open cholecystectomies for technical and/or anatomical reasons . One hundred and eleven patients received 1 g i.v . ceftazidime 1 h before surgery, and 105 patients 1 g i.v . ceftriaxone on an alternate basis . Thirty-nine patients (17.4%) with acute cholecystitis received at least one booster dose at the end of the operation; 30 out of 39 were given further therapy for 2-3 days, i.e . 1 g i.v . bid . Twenty-two patients treated elsewhere with ceftriaxone or ceftazidime before surgery were transferred to another prophylactic regimen . The final diagnosis in the laparoscopic cholecystectomy group was 219 bile stones, 3 adenomas, and 2 occult carcinomas . We had 4 complications (1.8% of 217 laparoscopic cholecystectomies), 2 of which were minor (infection of the umbilical access by S . aureus) and 2 major (1 biliary fistula {accessory duct} and 1 acute pancreatitis), both treated conservatively . Positive bile cultures (27 cases) were unrelated to the clinical course . The incidence of infections after laparoscopic cholecystectomy in our prospective series was <2% . Ceftriaxone is confirmed as the gold standard in biliary tract surgery, but ceftazidime was equivalent (no statistical difference between the two antibiotics, P=0.59 NS) . Ultra-short prophylaxis is enough in most cases, except in cholecystitis . We found no correlation between positive bile cultures and surgical infections after laparoscopic cholecystectomy . The umbilicus was the preferred site of infection in obese patients after the laparoscopic procedure . Major complications are usually related to technical pitfalls. Minerva Cardioangiol, 2004 Aug, 52(4), 255 - 61 Perioperative assessment and management of patients with valvular heart disease undergoing noncardiac surgery; Bach DS et al.; Valvular heart disease in a variety of forms is not uncommon, especially among older patients undergoing noncardiac surgery, and can be associated with increased perioperative cardiac risk . Patients with aortic stenosis are at greatest risk, although other valve lesions also can pose the risk of increased perioperative morbidity . During preoperative evaluation, attention to the presence, nature and severity of valvular heart disease allows appropriate perioperative monitoring and therapy with a goal to minimize the risk of perioperative cardiac morbidity and mortality associated with noncardiac surgery . Appropriate antibiotic prophylaxis reduces the risk of infective endocarditis . Finally, some patients with valvular heart disease and all patients with a mechanical valve prosthesis require long-term anticoagulation, which must be managed during the perioperative period. Bull Cancer, 2004 May, 91(5), 445 - 8 {A prospective evaluation of antibiotic prophylaxis efficacy for breast cancer surgery following previous chemotherapy}; Penel N et al.; Use of antibiotic prophylaxis (AP) in clean breast cancer surgery is still controversial . We assessed the efficacy of preoperative AP in a prospective study of 171 clean breast cancer procedures following previous anticancer chemotherapy . From June 1998 to July 2001, we analyzed 171 procedures . In 133 cases . AB with cefuroxime was performed . Wound infection rate was 3 out of 171 procedures (WI rate of 2/131 with AP compared with 1/37 without AP, p = 1.0) . This study suggests that AP is not systematically required in breast cancer surgery following previous anticancer chemotherapy. Ann Hepatol, 2002 Jul-Sep, 1(3), 102 - 20 Drug treatment for portal hypertension; Mela M et al.; Pharmacological treatment of portal hypertension has played an increasing clinical role in the past 20 years . In the setting of acute variceal bleeding, drug therapy should be considered the initial treatment of choice and can be administered as soon as possible; even during the transfer of the patient to hospital . Several recent trials have reported similar efficacy to emergency sclerotherapy, therefore drug treatment should no longer be considered as a "stop gap" therapy until definitive endoscopic therapy is performed but continued for several days . Antibiotic prophylaxis is an integral part of therapy as it reduces mortality and should be instituted from admission . Non selective b-blockers are the treatment of first choice for secondary and primary prevention . If they are contraindicated or non tolerated banding ligation can be used . There is less evidence for the benefit of ligation for primary prophylaxis . The use of haemodynamic targets for reduction in hepatic venous pressure gradient response need further study, and surrogate markers of pressure response need evaluation Am J Cardiol, 2004 Aug 1, 94(3), 386 - 9 Age-related prevalence of cardiac valvular abnormalities warranting infectious endocarditis prophylaxis; Croft LB et al.; The goal of our study was to determine the prevalence of older patients with cardiac valvular abnormalities warranting endocarditis prophylaxis . We performed a retrospective analysis of 1,000 randomly selected echocardiograms (inpatients and outpatients) from our tertiary care institution . We found that the prevalence of valvular abnormalities increased significantly with age, and that 50% of patients > or =60 years of age warranted endocarditis prophylaxis using current guidelines . With the aging population of the United States and the negative consequences of widespread antibiotic prophylaxis, further investigation is needed to identify patients who are truly at risk for infectious endocarditis. J Bone Joint Surg Br, 2004 Jul, 86(5), 688 - 91 Infection after total knee arthroplasty; Blom AW et al.; The aim of our study was to determine the current incidence and outcome of infected total knee arthroplasty (TKA) in our unit comparing them with our earlier audit in 1986, which had revealed infection rates of 4.4% after 471 primary TKAs and 15% after 23 revision TKAs at a mean follow-up of 2.8 years . In the interim we introduced stringent antibiotic prophylaxis, and the routine use of occlusive clothing within vertical laminar flow theatres and 0.05% chlorhexidine lavage during arthroplasty surgery . We followed up 931 primary TKAs and 69 revision TKAs for a mean of 6.5 years (5 to 8) . Patients were traced by postal questionnaire, telephone interview or examination of case notes of the deceased . Nine (1%) of the patients who underwent primary TKA, and four (5.8%) of those who underwent revision TKA developed deep infection . Two of nine patients (22.2%) who developed infection after primary TKA were successfully treated without further surgery . All four of the patients who had infection after revision TKA had a poor outcome with one amputation, one chronic discharging sinus and two arthrodeses . Patients who underwent an arthrodesis had comparable Oxford knee scores to those who underwent a two-stage revision . Although infection rates have declined with the introduction of prophylactic measures, and more patients are undergoing TKA, the outcome of infected TKA has improved very little. Cochrane Database Syst Rev . 2004;(3):CD004455. Antibiotic prophylaxis for operative vaginal delivery; Liabsuetrakul T et al.; BACKGROUND: Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery . Prophylactic antibiotics are prescribed to prevent these infections . However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear . OBJECTIVES: To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum and/or forceps deliveries . SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (November 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003) and MEDLINE (1966 to November 2003) . SELECTION CRITERIA: All randomised trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible . Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age undergoing vacuum or forceps delivery for any indications . Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium) compared with either placebo or no treatment . DATA COLLECTION AND ANALYSIS: Four reviewers assessed trial eligibility and methodological quality . Two reviewers extracted the data independently using prepared data extraction forms . Any discrepancies were resolved by discussion and a consensus reached through discussion with all reviewers . We assessed methodological quality of the included trial using the standard Cochrane criteria and the CONSORT statement of randomised controlled trials . We calculated the relative risks using a fixed effect model and all the reviewers interpreted and discussed the results . MAIN RESULTS: One trial, involving 393 women undergoing either vacuum or forceps deliveries, was included . This trial identified only two out of the nine outcomes specified in this review . It reported seven women with endomyometritis in the group given no antibiotic and none in prophylactic antibiotic group . This difference did not reach statistical significance, but the relative risk reduction was 93% (relative risks 0.07; 95% confidence interval (CI) 0.00 to 1.21) . There was no difference in the length of hospital stay between the two groups (weighted mean difference 0.09 days; 95% CI -0.23 to 0.41) . REVIEWERS' CONCLUSIONS: The data were too few and of insufficient quality to make any recommendations for practice . Future research on antibiotic prophylaxis for operative vaginal delivery is needed to conclude whether it is useful for reducing postpartum morbidity. Cochrane Database Syst Rev . 2004;(3):CD003996. Antibiotic prophylaxis in clean and clean-contaminated ear surgery; Verschuur HP et al.; BACKGROUND: Ear surgery may be performed in the treatment of chronic otitis media, ossicular chain disorders, tympanic membrane perforations and otitis media with effusion . Postoperative infection in ear surgery may result in: Wound infections Infection of the middle ear or mastoid resulting in discharge from the ear canal Failure of the tympanic membrane to close Labyrinthitis due to infection in, or adjacent to, the inner ear These complications may be associated with discomfort and inconvenience for the patient, an increase in morbidity and an increase in the costs of medical care . OBJECTIVES: The objective of this review was to assess the effects of local and/or systemic antibiotics for preventing complications such as postoperative discharge, graft failure and labyrinthitis in patients undergoing clean or clean-contaminated ear surgery . SEARCH STRATEGY: We searched MEDLINE (searched January 1966 to December 2002), EMBASE (searched January 1980 to December 2002), the Science Citation Index, The Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 4 2002); the Cochrane Acute Respiratory Infections Group and Cochrane Ear, Nose and Throat Group Specialised Registers and proceedings of scientific meetings . The date of the last search was December 2002 . We also contacted investigators in the field (Govaerts, Antwerp) . Bibliographies of identified articles were screened for further relevant trials . No language restriction was applied . SELECTION CRITERIA: Randomised or quasi-randomised trials involving: Participants: patients undergoing clean or clean-contaminated types of ear surgery . Skull base surgery was excluded . Intervention: any regimen of local and/or systemic antibiotic prophylaxis administered at or around the time of surgery compared to placebo, no antibiotic, or an alternative intervention group . Outcome measures: infection, discharge, graft failure, labyrinthitis, adverse effects of prophylaxis . DATA COLLECTION AND ANALYSIS: When possible, investigators were contacted for additional information on data and methodological issues . At least two reviewers independently extracted data and assessed trial quality . MAIN RESULTS: Eleven studies were included in the review . The methodological quality of the trials was fair to good . However, most studies presented insufficient detail on methodological data . Although definitions of outcome measures were heterogeneous, pooling of results was possible . There were no significant differences between antibiotic prophylaxis groups and control groups in terms of reduction of postoperative infections, graft failures, draining outer ear canals and adverse drug effects . REVIEWERS' CONCLUSIONS: There is no strong evidence that the large scale use of prophylactic of antibiotics in clean and clean-contaminated ear surgery is helpful in reducing postoperative complications such as wound infection, discharge from the outer ear canal, labyrinthitis and graft failure. Reprod Health Matters, 2004 May, 12(23), 136 - 43 Intrauterine contraceptive devices and risk of pelvic inflammatory disease: standard of care in high STI prevalence settings; Steen R et al.; The intrauterine contraceptive device (IUD) is highly effective and cost-effective . IUD use is limited in some regions, however, due to concerns about increased risk of pelvic inflammatory disease (PID) and subsequent complications such as infertility and ectopic pregnancy . Recent reviews suggest that the overall risk of PID with modern IUDs is lower than previously thought, at least in regions with a low prevalence of sexually transmitted infections (STIs) . Risk of PID may be higher, however, in places where gonorrhoea and chlamydia are prevalent, where screening for STIs is limited and where aseptic conditions for insertion are difficult to ensure . A World Health Organization multi-centre study and other studies have confirmed regional differences in STI prevalence, and the WHO study established that PID risk is temporally related to IUD insertion procedures . Studies of the effectiveness of antibiotic prophylaxis to prevent infectious complications are inconclusive due at least in part to use of sub-therapeutic regimens for pathogens commonly implicated in PID . In summary, the IUD can be safe and effective if inserted under aseptic conditions in women free of cervical infection . Further study is needed to define appropriate standards of care for IUD insertion where STI prevalence is high and ability to rule out infection is limited . Even with safe insertion, IUD promotion in areas of high STI/HIV prevalence must address women's needs for dual protection from infection and unwanted pregnancy. Infect Control Hosp Epidemiol, 2004 Jun, 25(6), 492 - 7 Prevention of infections associated with permanent cardiac antiarrhythmic devices by implementation of a comprehensive infection control program; Borer A et al.; OBJECTIVE: To implement a comprehensive infection control (IC) program for prevention of cardiac device-associated infections (CDIs) . DESIGN: Prospective before-after trial with 2 years of follow-up . SETTING: A tertiary-care, university-affiliated medical center . PATIENTS: A consecutive sample of all adults undergoing cardiac device implantation between 1997 and 2002 . INTERVENTION: An IC program was implemented during late 2001 and included staff education, preoperative modification of patient risk factors, intraoperative control of strict aseptic technique, surgical scrubbing and attire, control of environmental risk factors, optimization of antibiotic prophylaxis, postoperative wound care, and active surveillance . The clinical endpoint was CDI rates . RESULTS: Between 1997 and 2000, there were 7 CDIs among 725 procedures (mean annual CDI incidence, 1%) . During the first 9 months of 2001, there were 7 CDIs among 167 procedures (4.2%; P = .007): CDIs increased from 7 among 576 to 3 among 124 following pacemaker implantation (P = .39) and from 0 among 149 to 4 among 43 following cardioverter-defibrillator implantation (P = .002) . Of the 14 CDIs, 5 involved superficial wounds, 7 involved deep wounds, and 2 involved endocarditis . Following intervention, there were no cases of CDI among 316 procedures during 24 months of follow-up (4.2% reduction; P = .0005) . CONCLUSIONS: We observed a high CDI rate associated with substantial morbidity . IC measures had an impact on CDI . Although the relative weight of each measure in the prevention of CDI remains unknown, our results suggest that implementation of a comprehensive IC program is feasible and efficacious in this setting. Ann R Coll Surg Engl, 2004 Jul, 86(4), 263 - 6 Timing of antibiotic prophylaxis in surgery for adult hip fracture; Thonse R et al.; BACKGROUND: Antibiotic prophylaxis is widely used in surgery for hip fractures . METHODS AND RESULTS: In a retrospective study of case notes of 100 patients, frequent inaccuracies in dose administration were observed . This was applicable to both the pre-operative and the postoperative doses . Longer time intervals between the doses, failure to administer the prescribed doses, and failure of proper documentation were observed . CONCLUSIONS: Improvement in the awareness of staff and timely administration of prophylactic antibiotic has resulted from this study. Evid Based Dent . 2004;5(2):46. Is penicillin prophylaxis effective against bacterial endocarditis? Seymour R. DATA SOURCES: Cochrane Oral Health, Heart and Infectious Diseases Groups' Trials Registers Cochrane Central Register of Controlled Trials (CENTRAL) OLDMEDLINE; EMBASE SIGLE (to June 2002); and the Meta-register of current controlled trials . STUDY SELECTION: Due to the low incidence of BE a low yield of trials was expected so cohort and case-controlled studies were included where suitably matched control or comparison groups had been studied . The intervention was the administration of penicillin compared to no such administration before a dental procedure in people with an increased risk of BE . Outcomes of interest were: mortality or serious adverse event requiring hospital admission; development of endocarditis following any dental procedure in a defined time period; development of endocarditis due to other non-dental causes; any recorded adverse events to the antibiotics; and cost implications of the antibiotic provision for the care of those patients who develop endocarditis . DATA EXTRACTION AND SYNTHESIS: Two reviewers independently selected studies for inclusion, then assessed quality and extracted data from the included study . RESULTS: One case-control study met the criteria . This study included participants who died because of the endocarditis (using proxys) . It collected all the cases of endocarditis in the Netherlands over 2 years, finding 24 people who developed endocarditis within 180 days of an invasive dental procedure . Controls attended local cardiology outpatient clinics for similar cardiac problems, had undergone an invasive dental procedure within the past 180 days and were matched by age with the cases . No significant effect of penicillin prophylaxis on the incidence of endocarditis could be seen . No data were found on other outcomes . CONCLUSIONS: There is no evidence about whether penicillin prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure . There is a lack of evidence to support published guidelines in this area . It is not clear whether the potential harms and costs of penicillin administration outweigh any beneficial effect . Ethically practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration. Support Care Cancer, 2004 Oct, 12(10), 725 - 30 A prospective randomised evaluation of G-CSF or G-CSF plus oral antibiotics in chemotherapy-treated patients at high risk of developing febrile neutropenia; Lalami Y et al.; BACKGROUND: Febrile neutropenia (FN) remains a major dose-limiting complication among patients treated with chemotherapy . Haematopoietic colony stimulating factors (G-CSF and GM-CSF) made possible a significant improvement in the management of FN, both in the therapeutic and in the prophylactic approach . The use of antibiotic prophylaxis also permits a definite reduction of severe infections during neutropenia . Nevertheless, the possible role of these two interventions for secondary prevention of FN is still unclear . PATIENTS AND METHODS: We conducted a prospective randomised trial by comparing the efficacy of granulocyte-colony stimulating factor (G-CSF) and the association of G-CSF with oral antibiotics in the secondary prevention of FN . We included in our study those patients who, after an episode of FN, continued to be treated with the same chemotherapy without reduction of dose intensity . They were randomised into two groups: the first received G-CSF (group G; filgrastim, 5 microg/kg day), and the second was treated with an association of G-CSF and amoxicillin/clavulanate plus ciprofloxacin (group G/ACC) . RESULTS: Forty-eight patients were randomised (group G: n=23 and group G/ACC: n=25) . There was no recurrence of FN among the patients receiving G-CSF and only one episode in the combined therapy group (p=1) . With regard to the side effects, there was no significant difference in the two groups . CONCLUSION: The use of G-CSF for the secondary prevention of FN is extremely effective and allows the maintenance of chemotherapy dose intensity . Our study showed that the addition of antibiotics does not seem to be required. Hum Fertil (Camb), 2004 Jun, 7(2), 135 - 40 Prevention of iatrogenic pelvic infection during in vitro fertilization--current practice in the UK; Sowerby E et al.; Uterine instrumentation can provoke pelvic inflammatory disease in women infected with Chlamydia trachomatis . During an IVF treatment cycle, a fine plastic catheter is passed into the endometrial cavity to transfer the embryos . The objective of this survey was to find out what measures are being taken by IVF clinics to prevent ascending infection . Postal questionnaires were sent to 75 clinics in the UK, asking about their sexually transmitted infection screening policies and their protocols on antibiotic prophylaxis . Seventy clinics (93%) responded, of which 37 (53%) neither screen the female partner for C . trachomatis, nor give appropriate antibiotic prophylaxis . Approximately half of UK IVF clinics make no attempt to either detect or treat chlamydial infection prior to embryo transfer . More research is required to evaluate whether embryo transfer does pose a significant risk factor for pelvic inflammatory disease. J Chemother, 2004 Apr, 16(2), 160 - 5 Surveillance of post-operative infections and management of antibiotic surgical prophylaxis in an Italian region; Esposito S et al.; The aim of the study was to evaluate the incidence of post-surgical infections and to assess management of antibiotic surgical prophylaxis . The survey was carried out by means of a questionnaire in order to obtain diverse information such as demographics, length of pre- and post-operative hospitalization, type of surgery, intervention duration, possible antibiotic prophylaxis and onset of post-surgical infections also monitored by post-discharge ambulatory controls . Four General Surgery and five Obstetrics and Gynecology Departments in Campania (southern Italy) participated in the study, which was carried out from December 2001-January 2002 . Overall, 410 questionnaires were collected, referring to as many patients; antibiotic prophylaxis was performed in 385 (93.9%) patients . Antibiotic prophylaxis was generally managed not according to the general principles suggested by the international guidelines either for timing, for its duration or for the route of administration . Substantial differences were also noted in patient selection and antibiotic choice . Surgical site infections were recorded in 0.9% of patients undergoing clean surgery and in 3.6% of patients undergoing clean-contaminated surgery . Distant infections occurred in 1.5% in clean-contaminated surgery . The results of the present study suggest the need for continuous and accurate monitoring of post-surgical infections and the need to adopt appropriate guidelines to improve the management of surgical prophylaxis. Arch Mal Coeur Vaiss, 2004 May, 97(5), 507 - 14 {Characteristics of infectious endocarditis in ventricular septal defects in children and adults}; Di Filippo S et al.; The aim of this retrospective study was to analyse cases of infectious endocarditis (IE) of native or repaired ventricular septal defects (VSD) to determine its incidence, the circumstances of its occurrences, the outcome and prognosis of this complication . From 1966 to 2002, 36 IE occurred in 19 boys and 17 girls: the age at diagnosis was 13.4 +/- 11.8 years; 26 had an isolated VSD and 10 had VSD associated with a minor lesion . Eleven of the 36 cases (30.5%) had been previously operated: repair of an isolated VSD with a patch in 5 cases, associated with a Crafoord procedure for coarctation of the aorta in 2 cases, three times with conservative treatment of associated aortic regurgitation (AR) and with ligature of patent ductus arteriosus (PDA) in 1 case . Twenty-five of the 36 cases (69.5%) had not been operated before: 21 isolated type 1 VSD; 2 VSD + AR, 1 VSD with PDA (undiagnosed), 1 VSD with valvular pulmonary stenosis (PS) . The portal of entry was post-surgical in 7 out of 36 cases (19.4%): 4 VSD patches, 2 VSD patches + Crafoord and 1 VSD patch with ligature of PDA . The source of infection was dental in 14 out of the 36 cases (38.9%): one isolated VSD repair with residual shunt, 11 native VSDs, and 2 cases of unoperated VSD + AR . The other infectious causes (15 = 41.7%) were ENT (2 cases), skin (2 cases), gastrointestinal (2 cases), pulmonary (1 case) or unknown (8 cases), on operated lesions (3 VSD patches + AR) or native lesions (12 cases: 10 isolated VSDs, 1 VSD with PSD and 1 VSD with PS) . Twelve episodes occurred (33.3%) despite antibiotic prophylaxis, 7 out of 7 post-surgical and 5 out of 14 dental cases . The commonest localisation was the tricuspid valve (10 cases, always in isolated VSD) . Embolism was observed in 60% of right heart endocarditis (always multiple) and in 55% of IE of the left heart (single embolism) . Early surgery was required in 6 patients (16.7%) . The risk of early surgery was higher in patients with VSDs associated with other lesions (4 out of 10 = 40%) than in isolated VSD (2 out of 26, 7.7%, p = 0.027) . Thirteen patients underwent secondary surgery after an average interval of 2.96 years, median 0.86 years (from 4 months to 22.8 years) for VSD repair (10 cases), aortic valve replacement (2 cases) and aorto-aortic conduit (1 case) . The global follow-up period was 7.4 +/- 8.3 years, from 28 days to 27.9 years (median 3.3 years) . Five deaths were observed on average 3.7 +/- 6.2 years after the episode of IE (median 6 months): 2 were early, occurring less than 6 months after IE and directly related to the infective episode . The survival was 97.1% at 1 month, 94.3% at 6 months, 91.4% at 1 year and 86.6% at 5 and 10 years after IE . VSD is a benign cardiac lesion, the prognosis of which can be severely compromised by infectious endocarditis: surgical repair reduces the risk but does not totally exclude it because of minor associated abnormalities . Prophylactic antibiotic therapy and the diagnosis of latent infectious problems, particularly dental, remains essential before and after cardiac surgery. Am Surg, 2004 Jun, 70(6), 496 - 9 Use of percutaneous drainage to treat hepatic abscess after radiofrequency ablation of metastatic pancreatic adenocarcinoma; Thomas KT et al.; Radiofrequency ablation (RFA) is well described in the treatment of primary hepatic malignancies and colorectal carcinoma hepatic metastases . A known complication of RFA is the development of hepatic abscess . The management of hepatic abscesses subsequent to RFA for metastatic disease is not well described . A 49-year-old female with pancreatic adenocarcinoma underwent pancreaticoduodenectomy followed by adjuvant chemoradiation . Following 6 months' treatment, a new liver metastasis was identified . It remained stable for 6 months during additional chemotherapy and thereafter was treated with RFA . Three weeks after RFA, the patient presented with malaise and leukocytosis, and a CT scan demonstrated a large hepatic abscess at the site of the RFA . She remained febrile despite needle aspiration and intravenous antibiotics . A percutaneous drain was placed and the symptoms resolved . Contrast injection of the drain 4 weeks later demonstrated resolution of the abscess cavity but communication with the biliary tree . The drain was removed and the tract embolized with Gel-foam to prevent complications of biliary-cutaneous fistula . She remains well without evidence of abscess or disease recurrence . Thus, RFA can be used in treatment of limited isolated hepatic metastases from previously treated pancreatic adenocarcinoma . However, the incidence of hepatic abscess is increased due to bilioenteric anastomosis; extended antibiotic prophylaxis should be considered. Lijec Vjesn, 2003 Nov-Dec, 125(11-12), 317 - 21 {Therapeutic approach in acute pancreatitis}; Stimac D; Acute pancreatitis varies from mild to severe fulminant disease . Once the diagnosis of acute pancreatitis is established, the treatment is dependent on the early assessment of disease severity based on objective clinical and laboratory parameters . The purpose of this review is to describe the new developments in the treatment of acute pancreatitis which have an impact in the lowering of the morbidity and mortality . The roles of initial treatment and monitoring, nutritional support, specific therapy and antibiotic prophylaxis are analysed . The therapeutic approach to patients with early and late complications of acute pancreatitis could be medical, endoscopic or surgical and recommendations for relevant management are given. Lijec Vjesn, 2003 Nov-Dec, 125(11-12), 292 - 5 {Percutaneous endoscopic gastrostomy: 5-year experience at out center (1997-2002)}; Brkic T et al.; Gauderer and Ponsky first described percutaneous endoscopic gastrostomy (PEG) in 1979 . It was introduced as a routine method in the Division of Gastroenterology, University Hospital Rebro, Zagreb, in 1995 . Over the years the number of PEG insertions has increased significantly . We reviewed the available literature and compared the results with our experience according to indications, complications and efficacy of the procedure . We inserted PEG in 86 patients from January 1, 1997 until January 31, 2002 . There were 40 females and 46 males . The most frequent indication for PEG insertion was a neurological condition (60/86) . There were no deaths directly related to the procedure . One patient had a leakage of PEG feeding into the peritoneal cavity that caused severe peritonitis and required urgent laparatomy within 24 hours of the PEG insertion . Two patients had local infection and the tube had to be removed . The antibiotic prophylaxis has been given to 65 patients . Our experience confirms that PEG is a relatively safe and well tolerated procedure. Emerg Med J . 2004 Jul;21(4):503. Best evidence topic report . Prophylactic antibiotics for subungual haematoma; Costello J et al.; A short cut review was carried out to establish whether antibiotic prophylaxis is indicated after trephining of a subungual haematoma . Two papers were found using the reported search, of which neither presented any evidence to answer the clinical question . It is concluded that there is no evidence available to answer this question . Further research is needed. Emerg Med J . 2004 Jul;21(4):502. Best evidence topic report . Antibiotic prophylaxis for pretibial haematomas in the elderly population; Teece S et al.; A short cut review was carried out to establish whether prophylactic antibiotics reduce infections and other complications in elderly patients with pretibial haematomas . Altogether 65 papers were found using the reported search, of which none presented any evidence to answer the clinical question . It is concluded that there is no evidence available to answer this question . Further research is needed. Int J Gynaecol Obstet, 2004 Jul, 86(1), 12 - 5 Manual removal or spontaneous placental delivery and postcesarean endometritis and bleeding; Dehbashi S et al.; OBJECTIVES: To compare the effect of manual removal and spontaneous delivery of placenta on postcesarean bleeding and endometritis . METHODS: In this prospective study 400 pregnant women undergoing elective cesarean delivery were randomly assigned to two groups: spontaneous placental delivery (200 women) and manual placental delivery (200) . No antibiotic prophylaxis was administered in either group . The significance of blood loss due to cesarean delivery was defined by a drop in hemoglobin concentration of more than 1 g/dl 24 h after delivery in comparison with preoperative hemoglobin concentration . Endometritis was diagnosed in patients who developed clinical signs of fever and suprapubic tenderness 48 h after delivery . We analyzed the data using a t-test . RESULTS: The overall endometritis rate was 27%, in 40 women in the spontaneous placental delivery group (20%) and 68 women in the manual placental removal group (34%) . There was a statistically significant difference between the two groups (P=0.001) . Significant blood loss was experienced by 52 women (26%) in the spontaneous placental delivery group vs . 100 women (50%) in the manual placental delivery group . There was a statistically significant difference in blood loss between the two groups (P=0.000; RR=1.92) . CONCLUSION: Endometritis and blood loss in cesarean delivery is increased by manual removal of the placenta compared with the spontaneous method of placental removal. J Am Assoc Gynecol Laparosc, 2004 May, 11(2), 248 - 51 Survey among members of the roman group of gynecologic endoscopy on the use of agents for postoperative adhesion prevention; Muzii L; STUDY OBJECTIVE: To evaluate patterns of use of agents for postoperative adhesion prevention . DESIGN: Mail survey . SETTING: Departments of Obstetrics and Gynecology, university-affiliated and public hospitals, Rome, Italy . PARTICIPANTS: Members of the Roman Group of Gynecologic Endoscopy . INTERVENTION: Evaluation of forms returned . MEASUREMENTS AND MAIN RESULTS: The response rate to either electronic or regular mailing was 31%, for a total of 42 forms evaluated . For laparoscopy, the perceived postoperative de novo adhesion formation rate was 0%-25%, whereas the adhesion reformation rate was 26%-75%; for laparotomy, the rates were 26%-75% and >75%, respectively . Sixty-five percent of the respondents were using at least one method for postoperative adhesion prevention during laparoscopy, and 68% during laparotomy.The most frequently used method during laparoscopy was Ringer's lactate (77% of the respondents), followed by ferric hyaluronate gel (46% of the respondents), and 4% icodextrin (39% of respondents) . During laparotomy, the most frequently used methods were Ringer's lactate (28%), normal saline (20%), and 4% icodextrin (20%) . Antibiotic prophylaxis was used by 87.5% of respondents . CONCLUSION: Postoperative adhesion formation, and especially reformation, are perceived as significant problems . Sixty-five percent of the respondents used some method for adhesion prevention after operative laparoscopy, with Ringer's lactate, ferric hyaluronate gel, and 4% icodextrin being the most frequently used. BJOG, 2004 Jul, 111(7), 726 - 33 A randomised controlled trial of a tailored multifaceted strategy to promote implementation of a clinical guideline on induced abortion care; Foy R et al.; OBJECTIVE: To evaluate the effectiveness and efficiency of a tailored multifaceted strategy, delivered by a national clinical effectiveness programme, to implement a guideline on induced abortion . DESIGN: Cluster randomised controlled trial . SETTING AND PARTICIPANTS: All 26 hospital gynaecology units in Scotland providing induced abortion care . INTERVENTION: Following the identification of barriers to guideline implementation, intervention units received a package comprising audit and feedback, unit educational meetings, dissemination of structured case records and promotion of a patient information booklet . Control units received printed guideline summaries alone . MAIN OUTCOME MEASURES: Compliance with five key guideline recommendations (primary outcomes) and compliance with other recommendations, patient satisfaction and costs of the implementation strategy (secondary outcomes) . RESULTS: No effect was observed for any key recommendation: appointment with a gynaecologist within five days of referral (odds ratio 0.89; 95% confidence interval 0.50 to 1.58); ascertainment of cervical cytology history (0.93; 0.36 to 2.40); antibiotic prophylaxis or screening for lower genital tract infection (1.70; 0.71 to 5.99); use of misoprostol as an alternative to gemeprost (1.00; 0.27 to 1.77); and offer of contraceptive supplies at discharge (1.11; 0.48 to 2.53) . Median pre-intervention compliance was near optimal for antibiotic prophylaxis and misoprostol use . No intervention benefit was observed for any secondary outcome . The intervention costs an average of pound 2607 per gynaecology unit . CONCLUSIONS: The tailored multifaceted strategy was ineffective . This was possibly attributable to high pre-intervention compliance and the limited impact of the strategy on factors outside the perceived control of clinical staff. Nephrology (Carlton), 2004 Jun, 9(3), 167 - 70 Antibiotic prophylaxis in dialysis patients undergoing invasive dental treatment; Tong DC et al.; BACKGROUND AND AIMS: The role of antibiotic prophylaxis for invasive dental procedures in patients on dialysis therapy is unclear . We examined current clinical practice in Australia and New Zealand and compared our findings to a systematic review of the current literature . METHODS: Australian and New Zealand nephrology units were surveyed with regard to their use of antibiotic prophylaxis for dental procedures . A systematic review of the literature was performed by using an online web-based search engine (PubMed) using the key words: renal patients, dental and antibiotic prophylaxis . RESULTS: Forty-one per cent of respondents do not routinely give antibiotic prophylaxis to haemodialysis patients prior to dental surgery, but a majority (53%) would consider antibiotic prophylaxis if the patient had a synthetic arteriovenous fistula . CONCLUSIONS: The majority of clinicians follow the American Heart Association (AHA) guidelines with a single oral preoperative dose of 2 g amoxycillin or 600 mg clindamycin if patients are allergic to penicillin . From the literature and the data obtained by questionnaire, it would appear that renal patients receiving haemodialysis in Australia and New Zealand receive antibiotic prophylaxis prior to invasive dental procedures . The standard single dose of 2 g amoxycillin orally or 600 mg clindamycin orally 1 h preoperatively, as recommended by the AHA, is most frequently used . Peritoneal dialysis patients generally do not receive a prophylactic dose of antibiotics. Acta Paediatr, 2004 May, 93(5), 638 - 42 Retrospective evaluation of long-term efficacy and safety of splenectomy in chronic idiopathic thrombocytopenic purpura in children; Aronis S et al.; AIM: To review the long-term efficacy and safety of splenectomy in children with chronic idiopathic thrombocytopenic purpura (cITP) . PATIENTS AND METHODS: Data from 33 splenectomized children were retrospectively analysed (median follow up period: 18.8 y from the removal of the spleen) . The median age of children at splenectomy was 12 y and the median ITP duration 3.3 y . Indications for splenectomy were: persistent severe thrombocytopenia with extensive purpura, epistaxis and/or gum bleeds, menorrhagia (n = 5) and severe or recurrent haemorrhage from various sites (n = 11) . RESULTS: Eighty-five per cent of the patients showed an excellent (n = 26) or partial response to splenectomy . Five children (15%), all females, failed to respond . Of the responders, 25% experienced a transient recurrence of thrombocytopenia within 6 mo to 4 y from splenectomy . The mortality rate due to severe sepsis was 3% . However, the majority of the splenectomized patients have not so far suffered any severe or mild bacterial infection, despite incomplete vaccination and/or antibiotic prophylaxis . CONCLUSION: Splenectomy remains the only effective therapeutic modality for children with cITP, although it is associated with transient recurrence and rarely with post-splenectomy sepsis, which could be fatal . Nonetheless, splenectomy should be the last treatment option for the cITP patient, after all available therapeutic modalities have been exhausted and the child still remains profoundly thrombocytopenic and symptomatic. Int J Hematol, 2004 Apr, 79(3), 221 - 8 Diagnosis and clinical management of chronic graft-versus-host disease; Martin PJ et al.; Chronic graft-versus-host disease (GVHD) occurs in approximately 60% of patients who survive for more than 100 days after receiving an allogeneic marrow or peripheral blood stem cell transplant without T-cell depletion of the graft . Chronic GVHD represents a major cause of morbidity and mortality among hematopoietic stem cell transplant recipients . Risk factors for the development of chronic GVHD and for mortality among patients who develop this complication have been defined, but the pathogenesis of chronic GVHD is not well understood . This review discusses the clinical manifestations that lead to a diagnosis of chronic GVHD and outlines an approach for therapy with glucocorticoids and extended administration of a calcineurin inhibitor . The judicious use of glucocorticoids at the lowest effective dose and alternate-day administration can minimize steroid-related side effects . Antibiotic prophylaxis to prevent infection and supportive care to minimize morbidity and prevent disability are critically important components in the management of patients with chronic GVHD . Approximately 50% of patients with chronic GVHD are able to discontinue immunosuppressive treatment within 5 years after the diagnosis, and 10% require continued treatment beyond 5 years . The remaining 40% die or develop recurrent malignancy before the chronic GVHD resolves . An improved understanding of the pathogenesis of the disease is needed to develop more effective therapy. Pharmacotherapy, 2004 May, 24(5), 668 - 72 Cefazolin tolerance does not predict ceftriaxone hypersensitivity: unique side chains precipitate anaphylaxis; Poston SA et al.; A 48-year-old woman with a questionable history of an unspecified ceftriaxone allergy was treated with cefazolin for surgical antibiotic prophylaxis . After she tolerated cefazolin therapy for 4 days, the medical staff concluded that her allergy history was inaccurate, and she was treated with intravenous ceftriaxone for suspected nosocomial pneumonia . Approximately 10 minutes after the start of the infusion, the patient experienced anaphylaxis . Initial symptoms of oral angioedema and laryngopharyngeal constriction progressed to dyspnea, tachypnea, hypotension, and tachycardia, all of which quickly resolved after immediate treatment with hydrocortisone, diphenhydramine, and epinephrine . Skin testing with cefazolin, cefepime, and ceftriaxone revealed that the likely allergic determinant mediating the patient's hypersensitivity reaction was the unique ceftriaxone R2 side chain and not the beta-lactam ring, which initially was suspected by the physician . Immunoglobulin E-mediated hypersensitivity reactions to cephalosporins may occur due to antibody complexes with the beta-lactam ring or various cephalosporin side chains . Misconceptions regarding the nature of cephalosporin allergies complicate antibiotic selection for patients with questionable allergy histories and may lead to inappropriate drug reexposure and anaphylaxis . Detailed understanding of the antigenic determinants that mediate hypersensitivity reactions is essential for clinicians to avoid type 1 reactions in patients with a suspected allergy to cephalosporins. Head Neck, 2004 Jun, 26(6), 513 - 7 Previous chemotherapy as a predictor of wound infections in nonmajor head and neck surgery: Results of a prospective study; Penel N et al.; BACKGROUND: The goal of this prospective study was to determine the incidence of wound infections (WI) after clean uncontaminated head and neck cancer procedures and after emergency tracheotomies . METHODS: Two hundred twelve clean procedures without tracheotomy or opening of mucosa (neck dissections, large skin resections, thyroidectomies, parotid gland resections, and explorative cervicotomies) were studied at Oscar Lambret Cancer Center over a 24-month period . RESULTS: WI rate was 6.6% (14 of 212) . In a univariate analysis, only one variable was significantly related to the likelihood of WI: previous anticancer chemotherapy . All but one patient who had had previous chemotherapy demonstrated WI (14 of 15) . CONCLUSIONS: After previous chemotherapy, WI rate in clean uncontaminated head and neck surgery was as high as 90% . In this case, antibiotic prophylaxis should be evaluated . Int J Qual Health Care, 2004 Jun, 16(3), 245 - 51 Physician knowledge and adherence to prescribing antibiotic prophylaxis for sickle cell disease; Wurst KE et al.; OBJECTIVE: The purpose of this research was to examine how physician characteristics were associated with: (i) . physician knowledge of and adherence to sickle cell guidelines; and (ii) . the types of educational programs about sickle cell disease desired by physicians . METHODS: A survey was developed to assess the research objective . After the survey was pre-tested and an institutional review board exemption was obtained, it was sent to a systematic random sample of 375 pediatricians and all 125 practicing hematologists in North Carolina . They were asked to answer a six-item knowledge test relating to the antibiotic prophylaxis guidelines . RESULTS: The response rate was 57%, of which 61% were pediatricians . Over half (56%) were in a practice with at least one pediatric sickle cell patient . Fifty-nine percent of physicians answered five or more questions correctly on the knowledge test . The question most physicians answered correctly (97%) pertained to the necessity of antibiotics for children with sickle cell disease . The question most frequently answered incorrectly (62%) pertained to prescribing antibiotics to a child with unconfirmed sickle cell disease . Logistic regression results indicated that the number of sickle cell patients seen in practice influenced the number of questions answered correctly . Sixty-six percent of physicians prescribed prophylactic antibiotics for 100% of their patients with sickle cell disease and therefore were 100% adherent . Eighty-one percent of pediatricians compared with 12% of hematologists were 100% adherent in prescribing antibiotics . Hematologists and those practicing at a medical school or university were less likely to be 100% adherent in prescribing antibiotic prophylaxis . CONCLUSION: The majority of physicians surveyed were relatively knowledgeable about sickle cell guidelines, however there may be a need for continuing education programs that focus on the issues of prescribing antibiotics to a child with unconfirmed sickle cell disease and penicillin dosage. Br J Plast Surg, 2004 Jun, 57(4), 348 - 53 Hirudo Medicinalis and the plastic surgeon; Whitaker IS et al.; Medicinal leech therapy is an ancient craft that dates back to ancient Egypt and the beginnings of civilisation . The popularity of Hirudo Medicinalis has varied throughout history, reaching such a peak in Europe in the early 19th century that supplies were exhausted . During the latter half of the 19th century, their use fell out of favour, as they did not fit in with the emerging concepts of modern medicine . Leeches have enjoyed a renaissance in the world of reconstructive microsurgery during recent years, and their first reported use in alleviating venous engorgement following flap surgery was reported in this journal {M Derganc, F Zdravic, Venous congestion of flaps treated by application of leeches, Br J Plast Surg 13 (1960) 187} . Contemporary plastic and reconstructive surgeons in units throughout the United Kingdom and Ireland continue to use leeches to aid salvage of failing flaps . We carried out a survey of all 62 plastic surgery units in the United Kingdom and the Republic of Ireland to assess the current extent of use, and to investigate current practice . We have shown that the majority of plastic surgery units in the UK and Ireland use leeches post-operatively and that the average number of patients requiring leech therapy was 10 cases per unit per year . Almost all units use antibiotic prophylaxis, but the type of antibiotic and combination used is variable . We outline current practice and suggest a protocol for the use of leeches . Whilst the use of leeches is widespread, the plastic surgery community has progressed little in defining indications for their use or in achieving an accepted protocol for their application in units throughout the UK and Ireland. Lancet, 2004 May 15, 363(9421), 1608 - 10 Serum lipopolysaccharide-binding protein prediction of severe bacterial infection in cirrhotic patients with ascites; Albillos A et al.; Serum lipopolysaccharide-binding protein is increased in a subset of non-infected ascitic cirrhotic patients, a finding previously related to bacterial passage from the gut to the circulation without overt infection . We prospectively analysed the risk factors associated with a first episode of severe bacterial infection in 84 ascitic cirrhotics, followed up for a median of 46 weeks . The cumulative probability of such infection in patients with raised and normal lipopolysaccharide-binding protein was 32.4% and 8.0% (p=0.004), respectively . Increased lipopolysaccharide-binding protein was the only factor independently associated with severe bacterial infection in a multivariate analysis (relative risk 4.49, 95% CI 1.42-14.1) . Monitoring of serum lipopolysaccharide-binding protein could, therefore, help to target cirrhotic patients with ascites for antibiotic prophylaxis. Orthopade, 2004 Apr, 33(4), 424 - 30 {Antibiotic prophylaxis in cases of closed fractures and prostheses}; Walenkamp GH et al.; Antibiotic prophylaxis can be administered systemically or locally when bone cement is used for the implantation of prosthesis . In closed fracture surgery parenteral broad spectrum antibiotics are advised with 1 dose (in case of a long halflife) or for at least 12 hours when an antibiotic w