Antibiotic prophylaxis

Endoscopy, 1999 Feb, 31(2), 119 - 24
Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): a prospective randomized clinical trial; Gossner L et al.; BACKGROUND AND STUDY AIMS: The most frequent complication reported for percutaneous endoscopic gastrostomy (PEG) is peristomal wound infection which occurs in as many as 30 % of patients . In the studies published so far, the question of whether antibiotic prophylaxis reduces the incidence of peristomal wound infection has remained controversial . We therefore conducted a prospective, randomized trial to determine whether antibiotic prophylaxis can reduce the incidence of peristomal wound infection associated with PEG . PATIENTS AND METHODS: During a 2-year-period a total of 347 patients (251 men, 96 women; mean age 60.2+/-5) were included in our study . In all cases, a 9-French gauge Freka gastrostomy tube was inserted using the "pull" technique . The patients were randomly assigned to three different treatment groups (group 1, antibiotic prophylaxis with 2 g cefotaxime; group 2, antibiotic prophylaxis with 4g piperacillin plus 0.5g tazobactam; group 3, no antibiotic prophylaxis) . For a period of one week after gastrostomy, the peristomal area was evaluated using a wound score . According to the score, peristomal infections were classified as being of degree I-IV . Infections of up to degree III were regarded as minor, while an infection of degree IV was defined as a severe complication . RESULTS: PEG tubes were successfully placed in 336/347 patients (97 %) . Of the 336 patients, 29 were excluded because of incomplete follow up (dropout rate 9%) . Cases included were: in group 1, n = 101; in group 2, n = 100, and in group 3, n = 106 . There was no mortality related to PEG insertion . There were five instances of severe complications (1.6%) . Patients who received antibiotic prophylaxis had mean daily combined wound scores that were significantly lower than those of patients without antibiotic prophylaxis (P < 0.01) . The control group (no antibiotic prophylaxis) exhibited significantly more peristomal wound infections of degree III (n = 8) than antibiotic prophylaxis group 1 (n = 0, P < 0.001) or antibiotic prophylaxis group 2 (n = 1, P < 0.012) . Three patients in group 3 (no antibiotic prophylaxis) and one patient in group 2 developed peritonitis . CONCLUSIONS: Severe wound infections requiring medical or endoscopic intervention are very rare events after PEG insertion . Antibiotic prophylaxis significantly reduces the risk of peristomal wound infection associated with PEG insertion . Antibiotic prophylaxis, therefore, is to be recommended as a general measure in percutaneous endoscopic gastrostomy.

Circulation, 1999 Apr 27, 99(16), 2132 - 7
Infective endocarditis in hypertrophic cardiomyopathy: prevalence, incidence, and indications for antibiotic prophylaxis; Spirito P et al.; BACKGROUND: The literature on infective endocarditis in hypertrophic cardiomyopathy (HCM) is virtually confined to case reports . Consequently, the risk of endocarditis in HCM remains undefined . METHODS AND RESULTS: We assessed the occurrence of endocarditis in 810 HCM patients evaluated between 1970 and 1997 . Endocarditis was diagnosed in 10 patients, 2 of whom were excluded from analysis of prevalence and incidence because they were referred for acute endocarditis . At first evaluation, echocardiographic features consistent with prior endocarditis were identified in 3 of 808 patients, a prevalence of 3.7 per 1000 patients (95% CI, 0.8 to 11) . Of 681 patients who were followed, 5 developed endocarditis, an incidence of 1.4 per 1000 person-years (95% CI, 0.5 to 3.2); outflow obstruction was present in each of these 5 patients and was associated with the risk of endocarditis (P=0.006) . In the 224 obstructive patients, incidence of endocarditis was 3.8 per 1000 person-years (95% CI, 1.6 to 8.9) and probability of endocarditis 4 . 3% at 10 years . Left atrial size was also associated with the risk of endocarditis (P=0.007) . In patients with both obstruction and atrial dilatation (>/=50 mm), incidence of endocarditis increased to 9.2 per 1000 person-years (95% CI, 2.5 to 23.5) . Analysis of all 10 patients with endocarditis identified outflow obstruction in each and atrial dilatation in 7 . CONCLUSIONS: Endocarditis in HCM is virtually confined to patients with outflow obstruction and is more common in those with both obstruction and atrial dilatation . These results indicate that antibiotic prophylaxis is required only in patients with obstructive HCM.

Afr J Reprod Health, 1998 Apr, 2(1), 26 - 31
{Premature rupture of membranes: maternal and fetal outcome in the absence of antibiotic prophylaxis}; Mbu RE et al.; Antibiotic prophylaxis in the management of Premature Rupture of foetal Membranes (PROM) before term still remains controversial . 110 pregnant women with PROM were assigned to either group A (no treatment) or group B (treatment group) . The rates of premature deliveries were similar in the two groups, 71% versus 77% (p = 0.56) . Additionally, low birth weight, Apgar score, foetal distress, neonatal icterus and foetal sepsis were all observed in similar proportions in both groups . 6.5% of the subjects in group A developed endometritis as against 5.7% in group B (p = 0.69) . Perinatal mortality rates were high (33.3% and 50%, in group A and B, respectively), but not statistically different in the two groups (p = 0.13) . Prophylactic antibiotics do not seem to influence maternal and foetal outcome in patients who present with PROM in this environment.

Arch Otolaryngol Head Neck Surg, 1999 Apr, 125(4), 446 - 50
Otorrhea after insertion of silver oxide-impregnated silastic tympanostomy tubes; Gourin CG et al.; BACKGROUND: Silver oxide-impregnated tympanostomy tubes have been shown to decrease the incidence of postoperative otorrhea, but without a significant effect in the first postoperative week . OBJECTIVE: To evaluate prospectively our results with silver oxide-impregnated tympanostomy tubes and to identify factors associated with a higher incidence of early postoperative otorrhea . DESIGN: Prospective nonrandomized study . SETTING: University referral center . PATIENTS AND OTHER PARTICIPANTS: Six hundred thirty patients with chronic otitis media with effusion or recurrent otitis media . INTERVENTIONS: Silver oxide-impregnated Silastic tympanostomy tubes were inserted in 1254 ears . Subjects with mucoid or purulent effusions or blood at the myringotomy site at surgery were treated with topical antibiotic prophylaxis (sulfacetamide sodium-prednisolone acetate or neomycin sulfate-polymyxin B sulfate-hydrocortisone) for 5 days after tympanostomy tube placement . MAIN OUTCOME MEASURES: Incidence of otorrhea after tympanostomy tube insertion at 1 week and 1, 3, 6, 9, and 12 months after surgery . RESULTS: The overall incidence of postoperative otorrhea was 1.9% . The incidence of otorrhea in the first postoperative week was 5.6%; the incidence of otorrhea after the first postoperative week was 1.2% (P<.001) . Within the first postoperative week, a significantly greater incidence of otorrhea was noted in patients younger than 3 years (7.8%), in patients with mucoid effusions at surgery (8.6%), and in patients younger than 3 years with mucoid effusions at surgery (15.2%) . CONCLUSIONS: Silver oxide-impregnated tympanostomy tubes are associated with a low overall incidence of postoperative otorrhea . A significantly higher incidence of otorrhea is seen during the first postoperative week, compared with the incidence after the first week . Patients with thick middle ear effusions and age younger than 3 years have a significantly greater incidence of early otorrhea after tympanostomy tube placement.

Fertil Steril, 1999 Apr, 71(4), 756 - 60
A percutaneous large-needle aspiration biopsy technique for histologic examination of the testis in infertile patients; Carpi A et al.; OBJECTIVE: To describe a relatively new percutaneous large-needle aspiration biopsy technique for histologic examination of the testis in infertile patients . DESIGN: Retrospective analysis of clinical and pathologic data . SETTING: Clinical and academic research environment . PATIENT(S): Sixty-six infertile patients who underwent testicular biopsy . INTERVENTION(S): Local anesthesia was induced through spermatic cord block with lidocaine, and a relatively large needle (usually 18- or 20-gauge) was introduced percutaneously into the testicle without a scrotal incision . MAIN OUTCOME MEASURE(S): The number of seminiferous tubules per histologic section of each testicular biopsy sample . RESULT(S): A mean of 74 seminiferous tubules were obtained in the histologic sections of each biopsy sample . This number varied according to the size of the needle used; it was 24.7 when a 21-gauge needle was used, 56.2 when a 20-gauge needle was used, and 103 when an 18-gauge needle was used . The biopsies were performed in the office . No significant hematomas occurred, no antibiotic prophylaxis was prescribed, and no postbiopsy medical or pharmacologic interventions were required . CONCLUSION(S): Tissue specimens as large as those obtained with open surgical biopsy can be obtained from the testicles of infertile patients with the use of a percutaneous technique that is easier, less costly, and safer than any previously reported.

Gen Dent, 1998 Sep-Oct, 46(5), 508 - 15
The American Heart Association's guidelines for the prevention of bacterial endocarditis: a critical review; Little J; Since 1955, the American Heart Association (AHA) has made eight recommendations regarding the prevention of bacterial endocarditis . The most recent guidelines were published in 1997 . Presented here is a review of the AHA recommendations, with emphasis on the 1997 guidelines . The new recommendations list the medical conditions that require antibiotic prophylaxis, expand the number of dental procedures that do not require prophylaxis, and present single-dose regimens for use in patients who are susceptible to bacterial endocarditis . These single-dose oral regimens should lead to increased compliance by dentists and patients.

Br J Surg, 1999 Mar, 86(3), 320 - 2
Survey of antibiotic prophylaxis in acute pancreatitis in the UK and Ireland; Powell JJ et al.; BACKGROUND: Current surgical practice with regards to antibiotic prophylaxis in acute pancreatitis in the UK and Ireland was overviewed . METHODS: The 1103 members of the Association of Surgeons of Great Britain and Ireland were surveyed by postal questionnaire . A total of 528 replies were received (48 per cent) . Following exclusion of surgeons not treating patients with acute pancreatitis, analysis was carried out on 429 replies . RESULTS: Respondents treated a median of 12 (interquartile range (i.q.r.) 10-20) patients per year with acute pancreatitis . Prophylactic antibiotic therapy was used by 88 per cent of responding surgeons, of whom 24 per cent used it in all cases . For surgeons professing selective use of antibiotics, the most common indication for use was in patients with prognostically severe disease . A cephalosporin was prescribed in 72 per cent of patients; cefuroxime was the single most common antibiotic . Combination therapy with metronidazole was used in 48 per cent of attacks . The median duration of antibiotic therapy was 5 (i.q.r . 5-7) days . An adverse drug reaction attributable to the use of prophylactic antibiotics was reported by 11 per cent of respondents . CONCLUSION: This study has established that a significant body of clinicians charged with the responsibility of treating acute pancreatitis use antibiotic prophylaxis in the initial treatment of patients with predicted severe disease.

Ann Thorac Surg, 1999 Feb, 67(2), 462 - 5
Is mediastinitis a preventable complication? A 10-year review; Baskett RJ et al.; BACKGROUND: The incidence of mediastinitis after cardiac surgical intervention is reported to be between 0.15% and 5% and is a major cause of postoperative morbidity . A number of risk factors have been identified, most of which are not modifiable . It is our contention that this complication can be reduced to a minimum by the consistent application of good operative technique and postoperative management . METHODS: We reviewed the records of all 9,771 patients who underwent cardiac surgical procedures between 1987 and 1997 . All operations were performed using a common skin preparation, draping, and antibiotic prophylaxis . Cases of mediastinitis were defined according to Centers for Disease Control and Prevention criteria and were identified from three sources: medical records database, hospital infection control, and the Society of Thoracic Surgeons database . Risk factors were assessed using chi2 and Fisher's exact tests . RESULTS: Of 24 patients identified as having deep sternal wound infection (incidence, 0.25%), 2 died (mortality rate, 8.3%), 18 required reoperation (75%), and only 4 needed pectoral muscle flaps . Statistical analysis revealed only the presence of chronic obstructive pulmonary disease as a significant risk factor (p < 0.01) . Other factors, including diabetes, renal failure, smoking, sex, age, reoperation, morbid obesity, and steroid use, were not significant . The use of internal mammary arteries (single or bilateral) was not associated with mediastinitis . Postoperative complications, including prolonged ventilation, inotropic support, and the need for blood products, were not significant risk factors . The patients who developed mediastinitis were more likely to be readmitted to the hospital (p < 0.005) and more likely to require reoperation (p < 0.005) . CONCLUSIONS: In a large patient series we found a low incidence of mediastinitis (0.25%) and an even lower incidence of required reoperation (0.19%) . Except for the use of bone wax and the use of bilateral mammary arteries in diabetic patients, none of the previously identified risk factors are modifiable . We believe that with strict adherence to perioperative aseptic technique, attention to hemostasis, and precise sternal closure, a very low incidence of mediastinitis can be achieved.

Ann Thorac Surg, 1999 Feb, 67(2), 352 - 60; discussion 360-2
Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures; Furnary AP et al.; BACKGROUND: Diabetes mellitus is a risk factor for deep sternal wound infection after open heart surgical procedures . We previously showed that elevated postoperative blood glucose levels are a predictor of deep sternal wound infection in diabetic patients . Therefore, we hypothesized that aggressive intravenous pharmacologic control of postoperative blood glucose levels would reduce the incidence of deep sternal wound infection . METHODS: In a prospective study of 2,467 consecutive diabetic patients who underwent open heart surgical procedures between 1987 and 1997, perioperative blood glucose levels were recorded every 1 to 2 hours . Patients were classified into two sequential groups: the control group included 968 patients treated with sliding-scale-guided intermittent subcutaneous insulin injections (SQI); the study group included 1,499 patients treated with a continuous intravenous insulin infusion in an attempt to maintain a blood glucose level of less than 200 mg/dL . There were no differences between these groups with respect to age, sex, procedure, bypass time, antibiotic prophylaxis, or skin preparation methods . RESULTS: Compared with subcutaneous insulin injections, continuous intravenous insulin infusion induced a significant reduction in perioperative blood glucose levels, which led to a significant reduction in the incidence of deep sternal wound infection in the continuous intravenous insulin infusion group (0.8% {12 of 1,499}) versus the intermittent subcutaneous insulin injection group (2.0% {19 of 968}, p = 0.01 by the chi2 test) . Multivariate logistic regression revealed that continuous intravenous insulin infusion induced a significant decrease in the risk of deep sternal wound infection (p = 0.005; relative risk, 0.34), whereas obesity (p < 0.03; relative risk, 1.06) and use of an internal thoracic artery pedicle (p = 0.1; relative risk, 2.0) increased the risk of deep sternal wound infection . CONCLUSIONS: Use of perioperative continuous intravenous insulin infusion in diabetic patients undergoing open heart surgical procedures significantly reduces major infectious morbidity and its associated socioeconomic costs.

J Adolesc Health, 1999 Mar, 24(3), 160 - 2
Piercing and tattooing in patients with congenital heart disease: patient and physician perspectives; Cetta F et al.; PURPOSE: The frequency and safety of ear piercing and tattooing were assessed in a group of children, adolescents, and adults with congenital heart disease (CHD) . Also, a group of physicians who care for adolescents and adults with CHD were surveyed for opinions and experiences regarding piercing and tattooing . METHODS: An eight-question survey was mailed to 445 patients (181 adults and 264 children) from one center . A different five-question survey was mailed to 176 physician members of the International Society of Adult Congenital Cardiac Disease . RESULTS: The patient survey was completed by 152 of 445 (34%) patients (mean age +/- standard deviation 19.8 +/- 16.2 years; range 0.25-67 years) . Eighty-eight of 152 (58%) patients were female . Ear piercing occurred in 65 of 152 (43%) patients (mean age 12.4 +/- 8.7 years; range 0.25-45 years) . Prior to piercing, only 4 of 65 (6%) patients took antibiotics, but 15 of 65 (23%) had piercing-related infections . No patient had endocarditis . Infections occurred 1 week to 3 years after piercing . All were local skin infections . Tattoos were placed in 8 of 152 (5%) patients (median age 17.5 years; range 13-56 years) . No antibiotic use or infections were reported in patients with tattoos . The physician survey was completed by 118 of 176 (67%) physicians . The majority of physicians did not approve of patients having piercing or tattooing performed . However, 60% of physicians believed that antibiotic prophylaxis is indicated for these procedures . CONCLUSIONS: Despite the opinion of many physicians, most patients do not take antibiotic prophylaxis for piercing and tattooing . Patients apparently do not suffer serious sequelae . The efficacy of standard antibiotic regimes as applied to ear piercing and tattooing requires further study, since these procedures are increasingly popular in modern society.

Hosp Pharm, 1992 May, 27(5), 404, 406 - 7
Antibiotic prophylaxis in cardiothoracic surgery 1990: results of a third survey; Woods M et al.; The use of prophylactic antibiotics for cardiothoracic surgery has become an accepted medical practice . The choice of drug and duration of therapy is controversial, however . In 1985 and 1988 the authors conducted telephone surveys of cardiothoracic surgery programs to determine the most frequently used agents . The survey was repeated in in 1990 . In the 1990 telephone survey, all 51 hospitals contacted in 1988 responded . Of the hospitals responding, 31 (61%) had standard regimens used for all patients and 19 (37%) used automatic stop orders for these regimens . In institutions with standard regimens, 18 (58%) used first-generation cephalosporins, 8 (26%) cefuroxime and 4 (13%) cefamandole . First-generation cephalosporins were included in 33 (48%) of the 69 regimens reported to be used in all hospitals surveyed . Cefuroxime, cefamandole, ceftriaxone, and vancomycin were all used in multiple hospitals . Eight (16%) hospitals changed regimen in the last 12 months, with three of these changing to cefuroxime . The data obtained in this most recent survey are similar to the data obtained in the 1985 and 1988 reports . The results of this survey indicated that most hospitals continue to use first-generation cephalosporins for antibiotic prophylaxis in cardiothoracic surgery, but there is considerable variation among institutions.

Hosp Formul, 1993 Mar, 28(3), 285 - 6, 289-90
Antibiotic prophylaxis in cesarean section: use of cost per case comparison to influence prescribing practices; Weir B; Results of a previously conducted DUE revealed that 91% of obstetric patients received antibiotic prophylaxis with cefoxitin despite the existence of obstetric department guidelines recommending the use of cefazolin . In the present DUE, antibiotic selection in C-section prophylaxis was reviewed and individual prescribers, both compliant and noncompliant with guidelines, were identified . Over a 2-month period, physicians who prescribed other than cefazolin for C-section prophylaxis were issued "Dear Doctor" letters, reminding them of existing guidelines . A significant change in prescribing patterns following this intervention was not demonstrated . A multidisciplinary approach was then undertaken . Prescribers were stratified by number of procedures, antibiotic requested, and antibiotic cost per case (average and median) . Results were reviewed with Co-chiefs of Ob/Gyn . Letters to both compliant and noncompliant prescribers were issued . A grand rounds presentation describing the results of the DUE was also given . A follow-up review showed that the conversion to cefazolin prophylaxis reached 80%, with accompanied extrapolated yearly cost avoidance of nearly $5,500.

J Can Dent Assoc, 1999 Feb, 65(2), 95 - 6
Infective endocarditis and dentistry: outcome-based research; Epstein JB; Antibiotic prophylaxis for prevention of infective endocarditis has long been recommended for patients receiving dental care . Two studies of patients with endocarditis found limited risk associated with dental treatment . It is imperative that guidelines for therapy be based on outcome studies and on evidence of safety, efficacy and cost effectiveness.

J Oral Maxillofac Surg, 1999 Mar, 57(3), 226 - 30; discussion 230-2
Antibiotic prophylaxis in orthognathic surgery: a 1-day versus 5-day regimen; Bentley KC et al.; PURPOSE: The effect on infection rates of 1-day and 5-day administration of prophylactic antibiotics in orthognathic surgical procedures was compared . PATIENTS AND METHODS: A prospective, randomized, double-blind clinical trial using placebo was conducted . Thirty patients were distributed equally between two groups . Each group received penicillin G, two million units intravenously, immediately preoperatively, and one million units intravenously every 3 hours intraoperatively and once postoperatively 3 hours after the last intraoperative dose . Group 1 then received penicillin G, one million units intravenously, every 6 hours for eight doses, followed by penicillin V suspension 300 mg orally every 6 hours for eight doses . Group 2 received placebo in a similar dosing schedule . The wounds were inspected on a regular schedule and evaluated for infection according to criteria established by the Centers for Disease Control . RESULTS: One of 15 patients in group 1 (6.7%) and 9 of 15 patients (60%) in group 2 became infected . The overall infection rate was 33.3% . There was a statistically significant difference in rates of infection between the two groups (P < .01) . CONCLUSION: Antibiotic prophylaxis for orthognathic surgical procedures should continue beyond the immediate postoperative period . Five days of antibiotic administration appears to provide adequate coverage.

Am Surg, 1999 Mar, 65(3), 226 - 8
The absent role of prophylactic antibiotics in low-risk patients undergoing laparoscopic cholecystectomy; Dobay KJ et al.; A retrospective chart review was done to determine the infection rate and the use of prophylactic antibiotics in consecutive laparoscopic cholecystectomies done in a single community . Incisional infections were discovered in 11 of 566 cases, 10 of whom had received prophylactic antibiotics . The infected patients were significantly older, had longer procedures, and had more comorbidity than the uninfected patients . They were also more likely to have a palpable mass preoperatively and past biliary surgery . A second, prospective study was done to evaluate the efficacy of the use of antibiotic prophylaxis in low-risk patients . Fifty-three patients were randomized into two double-blinded groups . No incisional infections occurred in either group within 30 days postoperatively . This suggests prophylactic antibiotics are not needed to prevent infections for low-risk patients undergoing laparoscopic cholecystectomy.

Fogorv Sz, 1999 Jan, 92(1), 23 - 9
{Risk patients in dentistry}; Suri C et al.; Authors study the risk diseases in dental practice . They analyze the possible complications and the methods of their prevention in each risk group . They take deal with the importance of antibiotic prophylaxis, the problems of local anaesthesia and the management of patients who suffer from coagulation disturbances . They present the management of risk patients in two cases . They emphasize the importance of anamnestic history in every case before dental treatment.

Ned Tijdschr Geneeskd, 1998 Nov 14, 142(46), 2530 - 2
{Sickle cell anemia during pregnancy}; Radder CM et al.; A 31-year-old pregnant Creole woman with sickle-cell anaemia went through a crisis of acute cholecystitis at 29 weeks' amenorrhoea . The crisis subsided after cholecystectomy, at which relative reduction of the number of sickle-cells by blood transfusions, adequate oxygenation, fluid, and antibiotic prophylaxis were provided . After 35 weeks' amenorrhoea, a healthy son was delivered by caesarean section . After the delivery, she developed fever and abdominal aches with a wound infection, and 10 days later a generalized epileptic attack . She recovered without sequelae . Pregnancy in a woman with sickle-cell anaemia may induce a sickle-cell crisis . The maternal morbidity and mortality and perinatal mortality are high, in spite of a pronounced decrease due to improved care.

Klin Khir, 1998, (6), 8 - 9
{Prophylaxis of postop bronchopulmonary complications during surgical treatment of inflammatory diseases of hepatobiliary tract}; Koval' AI et al.; The combination of own breathing with heightened end-expiratory pressure and antibiotic prophylaxis, ultrasonic inhalation using proteolytic enzymes, bronchofibroscopic sanation have permitted to reduce the occurrence frequency of pulmonary complications from 16 to 7%.

Minerva Chir, 1998 Nov, 53(11), 895 - 8
{The role of drainage and antibiotic prophylaxis in thyroid surgery}; De Salvo L et al.; BACKGROUND: It is our habit to employ an open drainage after thyroid surgery in our department . We have also found a large number of surgical infections in these patients (5.8% vs 2.5) . Aim of the study is to evaluate prospectively if contamination happens during surgical procedure or in a later time according to the presence of the open drainage . METHODS: From October 1995 to November 1996, 113 patients who underwent a subtotal thyroidectomy were randomized into two groups: group A with antibiotic prophylaxis (57 patients) and group B without it (56 patients) . RESULTS: One case (1.7%) of sepsis among 57 patients of group A and 2 cases (3.4%) among 56 patients of group B were observed . CONCLUSIONS: No statistical difference was found between the two groups despite antibiotic prophylaxis covering surgical procedure . It is personal opinion that sepsis arose after surgical procedure, due to the presence of the open drainage.

Am J Surg, 1998 Dec, 176(6A Suppl), 62S - 66S
Oral trovafloxacin compared with intravenous cefoxitin in the prevention of bacterial infection after elective vaginal or abdominal hysterectomy for nonmalignant disease . Trovafloxacin Surgical Group; Roy S et al.; BACKGROUND: Trovafloxacin is a new fourth-generation fluoroquinolone whose pharmacokinetics and in vitro activity suggest that it is well suited for antibiotic prophylaxis in elective hysterectomy . METHODS: In a randomized, double-blind, multicenter study, parallel groups of women 18 years of age or older received either 200 mg trovafloxacin by mouth and intravenous (i.v.) placebo or 2 g cefoxitin by i.v . infusion and placebo by mouth before elective vaginal or abdominal hysterectomy for nonmalignant disease . RESULTS: In the 103 and 97 patients in the trovafloxacin and cefoxitin groups, respectively, who were evaluable for efficacy, the prophylactic success rates at hospital discharge (96% in both groups) and 30 +/- 6 days after hysterectomy (88% and 91% in the trovafloxacin and cefoxitin groups, respectively) were statistically equivalent . Both antibiotics were well tolerated . CONCLUSION: A single oral 200 mg dose of trovafloxacin is as effective and safe as a standard cefoxitin parenteral regimen in the prevention of primary bacterial infection after elective vaginal or abdominal hysterectomy for nonmalignant disease.

Am J Surg, 1998 Dec, 176(6A Suppl), 14S - 17S
Concentrations of trovafloxacin in colonic tissue and peritoneal fluid after intravenous infusion of the prodrug alatrofloxacin in patients undergoing colorectal surgery; Melnik G et al.; BACKGROUND: Trovafloxacin is a new fourth-generation fluoroquinolone whose pharmacokinetics and in vitro activity suggest that it is well suited for antibiotic prophylaxis in elective colorectal surgery . Alatrofloxacin is a prodrug that is rapidly hydrolyzed to trovafloxacin in the body . METHODS: Twelve patients received a single dose of alatrofloxacin equivalent to 200 mg trovafloxacin by intravenous infusion over 1 hour . Surgery was started at various time points relative to infusion time to allow determination of trovafloxacin concentrations in serum, colonic tissue, and peritoneal fluid as a function of time . RESULTS: The concentration in the earliest colonic tissue sample (1.4 hours after dosing) was 1.4 microg/g . The maximum colonic tissue concentration was 2.8 microg/g in a sample taken 2 hours after dosing . Colonic tissue/serum concentration ratios in samples taken 2-10 hours after the end of infusion ranged from 0.8 to 1.47 . Concentrations of trovafloxacin in peritoneal fluid ranged from below the level of quantitation to 2.1 microg/mL at the time of colonic tissue sampling and from below the level of quantitation to 2.5 microg/mL at the time of wound closure . Alatrofloxacin was well tolerated . CONCLUSIONS: After a single intravenous dose of alatrofloxacin equivalent to 200 mg trovafloxacin, trovafloxacin is distributed rapidly into colonic tissue and peritoneal fluids . Tissue concentrations approximate serum concentrations and decline in parallel for up to 10 hours after dosing.

Infect Control Hosp Epidemiol, 1999 Jan, 20(1), 77 - 9
Cost reduction with successful implementation of an antibiotic prophylaxis program in a private hospital in Ribeirão Preto, Brazil; Fonseca SN et al.; OBJECTIVE: To describe the implementation and results of a perioperative antibiotic prophylaxis (PAP) program . DESIGN: A protocol for correct use of PAP was implemented in December 1994 . For selected months we measured the PAP protocol compliance of a random sample of clean and clean-contaminated procedures and calculated the cost of incorrect use of PAP . SELLING: A 180-bed general hospital in Ribeirao Preto, Brazil . RESULTS: The cost of unnecessary PAP in the obstetric and gynecologic, cardiothoracic, and orthopedic services dropped from $4,224.54 ($23.47/procedure) in November 1994 to $1,147.24 ($6.17/procedure, January 1995), $544.42 ($3.58/procedure, May 1995), $99.06 ($0.50/procedure, August 1995), and $30 ($0.12/procedure, March 1996) . In November 1994, only 13.6% of all surgical procedures were done with correct use of PAP, compared to 59% in January 1995, 73% in August 1995, 78% in March 1996, 92% in November 1996, and 98% in May 1997 . CONCLUSIONS: Incorrect PAP use wastes resources, which is a particular problem in developing countries . Our program is simple and can be implemented without the use of computers and now is being adopted in other hospitals in our region . We credit the success of our program to the commitment of all participants and to the strong support of the hospital directors.

Eur J Pediatr Surg, 1998 Dec, 8(6), 347 - 51
Conservative treatment in primary neonatal megaureter; Arena F et al.; The authors report their experience on 22 neonates (14 males and 8 females) with primary megaureter . In 18 patients a prenatal diagnosis was available, in the other four the diagnosis was suspected during a neonatal ultrasound screening . The dilatation involved the right ureter 7 times and the left 13 times, in 2 patients it was bilateral . Intravenous urography documented a type I ureteral dilatation in 2 renal units (8.3%), a type II in 9 (37.5%) and a type III dilatation in 13 (54.2%) . Radionuclide scan (Tc99m DTPA) demonstrated in all the renal units with megaureter a stable function . From diuretic renal scan, non-obstruction appeared in 19 (83%), obstruction in 2 (8.5%) and an equivocal result in the remaining 2 . Antibiotic prophylaxis was administered to all patients . Follow-up period ranged from 18 to 54 months . The 2 obstructed megaureter were surgically treated . Other 2 patients with type III dilatation and non-obstructing megaureter underwent surgery at 18 and 24 months of age respectively . The remaining 17 patients were all conservatively treated . The 2 patients with type I dilatation resolved spontaneously . Of 9 patients with type II megaureter the dilatation resolved in 6 patients and 3 patients had a good reduction . In the remaining 8 patients with type III megaureter, the dilatation resolved in 5 cases and 3 patients had only a fair reduction . The renal function (> 40%) remained stable in all the patients.

Clin Obstet Gynecol, 1998 Dec, 41(4), 827 - 31
Neonatal consequences of preterm PROM; Ernest JM; Preterm premature rupture of the fetal membranes is associated with 30-40% of premature births and is an important cause of perinatal morbidity and mortality . Although the major causes of neonatal death associated with PPROM include prematurity complications, infection, and pulmonary hypoplasia, rupture in a preterm gestation also is associated with an increase in morbidity, including cerebral palsy, other developmental delays, as well as chronic lung disease . When PPROM occurs, antibiotic prophylaxis has been shown to reduce the potential for complications and should be considered . Neonates treated intrapartum with antibiotics should have fewer complications, a longer latency period, and an improved long-term outlook compared with those without antepartum or intrapartum prophylaxis.

Burns, 1998 Dec, 24(8), 760 - 2
Antibiotic prophylaxis--Hobson's choice in burns management; Pillai TA et al.; Antibiotic prophylaxis is a routine procedure in management of burns . As such it is a safe practice, yet unusual complications can occur with the use of even safest antibiotics and their emergency management may be life saving . Here we present a case of 35% second and third degree burns who was taken for a second sitting of stamp grafting for remnant raw areas, who was administered intraoperative prophylactic antibiotic, developed a series of unusual complications sequentially, which were life threatening . Prompt recognition of signs and symptoms of adverse reactions of the drug used and timely management resulted in the successful outcome . A good team effort by surgeon, anaesthetist and the physician was mandatory.

J Fr Ophtalmol, 1998 Nov, 21(9), 627 - 35
{Results of a National survey on antibiotic prophylaxis and antisepsis in cataract surgery}; Mary JC et al.; PURPOSE: We present the results of a national survey carried out in 1997 among French ophthalmologists on prophylactic antibiotic and antiseptic therapy in cataract surgery . METHOD: Among the 6050 questionnaires sent by post, 1082 answers recorded between January and February 1997 . RESULTS: The results give precise details on French surgeons attitude as regards prophylactic antibiotics for: topical, subconjunctival, intra-ocular and systemic administration . CONCLUSION: This kind of study is frequent in English-speaking countries and is useful to help our profession to formulate important current questions and to collect answers.

Infect Dis Obstet Gynecol, 1998, 6(5), 220 - 3
Incidence of postpartum endomyometritis following single-dose antibiotic prophylaxis with either ampicillin/sulbactam, cefazolin, or cefotetan in high-risk cesarean section patients; Noyes N et al.; OBJECTIVE: To assess the efficacy of single-dose antibiotic prophylaxis against postpartum endomyometritis in high-risk cesarean section patients . DESIGN: Patients were administered one of three single-dose antibiotic regimens following umbilical cord clamping after cesarean section delivery . SETTING: Prospective randomized trial at a university-based hospital . PATIENTS: The study evaluated 293 consenting women undergoing cesarean section who had either experienced labor for a duration of > or = 6 hr or rupture of amniotic membranes . MAIN OUTCOME MEASURES: Development of postpartum endomyometritis . RESULTS: The incidence of postpartum endomyometritis was 7/95 (7.4%) following the ampicillin/sulbactam regimen, 14/98 (14.3%) after the cefazolin regimen, and 11/99 (11.1%) after the cefotetan regimen . There was no significant difference in postpartum infection among the three study arms . In addition, the incidence of endomyometritis in the three single-dose study arms was not higher than previously noted in studies where three doses of antibiotic were administered . CONCLUSION: Single-dose antibiotic prophylaxis should replace the standard triple-dose therapy for uninfected women undergoing cesarean section who are at risk for postoperative endomyometritis . Ampicillin/sulbactam, cefazolin, and cefotetan are all reasonable antibiotic choices for single-dose therapy.

Hand Clin, 1998 Nov, 14(4), 657 - 66
The role of antibiotics in the management of elective and post-traumatic hand surgery; Hoffman RD et al.; The use of prophylactic antibiotics in elective and emergency hand surgery is an unsettled issue . Although their benefit in general surgical cases and certain orthopedic cases is well established, the lower infection rates in elective and emergency hand surgery have made attempts to prove the efficacy of prophylaxis more difficult . Valid arguments can be made for the use of antibiotics in human and animal bites . Prophylactic antibiotic use is efficacious in the following scenarios: (1) soft-tissue reconstructive procedures with large flaps, (2) total elbow or wrist implant arthroplasty, (3) procedures of long duration, and (4) complex open hand trauma with wound contamination and extensive soft-tissue and bony injury . Antibiotic prophylaxis does not appear warranted in clean, elective procedures lasting fewer than 2 hours . The duration of antibiotic use should be as short as possible to minimize complications and the development of bacterial resistance . The selection of a particular antibiotic regimen remains the surgeon's choice, but many inexpensive and relatively safe antibiotic agents are available . Although uncommon, potentially serious hazards exist with the use of antibiotics . Definitive guidelines on the use of antibiotics in hand surgery are not available; hand surgeons should apply basic principles of prophylaxis and be aware of the existing controversies.

Srp Arh Celok Lek, 1998 May-Jun, 126(5-6), 171 - 6
{Therapeutic approach in blast injuries of the ear}; Spremo S et al.; Otic blast injury is caused by arrhythmic air blast wave . The perforation of the tympanic membrane is the commonet finding associated with lacerations of mucosa in the middle ear . Makki {6} published 34 cases of myringoplasty after war blast injuries . However, healing of such perforations is common; Kerr {7} noted a healing rate of 83% after the blast injury . The aim of the study was to evaluate different therapic procedures of otic blast injuries . There were 74 patients with bilateral otic blast injuries, who underwent otomycroscopic examination . The following parameters were noted: Integrity of tympanic membrane and size of perforation, presence of haemorrhagic exudate in the middle ear and median value of conductive deafness (Table 2) . Main symptoms, presented in Table 1 were: pain, deafness and otohaematorrhoea . The first group of 19 patients received antibiotics by parenteral way during 7 days according to the bacterial finding in ear exudate . Healing rate was dependent on the size of tympanic membrane perforation, and rated from 71% in perforation of one third of tympanic membrane to 25% in total perforation of tympanic membrane . Data are presented in Table 3 . The second group of 24 patients received the same therapy as the first treatment, plus otomycroscopic removal of haemorrhagic exudate, lacerated middle ear mucosa, and repair of tympanic membrane lacerations . Healing rate was significantly better than the one obtained in the first group (Table 4) . Persistent tympanic perforation, as indicator of failed therapy, was present in 5 (35%) of all examined ears with two thirds of tympanic membrane perforation in the first group, while in the second group the rate was 3 (12%) . The third group received the same therapy as the second treatment, including administration of amicacyn into the external auditory canal . The results were statistically compared by chi 2 test, and we found that the second therapy protocol was significantly better . There was no significant difference between the second and the third therapy protocols . We found blast ruptures of tympanic membrane and auditory ossicles chain discontinuity in 88% of examined ears . In our material the high incidence of total tympanic membrane ruptures and subtotal ruptures (48%) is quite different in comparison to other authors {5-7} . We consider it as the effect of high power blast wave . Loss of conductive hearing was present in 91% of blast injured patients, while 7.4% of patients had mixed, predominantly senzoneural deafness . Consequently, in addition to mechanic blast injuries acoustic trauma could profoundly damage the inner ear . Spontaneous healing of tympanic membrane occurred in 71% of injured persons and this was a better result than the results obtained by other authors {3, 4, 6} . The spontaneous healing of tympanic membrane failed if infection of the middle ear occurred or blast caused the total tympanic membrane perforation . In the second and third therapy protocols significantly higher healing of tympanic membrane ruptures was evident; it rated from 88% to 91% . Better results could be explained by the effect of optimal healing conditions, based on removal of exudate from the middle ear and necrotic parts of tympanic membrane, completed by fitting of lacerated parts of tympanic membrane and antibiotic prophylaxis . Healing of tympanic membrane without scars and adhesions was more frequent than in patients treated only with antibiotics . Incidence of undesired outcome of persistent perforation of tympanic membrane was reduced . To prevent posttraumatic complications in the middle ear, we recommend early cleaning of margins, reposition of lacerated fragments of tympanic membrane, and removal of haemorrhagic exudate . Myringoplasty should be performed if spontaneous healing of tympanic membrane did not occur after 6 months . CONCLUSION: Otic blast injury was frequently found in war induced trauma . (ABSTRACT TRUNCATED)

J Indiana Dent Assoc, 1998 Spring, 77(1), 47 - 50
Antibiotic prophylaxis in dentistry: a common sense approach; Campbell JH; Current knowledge about potentially serious infections after dental treatment suggests that antibiotic prophylaxis is of benefit in their prevention . This article describes several regimens for preventing infectious sequelae in patients with heart disease, prosthetic joints, and other "high risk" medical conditions . The prudent dental practitioner will use them regularly.

Acta Otorhinolaryngol Ital, 1998 Apr, 18(2), 88 - 95
{Nasal packing and antibiotic prophylaxis in septoplasty: a controlled study}; Manzini M et al.; Systematic use of preoperative antibiotic prophylaxis (PAP) and nasal packing (NP) in septoplasty-both directly and indirectly affecting the cost of surgery (length of hospitalization)-appear based on controversial scientific data and, at times, even on unjustified clinical "habits" . A controlled study was thus performed on 100 adults undergoing exclusive nasal septoplasty to determine whether these techniques are actually useful . The subjects were randomly divided into four groups: TN-PAP-(29 subjects), TN-PAP+ (25 subjects), TN+ PAP- (21 subjects) and TN+ PAP+ (25 subjects) . Surgery was always performed by the same surgeon and was concluded with continuous suture of the mucoperichondrial layers . Only one patient (TN-PAP-) presented complications of infection (vestibulitis) . Three patients in the TN- group required nasal packing a few hours after surgery because of moderate bleeding . As of three months after surgery no other complications had arisen . Postoperative pain, evaluated on an analogicalvisual scale, was higher during the 12 hours after surgery . Analysis of variance showed that the only pain-related factor was nasal packing while PAP and the interaction between TN and PAP did not prove significant . The above results suggest that PAP and TN should not be systematically used, thus reducing the hospitalization period for septoplasty to the day of surgery (Day surgery).

J Reprod Med, 1998 Nov, 43(11), 975 - 85
Outcomes in abdominal hysterectomy patients with benign disease . Use of physician-developed clinical protocols; D'Amato LO Jr et al.; OBJECTIVE: To develop a clinical protocol for standardizing preoperative and postoperative care in abdominal hysterectomy patients with benign disease while maintaining quality and increasing efficiency . STUDY DESIGN: Protocol and nonprotocol groups of patients were compared with respect to key quality and efficiency outcomes in a non-randomized study . Patient group outcomes were compared using descriptive, Student's t, chi 2 and log-rank statistics . Statistical tests were performed at a .05 level of significance . RESULTS: Results from two separate protocol study periods conducted in 1996 and 1997 are reported . In both study periods statistical analyses and graphic presentations illustrate that protocol implementation improved quality of care by increasing the percentage of patients receiving appropriate antibiotic prophylaxis; maintained quality as monitored through 30-day readmission rates and a postdischarge patient survey; and improved efficiency, as evidenced by shorter times to incision and length of hospital stay . CONCLUSION: At Toledo Hospital, the clinical practice protocol directed at abdominal hysterectomy patients has been an effective tool in efforts to improve quality and efficiency in patient care.

Ann Intern Med, 1998 Nov 15, 129(10), 761 - 9
Dental and cardiac risk factors for infective endocarditis . A population-based, case-control study; Strom BL et al.; BACKGROUND: Although antibiotic prophylaxis against infective endocarditis is recommended, the true risk factors for infective endocarditis are unclear . OBJECTIVE: To quantitate the risk for endocarditis from dental treatment and cardiac abnormalities . DESIGN: Population-based, case-control study . SETTING: 54 hospitals in the Philadelphia area . PATIENTS: Persons with community-acquired infective endocarditis not associated with intravenous drug use were compared with community residents, matched by age, sex, and neighborhood of residence . MEASUREMENTS: Information on demographic characteristics, host risk factors, and dental treatment was obtained from structured telephone interviews, dental records, and medical records . RESULTS: During the preceding 3 months, dental treatment was no more frequent among case-patients than controls (adjusted odds ratio, 0.8 {95% CI, 0.4 to 1.5}) . Of 273 case-patients, 104 (38%) knew of previous cardiac lesions compared with 17 controls (6%) (adjusted odds ratio, 16.7 {CI, 7.4 to 37.4}) . Case-patients more often had a history of mitral valve prolapse (adjusted odds ratio, 19.4 {CI, 6.4 to 58.4}), congenital heart disease (adjusted odds ratio, 6.7 {CI, 2.3 to 19.4}), cardiac valvular surgery (adjusted odds ratio, 74.6 {CI, 12.5 to 447}), rheumatic fever (adjusted odds ratio, 13.4 {CI, 4.5 to 39.5}), and heart murmur without other known cardiac abnormalities (adjusted odds ratio, 4.2 {CI, 2.0 to 8.9}) . Among case-patients with known cardiac lesions--the target of prophylaxis--dental therapy was significantly (P = 0.03) less common than among controls (adjusted odds ratio, 0.2 {CI, 0.04 to 0.7} over 3 months) . Few participants received prophylactic antibiotics . CONCLUSIONS: Dental treatment does not seem to be a risk factor for infective endocarditis, even in patients with valvular abnormalities, but cardiac valvular abnormalities are strong risk factors . Few cases of infective endocarditis would be preventable with antibiotic prophylaxis, even with 100% effectiveness assumed . Current policies for prophylaxis should be reconsidered.

Am J Infect Control, 1998 Dec, 26(6), 594 - 604; quiz 605-6
Prevention of infection in the immunocompromised host; Risi GF et al.; The Association for Professionals in Infection Control and Epidemiology, Inc, is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation . This learner-paced study package is designated for 1.1 contact hours . APIC's California nursing provider number is CEP 7146.This continuing medical laboratory education activity is recognized by the American Society of Clinical Pathologists as meeting the criteria for 1 CMLE credit hour . ASCP CMLE credit hours are acceptable to meet the continuing education requirements for the ASCP Board of Registry Continuing Competence Recognition Program . (See the instructions and examination at the end of the article.)Infectious diseases represent a major cause of morbidity and mortality in immunocompromised patients . Infectious complications are often predictable and may be preventable . This article is an overview of practical considerations in the care of immunocompromised patients . Recognizing the compromised host, identifying and correcting risk factors in advance, and reducing sources of infection all play a role in prevention . Topics were chosen to include the areas of care that differ from the immune competent patient, such as diet, pet therapy, handwashing, immunizations, augmentation of host resistance, prevention of pneumonia, and antibiotic prophylaxis . National practice guidelines are cited when possible; evidence-based literature review and experience are applied to situations lacking consensus statements . Treatment decisions are made in areas for which information is often incomplete . A systematic approach to care of the immunocompromised host, tailored to the individual patient's needs, should reduce the risk of infection.

Gastroenterology, 1998 Dec, 115(6), 1513 - 7
Controlled clinical trial of pefloxacin versus imipenem in severe acute pancreatitis; Bassi C et al.; BACKGROUND & AIMS: Antibiotic prophylaxis in severe pancreatitis has recently yielded promising clinical results, with imipenem significantly reducing the incidence of infected necrosis compared with an untreated control group . On the bases of pefloxacin's spectrum of action and pancreatic penetration, we investigated whether such drugs represent a valid alternative to imipenem . METHODS: In a multicenter study, 60 patients with severe acute pancreatitis with necrosis affecting at least 50% of the pancreas were randomly allocated to receive intravenous treatment for 2 weeks with pefloxacin, 400 mg twice daily (30 patients), or imipenem, 500 mg three times daily (30 patients), within 120 hours of onset of symptoms . Age, sex, body weight, Ranson and Apache II scores, C-reactive protein, etiology, and time from onset of symptoms to treatment were well matched in the two groups . RESULTS: The incidences of infected necrosis and extrapancreatic infections were 34% and 44%, respectively, in the pefloxacin group and 10% and 20% in the imipenem group . Imipenem proved significantly more effective in prevention of pancreatic infections (P </= 0.05) . Mortality was not significantly different in the two groups . CONCLUSIONS: Despite its theoretical potential, pefloxacin is inferior to imipenem in the prevention of infections associated with severe pancreatitis.

Dakar Med, 1997, 42(2), 127 - 31
{Antibiotic prophylaxis à la carte in self-contaminated gynecologic and obstetric surgery: importance of cefotaxime}; Cisse CT et al.; Infections represents 5% of our post-operative morbidity and result in the use of expensive antibiotics and longer hospital stays . As a less expensive alternative to systematic antibiotherapy for all patients, the authors propose a prospective and descriptive study of the effectiveness of antibioprophylaxis by administering 1 g of Cefotaxime pre-operatively . The study concerns a continuous series of 103 cases in gynaecology and obstetrics operated in the Dakar University Teaching Hospital, during a 13 months period (April 95-April 96) . The average age of the patients is 30 years, the major types of surgery was cesarean sections, laparotomy for extra-uterine pregnancy and myomectomies . The duration of the surgery varied between 40 to 105 minutes with an average of 60 minutes . There was no intolerance to Cefotaxime . No cases of post operative infections were observed . All surgical wounds healed in 6 to 8 days except 2 minor cases of non-union of 1 cm . Antibioprophylaxis with Cefotaxime can therefore be considered as an effective means of preventing post-operative infections in clean surgery . It is easy to administer and also has the advantage of lower cost (4050 Fcfa compared to 29,000 Fcfa for classic antibiotherapy).

Ann Chir Gynaecol, 1998, 87(3), 200 - 3
Current principles of treatment in acute pancreatitis; Puolakkainen P et al.; The treatment of mild acute pancreatitis (AP) with fluid replacement and other conservative measures is adequate and sufficient in the majority of patients . The corner-stones of the treatment of patients with severe acute pancreatitis include early aggressive fluid resuscitation, intensive care with close monitoring and support of organ function, antibiotic prophylaxis, early supportive treatment of organ failure, and surgery in selected cases with infected pancreatic necrosis or deterioration of patient's condition in spite of maximal conservative therapy . Early endoscopic removal of common bile duct stones should be considered in cases with biliary AP . Altogether, increased accuracy in early diagnosis and development of intensive care have resulted in a significant decrease in mortality of patients with severe pancreatitis . In this paper, we review the current principles and methods of treatment in acute pancreatitis at Helsinki University Central Hospital.

Postgrad Med, 1998 Nov, 104(5), 149 - 56
Heart disease during pregnancy . Which cardiovascular changes reflect disease?
Villablanca AC.
Primary care physicians have an important role in timely diagnosis and appropriate treatment of gravid patients with cardiac disorders . Health of the mother and child can be optimized with thorough understanding of the pathophysiology of cardiac disorders during pregnancy, especially those with potentially serious effects, such as peripartum cardiomyopathy and acute myocardial infarction . Mitral stenosis often manifests for the first time during pregnancy . Mitral valve prolapse is usually benign but in some cases necessitates antibiotic prophylaxis for delivery . Pregnancy in women with prosthetic cardiac valves may expose mother and child to risks that can be minimized with appropriate safeguards.

J R Coll Surg Edinb, 1998 Oct, 43(5), 339 - 40
Audit of timing of antibiotic prophylaxis in hip and knee arthroplasty; Lewis K; Infection following arthroplasty can have devastating consequences . Antibiotic prophylaxis is routinely given in modern orthopaedic practice in an attempt to reduce infection rates . The aim is to achieve clinically useful tissue concentrations of antibiotic peri-operatively, and this is accomplished with antibiotic administration at induction of anaesthesia and at 6 and 12 h post-operatively . The case notes of 16 consecutive patients undergoing elective joint replacement surgery were reviewed . All received antibiotic prophylaxis, but the time intervals between doses were longer than the current standard in 50% of patients for the second dose and 81% of patients for the third dose . Our practice has been reviewed to ensure that all patients receive antibiotics at the appropriate times.

Br Dent J, 1998 Sep 26, 185(6), 295 - 8
Bacteraemia following local anaesthetic injections in children; Roberts GJ et al.; OBJECTIVES: To estimate odontogenic bacteraemia following three different types of local anaesthetic injections, namely: buccal infiltration analgesia (BIA), conventional intraligamental analgesia (CIA), and modified intraligamental analgesia (MIA) . PATIENTS AND METHODS: The bacteraemia-producing potential of three methods of injecting local analgesic solution was determined by taking blood samples, using aseptic technique, from 143 children, aged 1 year 11 months to 19 years 4 months, undergoing general anaesthesia for dental extractions . Of these 143 children, a subgroup of 50 had blood taken before any dentogingival manipulative procedures to provide a baseline level of bacteraemia . The injection methods were buccal infiltration, conventional intraligamental, and a modified intraligamental . The blood samples were taken 30 seconds after injection and cultured in aerobic and anaerobic broth cultures (Bactec) and from lysis filtration vials (Isolator) . RESULTS: The percentage prevalence of bacteraemia was: baseline level 8%; buccal infiltration analgesia 16%; modified intraligamental analgesia 50%; and conventional intraligamental analgesia 97% . These values were statistically significantly different using the chi-squared test (P < 0.001) . The mean value for colony forming units per millilitre (Isolator system) was 252 (sd = 646) for the intraligamental technique but zero for baseline, infiltration and modified intraligamental techniques . CONCLUSIONS: All local anaesthetic techniques studied were associated with bacteraemia which may have implications for antibiotic prophylaxis for dental treatment . The intraligamental techniques had statistically significantly greater percentage prevalence of bacteraemia compared with baseline . The modified intraligamental technique causes significantly less bacteraemia than the conventional intraligamental technique.

Int J Clin Pract Suppl, 1998 Jun, 95, 39 - 43
Surgical antibiotic prophylaxis: tradition and change; Gudiol F; The use of antibiotic surgical prophylaxis in the prevention of postoperative infection is now well accepted . It is also agreed that prophylactic antibiotics are only effective if given before surgery . This allows time for the antibiotics to concentrate in the blood before being incorporated into fibrin clots at the wound site after surgery . Despite the widespread use of antibiotic surgical prophylaxis, the incidence of surgical site infection remains high . Poor adherence to guidelines, resulting from conflicts of interest between hospital departments, and the inappropriate use of antibiotics has been blamed . Cooperation and consensus between physicians, pharmacists and surgeons is required if antibiotic misuse is to be reduced . Locally developed antibiotic practice guidelines, designed, in part, by computer-assisted decision-making systems, offer the best way of monitoring and improving prophylactic antibiotic efficacy and compliance.

Klin Monatsbl Augenheilkd, 1998 Sep, 213(3), 141 - 6
{Corneal penetration of various aminoglycosides and quinolones}; Luthardt K et al.; BACKGROUND: Penetration of the aminoglycosides gentamicin and tobramycin and chinolones ciprofloxacin and ofloxacin applied as eyedrops and soaked disposable lenses (ACUVUE), used as antibiotic prophylaxis, was investigated . MATERIALS AND METHODS: 217 patients received before undergoing cataract extraction 0.3% solutions of these antibiotics as eyedrops or by soaked ACUVUE-lenses . During surgery 50-100 microliters aqueous humor was aspirated; concentration of gentamicin and tobramycin was analysed by fluorescence polarisation immuno assay, concentration of ciprofloxacin and ofloxacin was analysed by high pressure liquid chromatography . RESULTS: After application of gentamicin and ofloxacin as eyedrops and via soaked ACUVUE-lenses as drug delivery system (DDS) we found higher concentrations than after application of tobramycin and ciprofloxacin by the same modes . After using of soaked lenses as DDS the aqueous humor concentrations of all tested substances were higher than the concentrations after the frequent instillation of eyedrops . CONCLUSIONS: Penetration of gentamicin through normal human cornea is higher than penetration of tobramycin; penetration of ofloxacin through normal human cornea is higher than penetration of ciprofloxacin . The aqueous humor concentrations of ofloxacin applied as eyedrops and DDS, of ciprofloxacin and gentamicin applied as DDS allow their use as antibiotic prophylaxis in cataract surgery.

Spec Care Dentist, 1997 Sep-Oct, 17(5), 153 - 60
Patients with prosthetic joints: are they at risk when receiving invasive dental procedures?
Little JW.
Most prosthetic joint infections (PJI) are due to wound contamination at the time of surgery . Some infections occur due to the hematogenous spread of bacteria from distant sites of infection . A review of the literature falls to associate PJI with transient bacteremias from invasive dental procedures . Several authors have described conditions which, they believe, render patients with prosthetic joints more at risk for infection . Prosthetic joint patients with these "high risk" conditions have the same types of infecting organisms as other patients with PJI . This indicates that the infecting bacteria are from wound contamination or distant sites of infection and not related to dental procedure bacteremias . Based on this review, antibiotic prophylaxis is not indicated for patients with prosthetic joints when receiving invasive dental procedures, since there is no proven benefit and there are known risks involved with the use of antibiotics . However, the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS), in an advisory statement, suggest prophylaxis for "high risk" patients . The ADA and AAOS recommend a single dose of amoxicillin, cephradine, or clindamycin when prophylaxis is selected . The dentist is ultimately responsible for making treatment recommendations for his or her patients.

Br J Surg, 1998 Oct, 85(10), 1378 - 81
Early results of a randomized trial of rifampicin-bonded Dacron grafts for extra-anatomic vascular reconstruction . Joint Vascular Research Group; Braithwaite BD et al.; BACKGROUND: The aim of this study was to determine whether the routine use of an antibiotic-bonded gelatin-coated Dacron graft could reduce the incidence of prosthetic graft infection . Extra-anatomic grafts were chosen for study as they have the highest risk of graft infection . This paper reports early results up to 1 month after surgery . METHODS: This multicentre study involved 14 vascular units in the UK . A total of 257 patients underwent extra-anatomic bypass . Patients were randomized to rifampicin bonding (1 mg/ml rifampicin soak for 15 min before graft insertion) or a control group . Routine three-dose antibiotic prophylaxis was administered to patients in both groups . RESULTS: There were 178 men and 79 women of median age 69 (range 43-92) years . Rifampicin-bonded (n=123) and control (n=134) groups were well matched for clinical details, risk factors and operative techniques . No side-effects were noted from rifampicin bonding . Only one patient (in the control group) developed a graft infection and this proved fatal . There were no significant differences between bonded and unbonded grafts in terms of perioperative mortality rate (9 and 5 per cent respectively), median hospital stay (10 days for both groups), total infective complications (15 and 21 per cent respectively) or need for postoperative antibiotics (13 and 18 per cent respectively) . CONCLUSION: Early results from this study have not identified any significant advantage in the routine use of rifampicin bonding, but the rate of graft infection was very low (0.4 per cent) . Gelatin coating alone may provide protection against infection . Definitive recommendations about the role of antibiotic bonding cannot be made until longer follow-up becomes available.

Am J Surg, 1998 Sep, 176(3), 239 - 43
Prospective, randomized, double-blind study of prophylactic antibiotics in axillary lymph node dissection; Bold RJ et al.; BACKGROUND: Antibiotic prophylaxis is controversial in patients undergoing axillary lymph node dissection (ALND) . We determined whether preoperative antibiotics decreased incidence or treatment cost of infectious complications following ALND . METHODS: Two hundred patients entered this prospective, randomized, double-blind trial . Patients received either placebo or cefonicid preoperatively . Loco-regional signs of infection were monitored for 4 weeks postoperatively . RESULTS: There was a trend toward fewer infections in the prophylactic group (placebo 13% versus cefonicid 6%; P = 0.080) . Cefonicid significantly decreased severe infections requiring hospitalization (placebo 8% versus cefonicid 1%; P = 0.033) . Cefonicid also decreased the treatment cost of infection per patient ($49.80 versus $364.87) . CONCLUSIONS: We demonstrated a trend toward fewer overall infections and significantly fewer severe infections in patients given prophylactic antibiotics, which translated into a decrease in the cost of treatment for infectious complications . These findings support antibiotic prophylaxis for patients undergoing ALND.

Am J Gastroenterol, 1998 Oct, 93(10), 1895 - 900
A cost analysis of long term antibiotic prophylaxis for spontaneous bacterial peritonitis in cirrhosis; Das A; OBJECTIVE: The aim of this study was to perform a cost analysis of different strategies of long term antibiotic prophylaxis for spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and ascites . The study involved a cost analysis using a decision analysis model and patients with cirrhosis and ascites who are at risk for developing SBP . METHODS: Two different strategies of antibiotic prophylaxis were compared with a "no prophylaxis" strategy in patients with cirrhosis and ascites using a decision analysis model . In strategy I, antibiotic prophylaxis was administered in all patients with cirrhosis and ascites and in strategy II, patients were stratified into a low risk and a high risk group on the basis of serum bilirubin and ascitic fluid protein levels; only patients in the high risk group received antibiotic prophylaxis . The cost per patient treated for 1 yr was the outcome measure compared in the different strategies . Clinical input probabilities and ranges used were obtained by searching the MEDLINE database for English language articles . Cost estimates were obtained from a university hospital setting . Cost analysis was done with a societal perspective, and only direct costs were taken into account . Sensitivity analyses were performed to evaluate the effect of variations in the key clinical probabilities and cost estimates ranging from a best case to a worst case scenario on the outcome measure . RESULTS: The estimated cost per patient treated in strategy I, strategy II, and strategy III (the strategy of "no prophylaxis") were $1311, $1123, and $3509, respectively . Over a broad range of clinical and cost variables, the strategy of risk stratification and restriction of antibiotic prophylaxis to the subgroup of patients with cirrhosis and ascites who were at high risk for SBP (as identified by serum bilirubin >2.5 mg/dl and ascitic fluid protein <1 g/dl) was the most favored strategy . However, when the cost of prophylaxis was low or the probability of a primary episode of SBP was at the lower end of the range reported in the literature, administering antibiotic prophylaxis to all patients with cirrhosis and ascites was the least costly strategy . CONCLUSION: This cost analysis indicates that antibiotic prophylaxis particularly when restricted to a subgroup of patients who, by simple laboratory parameters, are identified to be at high risk for SBP, is very cost-effective in the prevention of SBP in patients with cirrhosis and ascites.

Akush Ginekol (Sofiia), 1998, 37(1), 25 - 7
{Strategies in antibiotic prophylaxis in abdominal hysterectomy}; Tsankova M et al.; The following study presents the high effectiveness of the short-term antibiotic prophylaxis versus long-term in elective abdominal hysterectomy . The authors compare two groups of 68 patients each for a period of 10 months . In the first group 67 patients have received one antibiotic and one--a combination of two antibiotic per 24 hours . In the second group 66 patients have received one antibiotic and two patients--a combination of two antibiotics for a period of 3 days . The two groups were compared using two clinical characteristics--axillary temperature and pulse, and also postoperative complications--vulnerary infections (parametrial, subfascial, and subcutaneous) The results demonstrate that in these cases the short-term antibiotic prophylaxis has higher effectiveness than the long-term one in the prevention of febrile complications and postoperative infections.

Br J Obstet Gynaecol, 1998 Sep, 105(9), 1022 - 5
Do routine antibiotics after loop diathermy excision reduce morbidity?
Foden-Shroff J, Redman CW, Tucker H, Millinship J, Thomas E, Warwick A, Jones PW.
OBJECTIVE: To evaluate whether routinely giving an antibiotic after loop diathermy excision of the cervical transformation zone reduced post-operative vaginal loss . DESIGN: Prospective, randomised, double-blind placebo controlled parallel study . PARTICIPANTS: Five hundred women undergoing loop diathermy excision in a colposcopy clinic . INTERVENTION: Administration of either ofloxacin 400 mg (2x200 mg) once daily for 5 days or an identical placebo . MAIN OUTCOME MEASURE: Vaginal loss, assessed using a pictorial chart . RESULTS: No significant difference in post-operative vaginal loss was found . CONCLUSION: Routine antibiotic prophylaxis after loop diathermy excision is not justified.

Arch Pediatr, 1998 Jul, 5(7), 785 - 92
{Prevention of infective endocarditis in the child . Current status and protocols}; Di Filippo S et al.; Infective endocarditis remains a severe, potentially lethal disease, which justifies a rigorous prevention schedule . Children with cyanotic congenital heart disease, mitroaortic valvulopathies, prosthetic valve and uncorrected ventricular septal defect are the most susceptible . Dental care is the main cause of bacterial graft, followed by upper respiratory tract and cutaneous infections . Prevention is mainly based upon antibiotic prophylaxis but patient education and good dental hygiene are also important.

Ann Fr Anesth Reanim, 1998, 17(7), 764 - 8
{Survey of 39 South East Group hospital centers on the practice of antibiotic prophylaxis in surgery}; Martin C et al.; A survey was carried out in 39 hospitals regarding the prescribing of perioperative antibiotics . The day of the survey, hospital pharmacists collected information on prescription patterns of antibiotics and, for 3 days, the duration of their administration . A total of 1,131 cases were surveyed, originating from digestive surgery (20%), orthopaedics (31%), gynaecology (15%), ophthalmic surgery (15%), and others (19%) . Duration of surgery was 72 +/- 68 min . For all types of surgeries, antibiotics not recommended by the French consensus conference were prescribed . Third generation cephalosporins were used in 17% of patients in gynaecological surgery . In 20% of cases, antibiotics were administered at an inappropriate time: 9.5% after the beginning of surgery, 8% at the time of pre-medication, and 2.5% the day before surgery . Administration exceeded 48 hours in 10% of the cases . In conclusion, special attention should be paid to limit the prescription of third generation cephalosporins, to inject antibiotic at the induction of anaesthesia and to reduce the duration of their administration.

Ann Fr Anesth Reanim, 1997, 16(7), 913 - 7
{Perioperative antibiotic prophylaxis practice of French anesthesiologists and resuscitators: results of a national survey}; Martin C et al.; Antibiotics are the most prescribed drugs in French hospitals in one third of cases they are used for antiobiotic prophylaxis in surgery . In spite of the guidelines for antibioprophylaxis produced in the last years, their prescription patterns remain still often inappropriate . This survey aimed to assess whether the prescription of antibiotics for prophylaxis by French anaesthetits complied with the French recommendations for antibioprophylaxis in surgery . It focused on the recommended agents, the time of the first injection, the duration of treatment . A sample of 1,473 anaesthetists participated in the survey . In 93% of cases, the first injection of the antibiotic took place at anaesthesia induction, as specified by the recommendations . Cephalosporins of the first and second generation were often administered, as well as the association amoxicillin-clavulanic acid . In contradiction with the recommendations, the cephalosporins of the third generation were widely prescribed in digestive and urological surgery, and the quinolones in urology and ophtalmology . The duration of treatment was restricted to 48 hours by 94% of anaesthetists . However there was a strong tendency to prolonge it in immunodepressed patients and in case of major surgery . This survey showed disparities between the French recommendations for antibioprophylaxis in surgery and the prescription patterns of anaesthetists . The lack of compliance occurred mainly for recent cephalosporins and treatment duration of over 48 hours . It is concluded that a stronger adherence to the principles of antibioprophylaxis is required in surgical patients.

Eur Urol, 1998 Oct, 34(4), 303 - 12
Considerations regarding prostate biopsies; Beerlage HP et al.; OBJECTIVES: To review the current clinical practice concerning prostate biopsies and indications for prostate biopsies and to study the value of biopsies in grading and staging of prostate cancer . METHODS: The literature from 1990 onwards was reviewed systematically . A selection out of the huge number of publications concerning the subject was made based on the relevance of the study (e.g., number of patients, study design) . RESULTS: Transrectal ultrasound-guided biopsies have become a routine procedure in urological practice and can be performed safely . Antibiotic prophylaxis is recommended generally . Sextant biopsies should be performed when no lesion is visible or added to lesion-directed biopsies in case of a visible lesion . The indications for biopsies and for repeat biopsies are discussed . The indication for biopsies remains a problem in spite of prostate-specific antigen and prostate specific antigen derived indexes and in spite of new imaging techniques . The value of prostate biopsy in grading and staging is limited, and care should be taken not to base treatment decisions on prostate biopsy results only and not to compare treatment results based on biopsy data . CONCLUSIONS: Prostate biopsies have become a routine procedure in urology . Although very helpful in many cases, their limitations should be kept in mind . More efforts will have to be made to reduce the (too) large number of negative biopsies by improvement of imaging techniques and development of more sensitive and specific tumor markers.

Epidemiol Infect, 1998 Aug, 121(1), 103 - 8
Transmission risk of Borrelia burgdorferi sensu lato from Ixodes ricinus ticks to humans in southwest Germany; Maiwald M et al.; The risk of Borrelia burgdorferi infection and the value of antibiotic prophylaxis after tick bite are controversial . In this study, performed in two areas of southwestern Germany, ticks were collected from 730 patients and examined by the polymerase chain reaction (PCR) for B . burgdorferi . To assess whether transmission of B . burgdorferi occurred, the patients were clinically and serologically examined after tick removal and during follow-up examinations . Data from all tick bites gave a total transmission rate of 2.6% (19 patients) . Eighty-four ticks (11.3%) were PCR positive . Transmission occurred to 16 (26.7%) of 60 patients who were initially seronegative and could be followed up after the bite of an infected tick . These results indicate that the transmission rate from infected ticks in Europe is higher than previously assumed . Examination of ticks and antibiotic prophylaxis in the case of positivity appears to be indicated.

Chest Surg Clin N Am, 1998 Aug, 8(3), 529 - 39, viii
Postoperative pneumonia; Ferdinand B et al.; Thoracic surgical patients are susceptible to pneumonia because of impaired systemic and lung host defenses . The incidence of pneumonia is higher with more extensive lung resections . Current prophylactic antibiotic therapy is based primarily on general surgical experience with emphasis on wound infection, not pneumonia . With expansion of indications for lung resection to include higher risk patients, there is a need to render antibiotic prophylaxis more specific to bacteria causative of pneumonia.

Mund Kiefer Gesichtschir, 1998 Jul, 2(4), 194 - 201
{Perioperative antibiotic prophylaxis in orthodontic bone operations of the facial skull}; Reinhart E et al.; Intraoral orthognathic surgical procedures are clean-contaminated operations because of the facultative pathogenic flora of the oral cavity . Without antibiotic prophylaxis in this kind of operation a postoperative wound infection can be expected in 20-31% of cases . Therefore, a retrospective analysis of the clinical course of 545 patients with various dentofacial deformities was performed to evaluate the importance of perioperative antibiotic prophylaxis . The total rate of wound infections was 2.8% and lower than rates published in other comparable studies without antibiotic prophylaxis . The rate of wound infection after single mandibular osteotomy (4.1%) was significantly higher than the analogous amount after single maxillary osteotomy (0.8%) because of the mechanical strain of the surgical wound in the region of the mandibular angle and because of the high retention of food particles and other decay products in this area . The recognized rise in the wound infection rate by increasing the length of operation demonstrates that the extent of bacterial contamination of the surgical wound depends on the dimension and duration of surgery . Bacterial flora caused the noticed wound infections in 61.5% of cases aerobic-anaerobic mixed infections, which is in accordance with the results of similar publications . With increasing length of antibiotic prophylaxis, an increase in the incidence of antibiotic-associated side effects and in the wound infection rate could be observed . Therefore, an antibiotic prophylaxis which exceeds 3 days does not seem to be useful . In this study, in which cephalosporins were mostly used, the total rate of antibiotic-associated side effects (4.6%) was lower than analogous amounts of other groups of antibiotics . The analysis demonstrates that a short-term prophylaxis with broad-spectrum cephalosporins such as cefatoxime of 48 h is very effective and useful.

J Clin Epidemiol, 1998 Sep, 51(9), 773 - 8
Impact of an educational program on antibiotic use in a tertiary care hospital in a developing country; Thamlikitkul V et al.; A multi-cross-sectional study was conducted in a 2000-bed tertiary care university hospital in Bangkok, Thailand, from September 1993 to May 1994 to assess the effectiveness of an educational program on the use of antibiotics . Data on the study covered antibiotic usage both in-patients and out-patients . Data were collected for a 24-hour period every 2 weeks for 7 days for each 3-month period . The target population were residents, general practitioners, and sixth-year medical students . The educational program provided information derived from the data of inappropriate use of antibiotics during the pre-intervention period and guidelines on the use of antibiotics which were agreed to by a consensus among the faculty in all clinical departments . The study revealed: (1) the prevalence of antibiotic use and the cost of antibiotics during post-intervention period was significantly decreased by 20%; (2) the use of antibiotic prophylaxis for obstetrics patients and patients undergoing cataract surgery decreased significantly; (3) there was a shift from second or third generation cephalosporins to cefazolin for surgical prophylaxis; (4) the duration of perioperative antibiotic prophylaxis was reduced to under 2 days; (5) there was a shift from netilmicin or amikacin to gentamicin for the treatment of community acquired infection; and (6) the mortality, median length of hospital stay, and nosocomial infection rate among the patients who received antibiotics during the post-intervention period were not significantly different from those during the pre-intervention period . These results suggest that this educational program comprising information feedback and antibiotic usage guidelines was effective in improving antibiotic use at this tertiary care university hospital in Thailand.

Int Orthop, 1998, 22(3), 182 - 4
Serum albumin and deep infection in femoral neck fractures . A study of 437 cases followed for one year; Hedstrom M et al.; Four hundred and thirty-seven patients with femoral neck fractures were studied to determine the value of serum albumin estimations on admission . Serum albumin is a good predictor of mortality, and patients with low levels should be given additional nutritional support . We found that the serum albumin level is not useful in predicting deep wound infection . The infection rate of 3% does not justify the use of antibiotic prophylaxis in general.

AIDS, 1998 Aug 20, 12(12), 1451 - 7
Mycobacterium tuberculosis infection and disease are not associated with protection against subsequent disseminated M . avium complex disease; Sterling TR et al.; OBJECTIVE: To determine the relationship between Mycobacterium tuberculosis infection and disease and subsequent disseminated M . avium complex (MAC) disease in HIV-infected persons . DESIGN: A prospective observational cohort study . SETTING: The AIDS Linked to the Intravenous Experience (ALIVE) cohort of injecting drug users and the Johns Hopkins Hospital Adult HIV Clinic (JHHAHC) . PARTICIPANTS: HIV-infected persons aged > 18 years with CD4 lymphocytes < 100 x 10(6)/l were followed between July 1989 and 31 October 1996 . There were 182 persons in the ALIVE cohort and 1129 persons in JHHAHC who met these criteria . MAIN OUTCOME MEASURE: The relative risk of disseminated MAC was determined according to a history of prior opportunistic infection, MAC prophylaxis, antiretroviral therapy, M . tuberculosis infection or disease, race, sex, and injecting drug use . RESULTS: Amongst the 30 patients with active tuberculosis, eight developed disseminated MAC, compared with 208 cases of disseminated MAC amongst 1148 patients without prior M . tuberculosis infection or disease {relative risk (RR), 1.5; 95% confidence interval (CI), 0.8-2.7; P=0.2} . Amongst the 10 patients with extrapulmonary tuberculosis, five developed disseminated MAC (RR, 2.8; 95% CI, 1.5-5.2; P=0.02) . Injecting drug use was associated with a decreased risk of disseminated MAC (RR, 0.7; 95% CI, 0.6-0.9; P=0.007) . In a logistic regression analysis, disseminated MAC was significantly associated with extrapulmonary tuberculosis and other opportunistic disease, whereas antibiotic prophylaxis and injecting drug use were protective . CONCLUSIONS: A history of M . tuberculosis infection or disease was not associated with protection against subsequent disseminated MAC disease in HIV-infected persons . However, persons with extrapulmonary tuberculosis were at increased risk for disseminated MAC, particularly at low CD4 cell levels.

Int J Gynaecol Obstet, 1998 Jul, 62(1), 23 - 9
Single or triple dose piperacillin prophylaxis in elective cesarean section; Shah S et al.; OBJECTIVE: To evaluate the efficacy and safety of piperacillin in the prevention of perioperative febrile morbidity in elective cesarean sections, a combination of cephradine plus metronidazole vs . a control group which did not receive any antibiotic prophylaxis . METHOD: 198 women undergoing elective cesarean section were included in a randomized control study to compare the prophylactic efficacy and safety of a single dose (4 g) or three doses (2 g) of piperacillin, three doses of cephradine plus metronidazole combination, when administered peri-operatively and a control group which did not receive prophylactic antibiotics . RESULT: 198 women were randomized to the study, but 14 had to be excluded leaving 184 for analysis . Statistically significant difference was reached when comparing the piperacillin groups (group A and group C) with control (group D) in the prevention of postoperative febrile morbidity inclusive of wound infection and endomyometritis (single-dose piperacillin group A: Relative Risk = 0.14, 95% CI 0.03-0.58) . Multi-dose piperacillin therapy group C: R.R . = 0.27, 95% CI 0.10-0.77) . The combination of cephradine and metronidazole (group B) when compared with the control group did not show any statistical significant difference in prevention of postoperative febrile morbidity (R.R.= 0.49, 95% CI 0.22-1.10) . Single-dose piperacillin when compared to multi-dose piperacillin regimen appears to be more effective at reducing postoperative infective morbidity but this is not statistically significant (R.R . = 0.51, 95% CI 0.10-2.65) . When febrile morbidity is separated into wound infection and myometritis, the reduction rates in either of them in each antibiotic study group A, B and C compared to the control group D are not significant except when study groups A and C are combined and compared to control group D (R.R . = 0.21, 95% CI 0.76-0.06) . CONCLUSION: Piperacillin single agent therapy, either as a single dose of 4 g or a triple dose of 2 g, is effective and safe in the prevention of postoperative infection when given as prophylaxis in elective cesarean cases.

J Vasc Surg, 1998 Aug, 28(2), 340 - 4
Infected renal artery pseudoaneurysm and mycotic aortic aneurysm after percutaneous transluminal renal artery angioplasty and stent placement in a patient with a solitary kidney; Deitch JS et al.; Endovascular infections after percutaneous transluminal renal angioplasty with stenting (PTRAS) are rarely reported . Because strict longitudinal follow-up of patients undergoing PTRAS is lacking, the true incidence of such complications remains obscure . We report the first case of a patient with an infected renal artery pseudoaneurysm and de novo mycotic aortic aneurysm after PTRAS . This case serves to illustrate several important points, including (1) the retrieval of renal function in patients with renal artery occlusion, (2) the pathogenesis of infection after PTRAS, (3) the diagnosis and management of endovascular infection after percutaneous vascular intervention, and (4) recommendations for periprocedural antibiotic prophylaxis during PTRAS.

Acta Otorrinolaringol Esp, 1998 Jun-Jul, 49(5), 397 - 9
{Comparative study of 2 antibiotic prophylactic protocols in oncologic surgery of the pharynx and larynx}; Ibarrondo J et al.; The use of antibiotic prophylaxis in oncological pharyngeal and laryngeal surgery has reduced the risk of postoperative wound infection, which decreases morbidity and health-care costs . We report the results of a prospective randomized study in our hospital comparing the effectiveness of two antibiotic protocols, amoxicillin-clavulanate and clindamycin plus gentamicin, both given for 24 hours, in patients who underwent clean-contaminated oncological surgery of the pharynx or larynx.

Clin Infect Dis, 1998 Aug, 27(2), 364 - 9
Antibiotic prophylaxis after basilar skull fractures: a meta-analysis; Villalobos T et al.; Antibiotic prophylaxis after basilar skull fractures remains controversial . Previous studies have not clearly delineated the utility of prophylactic antibiotics in this setting . We undertook this study to determine if antibiotic prophylaxis after basilar skull fractures prevented meningitis . We performed a formal systematic review of previously published studies after a computerized search with use of the MEDLINE data base (1970-1996) . Fourteen studies were identified, and 12 studies met the criteria for inclusion . Study design and quality were assessed by two independent investigators with use of a predetermined protocol . A total of 1,241 patients with basilar skull fractures were included; 719 patients received antibiotics, and 522 patients did not receive antibiotics . Overall results suggest that antibiotic prophylaxis did not prevent meningitis among patients with basilar skull fractures (odds ratio {OR} = 1.15; 95% confidence interval {CI} = 0.68-1.94; P = .678) . Patients with basilar skull fractures and cerebrospinal fluid leakage were analyzed separately (OR = 1.34; 95% CI = 0.75-2.41; P = .358), as were children (OR = 1.04; 95% CI = 0.07-14.90; P = 1.000) . Antibiotic prophylaxis after basilar skull fractures does not appear to decrease the risk of meningitis.

Laryngoscope, 1998 Aug, 108(8 Pt 1), 1129 - 35
The failing flap in facial plastic and reconstructive surgery: role of the medicinal leech; Utley DS et al.; OBJECTIVE: To review the use of the medicinal leech, Hirudo medicinalis, in salvaging the failing, venous-congested flap . A protocol for the use of leeches is presented . Four illustrative cases of failing flaps (pectoralis major, midline forehead, and temporalis) are presented . STUDY DESIGN: Literature review comprised of MEDLINE search 1965 to present . Retrospective review of four cases involving the management of the failing, venous-congested flap . METHODS: A retrospective review of four cases of failing, venous-congested flaps was performed . RESULTS: The authors' experience, as well as the data from the reviewed medical literature, demonstrates the importance of early intervention in order to salvage the failing, venous-congested flap . Leeches are an immediate and efficacious treatment option . CONCLUSIONS: 1 . Review of the literature indicates that the survival of the compromised, venous-congested flap is improved by early intervention with the medicinal leech . H medicinalis injects salivary components that inhibit both platelet aggregation and the coagulation cascade . The flap is decongested initially as the leech extracts blood and is further decongested as the bite wound oozes after the leech detaches . 2 . When a flap begins to fail, salvage of that flap demands early recognition of reversible processes, such as venous congestion . The surgeon must be familiar with the use of leeches and should consider their use early, since flaps demonstrate significantly decreased survival after 3 hours if venous congestion is not relieved . In the four cases presented, a standardized protocol facilitated early leech use and provided for the psychological preparation of the patient, availability of leeches, and an antibiotic prophylaxis regimen . 3 . The complications associated with leech use can be minimized with antibiotic therapy, wound care, and hematocrit monitoring . 4 . The use of the medicinal leech for salvage of the venous-congested flap is a safe, efficacious, economical, and well-tolerated intervention.

J Clin Oncol, 1998 Aug, 16(8), 2651 - 8
Randomized trial of intensive cyclophosphamide, epirubicin, and fluorouracil chemotherapy compared with cyclophosphamide, methotrexate, and fluorouracil in premenopausal women with node-positive breast cancer . National Cancer Institute of Canada Clinical Trials Group; Levine MN et al.; PURPOSE: To determine the relative efficacy of an intensive cyclophosphamide, epirubicin, and fluorouracil (CEF) adjuvant chemotherapy regimen compared with cyclophosphamide, methotrexate, and fluorouracil (CMF) in node-positive breast cancer . PATIENTS AND METHODS: Premenopausal women with node-positive breast cancer were randomly allocated to receive either cyclophosphamide 100 mg/m2 orally days 1 through 14; methotrexate 40 mg/m2 intravenously (i.v.) days 1 and 8; and fluorouracil 600 mg/m2 i.v . days 1 and 8 or cyclophosphomide 75 mg/m2 orally days 1 through 14; epirubicin 60 mg/m2 i.v . days 1 and 8; and fluorouracil 500 mg/m2 i.v . days 1 and 8 . Each cycle was administered monthly for 6 months . Patients administered CEF received antibiotic prophylaxis with cotrimoxazole two tablets twice a day for the duration of chemotherapy . RESULTS: The median follow-up was 59 months . One hundred sixty-nine of the 359 CMF patients developed recurrence compared with 132 of the 351 CEF patients . The corresponding 5-year relapse-free survival rates were 53% and 63%, respectively (P = .009) . One hundred seven CMF patients died compared with 85 CEF patients . The corresponding 5-year actuarial survival rates were 70% and 77%, respectively (P = .03) . The rate of hospitalization for febrile neutropenia was 1.1% in the CMF group compared with 8.5% in the CEF group . There was one case of congestive heart failure in a patient who received CMF compared with none in the CEF group . Acute leukemia occurred in five patients in the CEF group . CONCLUSION: The results of this trial show the superiority of CEF over CMF in terms of both disease-free and overall survival in premenopausal women with axillary node-positive breast cancer.

Infect Control Hosp Epidemiol, 1998 Jul, 19(7), 513 - 5
Identification and voluntary reduction of vancomycin use for perioperative antibiotic prophylaxis during coronary artery bypass graft surgery; Pear SM et al.; Vancomycin prophylaxis for coronary artery bypass graft surgery without prosthetic valve implantation voluntarily decreased from 94% to 18% in one medical center . Median hospital stay (10 vs 9 days, P = .30) and number of postoperative infections (17.0% vs 14.3%, P = .60) did not differ among patients who received vancomycin and those who did not.

Schweiz Med Wochenschr, 1998 Jun 20, 128(25), 1012 - 9
{Status and after-care of young adults with congenital heart defects}; Immer FF et al.; INTRODUCTION: We studied patients with congenital heart defects born in 1975 and followed by our institution . We were interested in the outcome of these patients at the age of 20 years with regard to professional status, physical activity and psychosocial aspects . Furthermore, we investigated the handover from the paediatric to the adult cardiologist as well as the information level concerning antibiotic prophylaxis against bacterial endocarditis . METHODS: From a previous follow-up study to the age of 16 years, we knew 224 patients with congenital heart disease born in 1975, 119 were considered to need further cardiological follow-up . In 112 (94%) we have a complete follow-up to the age of 20 years with a structured interview by phone . RESULTS: Mortality and medical care during the period between 16 and 20 years of age were at a lower level than in the previous periods . Except in patients suffering from complex or surgically treated cyanotic heart disease, the results, compared to the standard population at the age of 20 years, are better with regard to professional status, and equal for physical activity and psychosocial integration . Only 60% of the patients were followed by an adult cardiologist and only 45% of the patients needing antibiotic prophylaxis against bacterial endocarditis are aware of this . CONCLUSION: Except in patients with complex congenital or surgically treated cyanotic heart diseases, the outcome at the age of 20 years with regard to professional status, physical activity and psychosocial integration is very good compared with the standard population at the age of 20 years . The handover to the adult cardiologist is inadequate and knowledge and awareness of antibiotic prophylaxis against bacterial endocarditis is also insufficient-both aspects need improvement.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1998 Jul, 86(1), 55 - 64
Oral management of the patient with end-stage liver disease and the liver transplant patient; Douglas LR et al.; The patient with end-stage liver disease who is in need of a liver transplant should have a pretransplant dental evaluation . Such a patient faces lifelong immunosuppression with an increased risk of infection . This article discusses both the need for control of oral diseases before liver transplantation and guidelines for oral care in the immediately postoperative and long-term transplant patient . Specific indications for antibiotic prophylaxis and antibiotic regimens are presented; in addition, adverse reactions and side effects of immunosuppressant drugs are discussed . Pertinent drug interactions salient to the dental management of patients with end-stage liver disease are reviewed, and specific management recommendations for these patients are presented.

J Natl Med Assoc, 1998 Jul, 90(7), 417 - 23
Antibiotic prophylaxis for intracranial pressure monitors; Jacobs DG et al.; To determined the safety and efficacy of prophylactic antibiotics in head-injured patients requiring intracranial pressure monitors, the files of 30 consecutive patients with isolated, severe head injuries admitted over a 1-year period were reviewed . Patients .15 years with severe closed-head injury who did not have severe concomitant, extracranial injury (Abbreviated Injury Score, 3) and survived .48 hours following hospital admission were included . Fourteen patients underwent intracranial pressure monitor placement and received prophylactic antibiotics for the duration of monitoring and the remaining 16 patients were neither monitored nor given prophylactic antibiotics . Length of hospital stay, length of intensive care stay, overall and septic complication rate, and death rate were compared for the two treatment groups . The groups were similar with regard to patient characteristics, associated injuries, and injury severity . Patients who received prophylactic antibiotics demonstrated statistically higher septic morbidity rates (78.6% versus 31.3%) and statistically higher pneumonia rates (57.1% versus 18.8%) compared with patients who did not . No patient developed central nervous system infection related to the monitor itself . These results indicate that the administration of prophylactic antibiotics to head-injured patients for the duration of intracranial pressure monitoring is unnecessary and potentially detrimental . Antibiotics, if given at all, should be limited to the period immediately surrounding intracranial pressure monitor placement.

Gen Dent, 1998 Jan-Feb, 46(1), 89 - 91
Clinical consideration for infective endocarditis antibiotic prophylaxis; Roberts HW et al.; American Heart Association (AHA) guidelines to prevent infective endocarditis recommend the use of antibiotic prophylaxis to treat hypertrophic cardiomyopathy caused by mitral regurgitation . The syndrome of congestive heart failure is frequently seen with clinical findings similar to those of hypertrophic cardiomyopathy, but antibiotic prophylaxis is not specifically recommended in the current AHA guidelines for congestive heart failure . Clinicians should be aware of the incidence of valvular abnormalities in congestive heart failure, and other cardiomyopathies, and consider the use of infective endocarditis antibiotic prophylaxis per AHA guidelines.

Acta Chir Plast, 1998, 40(2), 36 - 40
Prophylactic antibiotics administration head and neck cancer surgery with major flap reconstruction: 1-day cefoperazone versus 5-day cefotaxime; Bhathena HM et al.; Patients who undergo surgery of the head and neck cancer with major flap reconstruction, benefit from perioperative antibiotic prophylaxis . Head and neck surgery, especially ablative cancer surgery with major flap reconstruction is potentially contaminated iatrogenic wound, and the use of preoperative, perioperative and post operative chemoprophylaxis for infection is mandatory . This study is being done to determine if shorter course of antibiotic administration (Cefoperazone) would be more effective than conventional 5-day antibiotic administration (Cefotaxime) . Patients who are identified as requiring major flap reconstruction after extensive ablative surgery for head and neck cancer, are considered as potential candidates for this study . The choice of ideal antibiotics and duration period are still under discussion . Patients were assigned randomly to receive Cefoperazone sodium for either 24 hr . (study group) or Cefotaxime sodium for 120 hr . (control group) . A total of fifty patients were studied . The incidence of wound infection, flap death and major complications are evaluated . Out of the fifty patients studied, twenty-eight were assigned to 1-day prophylaxis . Incidence of failure of prophylaxis (F . P.) was 7.1% in this group . Twenty-two patients were assigned to 5-day prophylaxis, in whom F . P . rate was 9.8% . This study suggests that, there is no beneficial effect from administration of antibiotics for more than 24 hr . postoperatively in patients two undergo major flap reconstruction for head and neck cancer after extensive radical ablation surgery.

Am Surg, 1998 Jul, 64(7), 617 - 20; discussion 620-1
Role of prophylactic antibiotics for tube thoracostomy in chest trauma; Gonzalez RP et al.; The objective of this study was to evaluate the efficacy of antibiotic prophylaxis in association with tube thoracostomy for chest trauma patients with Injury Severity Scores of 9 or 10 . A double-blind randomized clinical trial of patients requiring tube thoracostomy was performed at an urban Level 1 trauma center . All patients included in this series were patients with Injury Severity Scores of 9 or 10 (hemothorax/pneumothorax) who suffered isolated chest trauma secondary to blunt or penetrating trauma . Before chest tube placement, 139 patients (34 blunt trauma, 105 penetrating trauma) were blindly randomized to Group A (71 patients) for which they received 1 g cefazolin intravenously every 8 hours or Group B (68 patients) for which they received a placebo intravenously every 8 hours . Antibiotic or placebo was administered before chest tube insertion and continued until the time of chest tube removal . The majority of patients underwent chest tube placement in the emergency room with a small number of delayed pneumothoraces (4 patients) treated after admission . In the 71 patients receiving antibiotic, 7 complications (1 pleural effusion, 2 chest tube reinsertions, 4 additional chest tubes) occurred, none of which were infectious . In the 68 patients receiving placebo, 7 complications (2 empyemas, 2 pneumonias with effusions, 1 pleural effusion, 2 chest tube reinsertions) occurred, 4 of which were infectious and required antibiotic intervention (P = 0.05, Fisher's exact test) . This study showed that patients receiving antibiotics have a significantly reduced incidence of infectious complications and suggests that patients who undergo tube thoracostomy for chest trauma would benefit from administration of prophylactic antibiotics.

New Horiz, 1998 May, 6(2 Suppl), S11 - 9
Antibiotic prophylaxis; Cainzos MA; During the past 30 years, antibiotic prophylaxis has proved of enormous efficacy in reducing the incidence of surgical wound infections, postoperative morbidity and mortality, the duration of the postoperative period, and the overall cost of surgical treatment . In this paper, the timing and route of administration of antibiotic prophylaxis as well as the dosage and duration, the indications for antibiotic prophylaxis, the importance of the alterations of the delayed hypersensitivity response, and the value of antibiotic prophylaxis for prevention of postoperative septic complications in anergic patients are analyzed . The possibility of combining antibiotic prophylaxis with immunoprophylaxis for high-risk patients is also analyzed.

J Urol, 1998 Feb, 159(2), 365 - 8
Renal colic during pregnancy: a case for conservative treatment; Parulkar BG et al.; PURPOSE: We defined the merits of early evaluation and conservative treatment of pregnant patients admitted with renal colic . MATERIALS AND METHODS: We retrospectively evaluated 72 pregnancies in 70 patients who were hospitalized with the diagnosis of renal colic between 1984 and 1995 . Urinalysis was performed in every case . Ultrasound was the primary diagnostic test in 65 patients . The patients were followed for 2 weeks to 3 months after delivery (mean 21 days) . RESULTS: Mean patient age at presentation was 27.4 years . The majority of patients were multiparous (47 of 70) and presented in the third trimester (44 of 70) . Microscopic urinalysis was not helpful in identifying stone disease in pregnant patients . The sensitivity of ultrasound for the diagnosis of renal calculi was 95.2% . Watchful conservative nonsurgical treatment resulted in spontaneous passage of stones in 64.3% of cases . Of the 19 pregnancies in which intervention was necessary cystoscopy and Double-J* silicone stent placement were done in 15, and ureteroscopy and stone basketing were done in 4 . Two patients, who presented with pyelonephritis and premature ruptured membranes had fetal loss . Long-term antibiotic prophylaxis was maintained in all stented and bacteriuric patients . CONCLUSIONS: Renal colic in pregnant patients can be complicated by pyelonephritis and premature labor, especially if misdiagnosed or inadequately treated . Ultrasound is a safe and sensitive diagnostic test . Approximately two-thirds of renal calculi will pass spontaneously . For those who require intervention, placement of a Double-J stent is a safe and effective option.

Transplantation, 1998 Jun 15, 65(11), 1500 - 3
Pathogenesis of early operative site infections after orthotopic liver transplantation; Arnow PM et al.; BACKGROUND: We hypothesized that operative site infections after orthotopic liver transplantation arise from bacteria in bile or jejunum . METHODS: To ascertain the validity of this hypothesis and to assess the effect of systemic antibiotic prophylaxis, we obtained intraoperative cultures of peritoneum, fascia, explant and donor liver bile, and jejunal lumen in 77 liver transplantations, and we monitored outcome . RESULTS: Pathogens were recovered from peritoneum, fascia, or bile in 11 cases . By univariate analysis, a positive culture was significantly associated with choledochojejunostomy (P=0.0002), previous liver transplantation (P=0.0002), and previous hepatobiliary surgery (P=0.002) . Operative site infections during the first 2 weeks after transplantation occurred only in cases with positive intraoperative cultures, and three of the four infections were caused by the same bacteria detected intraoperatively . Antibiotic susceptibility of intraoperative isolates was tested in nine cases; infection occurred in two of three cases in which the isolates were resistant to the systemic antibiotic prophylaxis and in none of six cases with susceptible isolates . CONCLUSIONS: Our findings suggest that systemic antibiotic prophylaxis for more than 2 days may be beneficial in cases with bacterial contamination of the operative site but may not be necessary in other cases.

Acta Otorrinolaringol Esp, 1998 Apr, 49(3), 221 - 4
{Risk factors in surgical wound infection in oncological surgery of the head and neck}; Rodrigo Tapia JP et al.; Although the use of antibiotic prophylaxis has significantly reduced the frequency of postoperative wound infections, they continue to be a critical issue in head and neck cancer surgery . A study was made of possible risk factors for the development of these infections . A prospective study was made of 159 patients with pharyngo-laryngeal squamous-cell carcinoma who underwent open-pharynx surgery in order to analyze the factors associated with wound infections . Postoperative wound infection was defined as purulent drainage or mucocutaneous fistula formation, or both, in the first 10 days after surgery . Potential risk factors examined were age, medical illnesses, prior surgery and radiotherapy, TNM stage, type of operative procedure, method of reconstruction, and operative time . The overall wound infection rate was 23% . Although the incidence of wound infection was higher in patients who received preoperative radiotherapy, in patients with advanced stage disease, and in those who required flap reconstruction, the only preoperative factor that significantly increased the rate of wound infection was the concurrence of medical illnesses (chronic obstructive pulmonary disease and diabetes mellitus; p = 0.018) . In conclusion, the presence of prior medical diseases was the main risk factor in the development of postoperative wound infections.

Schweiz Rundsch Med Prax, 1998 May 20, 87(21), 716 - 8
{Dog, cat and human bites}; Krause M; Animal and human bites carry a high risk of infectious complications . Human bites and in particular clenched-fist injuries as well as cat bites are highly prone to infection as are wounds that involve the hand or deep structures including joints, bones and tendons . The management of bite wounds consists of intensive irrigation with large volumes of normal saline and a cautions debridement of devitalized tissues . Generally, it appears prudent to leave the wounds open, however, in cases carrying a low risk of infection, a primary surgical closure might be appropriate . If a bite wound is infected, an antibiotic course with amoxycillin/clavulanic acid (first choice) or tetracyclines (second choice) for 10-14 days is recommended . In patients who present early after the injury, an antibiotic prophylaxis for 3-5 days is appropriate, particularly when the risk for the development of infection is high . Furthermore, a tetanus booster and in case of possible transfer of rabies, a rabies vaccination with immunoglobulins and inactivated virus preparation is recommended.

Zentralbl Chir, 1998, 123 Suppl 2, 25 - 30
{Current surgical treatment status of gallstones in East Germany}; Asperger W et al.; The changes of surgical treatment of gallstone disease to the laparoscopic procedure was performed just at the same time in East Germany was destroyed the socialism . That's why the new operative technique was possible in many hospitals in 1992/93 first . To describe the actually situation and the trend we started a prospective multi-institutional study included 29 East German surgical departments of all kinds . The most interesting things were perioperative antibiotic prophylaxis, laparoscopically procedures in elderly or high risc patients, the management of common bile duct stones and the minor and major complications . We discuss the results and the comparison with the results of externe quality assurance.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1998 May, 85(5), 509 - 11
Dental implant installation without antibiotic prophylaxis; Gynther GW et al.; The objective of this study was to retrospectively compare the outcomes of dental implant treatment with and without antibiotic prophylaxis . Two groups of patients with edentulous or partially edentulous maxillas or mandibles (or both) were treated with dental implants . One group, consisting of 147 patients (790 implants), was given prophylaxis with oral phenoxymethylpenicillin; 1 g of antibiotic was administered 1 hour preoperatively, and 1 g was administered every 8 hours for 10 days postoperatively . The other group, consisting of 132 patients (664 implants) was not given any antibiotics preoperatively or postoperatively . There were no significant differences with respect to early and late postoperative infections or with respect to implant survival between the two groups . It appears that antibiotic prophylaxis for routine dental implant surgery offers no advantage for the patient.

J Vasc Interv Radiol, 1998 May-Jun, 9(3), 401 - 6
Investigation of antibiotic prophylaxis usage for vascular and nonvascular interventional procedures; Dravid VS et al.; PURPOSE: To investigate current antibiotic prophylactic usage for arteriography, angioplasty, vascular stent placement, transjugular intrahepatic portosystemic shunt placement (TIPS), tunneled-port placement, inferior vena cava (IVC) filter placement, biliary drainage, genitourinary drainage, abdominal drainage, and enteral tube placement with an aim to better clarify indications and regimens for prophylaxis . METHODS: A questionnaire regarding antibiotic prophylactic usage was sent to 2,039 members of the Society of Cardiovascular and Interventional Radiology (SCVIR) . There were 401 respondents . Replies were evaluated for frequency and indications of prophylaxis, specific prophylaxis used, and clarity of indications for prophylaxis . RESULTS: A majority of responders never used prophylaxis for arteriography, angioplasty, vascular stent placement, IVC filter placement, abdominal drainage, and enteral tube placement . Infective complication rates from nonusage ranged between 1% and 15% . Approximately 45% always used prophylaxis for tunneled-port placement and TIPS with a 13%-16% infective complication rate among nonusers . In contrast, a majority of responders always used prophylaxis for biliary and genitourinary drainage, with a 40%-58% infective complication rate in nonusers . More than 70% of responders believed that the indications for prophylaxis were not clear for arteriography, angioplasty, vascular stent placement, tunneled-port placement, TIPS, IVC filter placement, and enteral tube placement, and in contrast, that the indications for prophylaxis for biliary and genitourinary drainage were clear . Fifty-one percent of responders believed that indications for prophylaxis for abdominal drainage were clear . CONCLUSIONS: Indications for antibiotic prophylaxis are not clear to interventionalists for a large number of vascular and nonvascular interventional procedures . Prophylaxis appears unnecessary for routine arteriography, angioplasty, IVC filter placement, vascular stent placement, or enterostomy tube placement . Antibiotic prophylaxis is warranted for TIPS and tunneled-port placement . Conversely, indications for antibiotic prophylaxis are clear to interventionalists for biliary and genitourinary drainage procedures . Routine prophylaxis remains warranted for both.

Endoscopy, 1998 Mar, 30(3), 318 - 24
Guidelines of the European Society of Gastrointestinal Endoscopy (E.S.G.E.) antibiotic prophylaxis for gastrointestinal endoscopy . European Society of Gastrointestinal Endoscopy; Rey JR et al.; There are two situations when antibiotic prophylaxis is recommended . The first is associated with procedures known to be followed by high rates of bacteraemia, involving organisms prone to cause endocarditis . These include oesophageal dilatation, variceal sclerotherapy and laser therapy in the upper gastrointestinal tract . As bacteraemia following these procedures is usually harmless in average risk patients antibiotic prophylaxis is recommended only for a patient with a lesion susceptible to endocarditis or one who is at increased risk of symptomatic bacteraemia due to neutropenia or immunosuppression . In most cases parenteral amoxycillin and gentamicin is recommended plus metronidazole for neutropenic patients . Vancomycin or teicoplanin replace amoxycillin in a case of allergy . The second situation concerns procedures with a high incidence of local infection or which may lead to serious sepsis . These include therapeutic retrograde cholangiopancratography and percutaneous endoscopic gastrostomy where antibiotic prophylaxis is recommended even in average risk patients . Several antibiotics are recommended including oral ciprofloxacin or parenteral gentamicin or quinolone for ERCP and amoxycillin for PEG or cephalosporin or ureidopenicillin for both.

Circulation, 1998 May 12, 97(18), 1796 - 801
Antibiotic prophylaxis for permanent pacemaker implantation: a meta-analysis; Da Costa A et al.; BACKGROUND: Infection remains a serious complication after permanent pacemaker implantation . Antibiotic prophylaxis is frequently prescribed at the time of insertion to reduce its incidence, although results of well-designed, controlled studies are lacking . METHODS AND RESULTS: We performed a meta-analysis of all available randomized trials to evaluate the effectiveness of antibiotic prophylaxis to reduce infection rates after permanent pacemaker implantation . Reports of trials were identified through a Medline, Embase, Current Contents, and an extensive bibliography search . Trials that met the following criteria were included: (1) prospective, randomized, controlled, open or blind trials; (2) patients assigned to a systemic antibiotic group or a control group; (3) end point events related to any infection after pacemaker implantation: wound infection, septicemia, pocket abscess, purulent secretion, right infective endocarditis, inflammatory signs, a positive culture, septic pulmonary embolism, or repeat operation for an infective complication . Seven trials met the inclusion criteria . They included 2023 patients with established permanent pacemaker implantation (new implants or replacements) . The incidence of end point events in control groups ranged from 0% to 12% . The meta-analysis suggested a consistent protective effect of antibiotic pretreatment (P=.0046; common odds ratio: 0.256, 95% confidence interval: 0.10 to 0.656) . CONCLUSIONS: Results of the present meta-analysis suggest that systemic antibiotic prophylaxis significantly reduces the incidence of potentially serious infective complications after permanent pacemaker implantation . They support the use of prophylactic antibiotics at the time of pacemaker insertion to prevent short-term pocket infection, skin erosion or septicemia.

BMJ, 1998 Apr 25, 316(7140), 1275 - 85
Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomised controlled trials; D'Amico R et al.; OBJECTIVE: To determine whether antibiotic prophylaxis reduces respiratory tract infections and overall mortality in unselected critically ill adult patients . DESIGN: Meta-analysis of randomised controlled trials from 1984 and 1996 that compared different forms of antibiotic prophylaxis used to reduce respiratory tract infections and mortality with aggregate data and, in a subset of trials, data from individual patients . SUBJECTS: Unselected critically ill adult patients; 5727 patients for aggregate data meta-analysis, 4343 for confirmatory meta-analysis with data from individual patients . MAIN OUTCOME MEASURES: Respiratory tract infections and total mortality . RESULTS: Two categories of eligible trials were defined: topical plus systemic antibiotics versus no treatment and topical preparation with or without a systemic antibiotic versus a systemic agent or placebo . Estimates from aggregate data meta-analysis of 16 trials (3361 patients) that tested combined treatment indicated a strong significant reduction in infection (odds ratio 0.35; 95% confidence interval 0.29 to 0.41) and total mortality (0.80; 0.69 to 0.93) . With this treatment five and 23 patients would need to be treated to prevent one infection and one death, respectively . Similar analysis of 17 trials (2366 patients) that tested only topical antibiotics indicated a clear reduction in infection (0.56; 0.46 to 0.68) without a significant effect on total mortality (1.01; 0.84 to 1.22) . Analysis of data from individual patients yielded similar results . No significant differences in treatment effect by major subgroups of patients emerged from the analyses . CONCLUSIONS: This meta-analysis of 15 years of clinical research suggests that antibiotic prophylaxis with a combination of topical and systemic drugs can reduce respiratory tract infections and overall mortality in critically ill patients . This effect is significant and worth while, and it should be considered when practice guidelines are defined.

J Can Dent Assoc, 1998 Apr, 64(4), 281 - 6, 289-92
Infective endocarditis: dental implications and new guidelines for antibiotic prophylaxis . American Heart Association; Epstein JB; The American Heart Association (AHA) has developed new guidelines for antibiotic prophylaxis for patients at risk of infective endocarditis (IE) . These guidelines are based on the on-going study of endocarditis cases and continued experience with antibiotic prophylaxis, and are an update of the 1990 recommendations . The major changes from the 1990 guidelines are: the recognition that most cases of IE are not attributable to an invasive procedure; that cardiac conditions may present different levels of risk categories; increased delineation of when prophylaxis should be given in cases of mitral valve prolapse; a change to a single dose of antibiotic and changes in the antibiotics recommended for prophylaxis . The revised AHA guidelines parallel those in Europe and the United Kingdom . It is essential that all dental professionals be fully aware of the modifications to these guidelines because of their importance in patient care and their medico-legal implications.

Plast Reconstr Surg, 1998 May, 101(6), 1524 - 8
The inflammatory reaction in elective flap surgery; Blomqvist L et al.; The inflammatory response in three different flap procedures was investigated by measuring the preoperative and postoperative levels of C-reactive protein, leukocyte count, and body temperature . Patients scheduled for delayed breast reconstruction were operated on with the lateral thoracodorsal flap, the latissimus dorsi flap, or the pedicled TRAM flap . All patients received 2 gm of intravenous cloxacillin for antibiotic prophylaxis and 1 gm of paracetamol four times a day as basic treatment for postoperative pain . Within each treatment group, significant postoperative changes in C-reactive protein levels, leukocyte count, and body temperature were noted when compared with preoperative values . The highest C-reactive protein level (130 mg/ml) was found in the TRAM group on the third postoperative day . The kinetic pattern of C-reactive protein was similar for the latissimus dorsi flap and lateral thoracodorsal flap procedures, but the maximum C-reactive protein levels were significantly lower, 74 and 44 mg/ml respectively . Small (0.5 to 0.9 degrees C) but significant differences in body temperature were also noted on the second and third postoperative day . The TRAM flap group had the highest, the latissimus dorsi flap group intermediate, and the lateral thoracodorsal flap group the lowest value . The postoperative C-reactive protein levels seem to reflect the extent of the surgical trauma.

J Fam Pract, 1998 Apr, 46(4), 304 - 10
Tubes, antibiotic prophylaxis, or watchful waiting: a decision analysis for managing recurrent acute otitis media; Bergus GR et al.; BACKGROUND: The two most frequently used options to reduce the occurrence of acute otitis media (AOM) are tympanostomy tubes and prophylactic antibiotics . The goal of this study was to create a decision model to identify which intervention, if any, is preferred from the perspective of parents with young children . METHODS: We developed a decision analysis model based on probabilities obtained from the literature and outcome disutilities obtained by interviewing parents . These parameters were placed into the model along with the anticipated number of episodes of AOM a child was expected to have in the coming year without intervention . Sensitivity analyses were performed on the effectiveness of the interventions, the disutilities (burdens associated with specific outcomes or interventions) associated with the interventions, and the characteristics of AOM episodes that the child would experience without any intervention . RESULTS: Thirty-seven parents with young children were interviewed for this project . The preferred intervention for a child was sensitive to the number of episodes of AOM the child was anticipated to have in the coming year, the percentage of these episodes predicted to be severe, and how parents rated tympanostomy tubes compared with prophylactic antibiotics . In our base case of four episodes of AOM in the coming year (two mild episodes and two severe episodes), we found that tympanostomy tubes resulted in the best average outcome . Under different patient conditions, however, the preferred strategy could be either the use of prophylactic antibiotics or watchful waiting . CONCLUSIONS: In our base case, the model suggested that tympanostomy tubes were preferable to prophylactic antibiotics . However, there is no single preferred preventive intervention for all children with recurrent AOM because of variation in the character of infections and the values parents give to the potential outcomes.

Langenbecks Arch Chir Suppl Kongressbd, 1997, 114, 1022 - 5
{Perioperative antibiotic prophylaxis in visceral surgery--pro and contra}; Kasperk R et al.; Perioperative antibiotic prophylaxis aims at reducing the enormous cost of hospital-acquired infections . Primary indications for antibiotic prophylaxis are wounds of the clean-contaminated and contaminated category . Use of antibiotic prophylaxis in clean surgery is still very controversial . To be effective, the antibiotic must be given in the period immediately before incision . A single-dose application is at least as effective as a multiple-dose regimen . Second-generation cephalosporins are still the main stay of antibiotic prophylaxis . In colorectal surgery they should be combined with, e.g., Metronidazol.

J Kans Dent Assoc, 1997 Oct, 82(4), 14, 16 - 7
Antibiotic prophylaxis for dental patients with total joint replacements . American Dental Association; American Academy of Orthopaedic Surgeons; Single-dose cefodizime as infection prophylaxis in abdominal surgery: a prospective multicenter study; Universitatsklinik fur Innere Medizin I, Klinische Abt . fur Infektionen und Chemotherapie, Wien, AustriaThis prospective pilot study was performed to evaluate the efficacy, safety and tolerability of a single dose of cefodizime as infection prophylaxis in patients undergoing major abdominal surgery . One hundred forty-nine patients received 2g cefodizime, a third-generation cephalosporin, 30 min before abdominal surgery . The mean operation time was 116 +/- 66 min . Eighteen patients received metronidazole additionally . In 8/149 patients (5.4%) the final outcome was considered to be a treatment failure . 94.6% of the patients had no signs of infection . The long half-life of cefodizime allows a single-dose perioperative prophylaxis even in abdominal surgery lasting 3 to 4 h . Cefodizime can be regarded as a safe antibiotic prophylaxis with few side effects.

Zentralbl Chir, 1998, 123(2), 193 - 5
{Is there an indication for general perioperative antibiotic prophylaxis in laparoscopic plastic hernia repair with implantation of alloplastic tissue?}; Schwetling R et al.; The implantation of alloplastic material in laparoscopically operated groin hernias is usually connected with perioperative prophylaxis by antibiotics . We doubted the usefulness of the general application in these operations . Therefore we made a prospective randomized study in 80 patients, beginning since April 1996 . 40 of them received perioperatively antibiotics, other 40 ones remained without antibiotics . These 80 patients underwent an unilateral hernioplasty and were without major anaesthesiologic risk . Both the groups were statistically comparable . As a result, no patient of both the groups suffered from an infectious complication . Thus, we can recommend the laparoscopic implantation of alloplastic meshes in "simple hernias" without perioperative antibiotic prophylaxis . In risk patients, antibiotics should still given further.

Lancet, 1998 Apr 4, 351(9108), 1005 - 8
Randomised controlled trial of prophylactic antibiotics before insertion of intrauterine devices . IUD Study Group; Walsh T et al.; BACKGROUND: The value of antibiotic prophylaxis before insertion of an intrauterine device (IUD) remains uncertain . We undertook a triple-masked, randomised, placebo-controlled trial to find out whether such prophylaxis reduces the rate of IUD removal within 90 days . METHODS: 11 clinic sites in southern California enrolled women who requested IUD insertion and were at low risk of sexually transmitted infection according to self-reported medical history . We randomly assigned 1985 participants either 500 mg azithromycin or placebo capsules of identical appearance taken about 1 h before insertion of a Copper T 380A IUD . 118 women did not have an IUD inserted . We followed up 1833 of the remaining 1867 (98%) participants for at least 90 days after insertion . FINDINGS: The rate of IUD removal for any reason other than partial expulsion was 3.8% (35/918) in the antibiotic group and 3.4% (31/915) in the placebo group (relative risk 1.1 {95% CI 0.7-1.8}) . The two treatment groups sought medical attention with equal frequency (mean 38 visits per 100 women) . During the 90 days after IUD insertion, only one woman from each assignment group had salpingitis, as defined by established criteria . INTERPRETATION: Prophylaxis with azithromycin did not affect the likelihood that a woman would retain her IUD at 90 days or the frequency of postinsertion medical attention . In appropriately screened women, the risk of upper-genital-tract infection is negligible after IUD insertion, with or without the administration of prophylactic antibiotics.

Pharmacotherapy, 1998 Mar-Apr, 18(2), 227 - 34
Current management of human bites; Bunzli WF et al.; Human bites should be considered dangerous injuries with potentially serious complications . Their characteristics vary from an uninfected abrasion to a serious infection such as cellulitis or osteomyelitis . An estimated 10% of the injuries become infected; suspected pathogens include oral and skin flora . Management consists of history and examination, wound care, surgical intervention if necessary, assessment of risk of disease transmission, and appropriate antibiotic prophylaxis or treatment . The best choice for oral or intravenous antibiotic therapy remains the combination of a beta-lactam antibiotic with a beta-lactamase inhibitor . Among the most serious human bites are clenched fist injuries, which often require surgical intervention and intravenous antibiotic therapy.

Spine, 1998 Mar 1, 23(5), 615 - 20
Spondylodiscitis after lumbar discectomy . Incidence and a proposal for prophylaxis; Rohde V et al.; STUDY DESIGN: An analysis of the incidence of spondylodiscitis after lumbar disc surgery in 1642 patients . In 508 patients no prophylactic antibiotics were given . In 1134 patients a collagenous sponge containing gentamicin was placed in the cleared disc space . OBJECTIVES: To report the incidence of postoperative spondylodiscitis in cases in which no antibiotic prophylaxis was used, and to define the value of a collagenous sponge containing gentamicin in preventing disc space infections . SUMMARY OF BACKGROUND DATA: Spondylodiscitis is considered to be a rare complication of lumbar disc surgery . The retrospective design of most studies and the rare use of magnetic resonance imaging for early radiologic diagnosis suggest that the reported incidence rates may be underestimates . Postoperative spondylodiscitis is the result of intraoperative contamination and, theoretically, could be prevented by treating these patients with prophylactic antibiotics . METHODS: In 1642 patients, 1712 discectomies were performed . In 508 of these patients no prophylactic antibiotics were given; in 1134 of these patients a collagenous sponge containing gentamicin was placed in the cleared disc space . Clinical reexamination and, in cases of unsatisfactory results, laboratory and radiologic investigations were performed 4-8 weeks after surgery . RESULTS: In nineteen of the 508 patients who were not treated with antibiotic prophylaxis (3.7%) a postoperative spondylodiscitis developed, whereas none of the 1134 patients who received antibiotic prophylaxis became symptomatic (P < 0.00001) . CONCLUSION: In the current study, a 3.7% incidence of postoperative spondylodiscitis was found in the absence of prophylactic antibiotics . Gentamicin-containing collagenous sponges placed in the cleared disc space were effective in preventing postoperative spondylodiscitis.

P N G Med J, 1996 Mar, 39(1), 12 - 5
How should very low birthweight babies best be managed in Papua New Guinea?
Brown N.
Short-term outcome in very low birthweight babies has never been closely examined in Papua New Guinea . A cohort of neonates born over a year at Port Moresby General Hospital was followed from birth to death or discharge . Intrauterine growth retardation was an important contributor to low birthweight . Simple, inexpensive care resulted in respectable survival figures . Improving antenatal surveillance will have much more impact in reducing mortality in this group in the future than trying to emulate sophisticated and costly western neonatal carePIP: A cohort of 98 consecutive very-low-birth-weight infants (under 1500 g) born at Port Moresby General Hospital (Papua New Guinea) over a 12-month period was followed from birth until either death or discharge from the Special Care Nursery . The infants were managed with warming, "blind" antibiotic prophylaxis, intravenous fluids, nasopharyngeal oxygen for respiratory distress, and phototherapy and/or exchange transfusion for jaundice . The majority of these infants had intrauterine growth retardation . Mean weekly weight gain was 142 g, while the mean weekly increase in head circumference was 6.46 mm . Overall mortality was 54% and markedly inversely associated with birth weight . The major causes of death were intraventricular hemorrhage (31%), hyaline membrane disease (31%), and septicemia (10%) . Since only 40% of discharged infants were returned for review beyond 6 weeks, late outcomes could not be assessed . One-third of infants who were examined after 6 weeks showed signs of subtle or isolated neurodevelopmental delay and there was one case of cerebral palsy . Prevention of very low birth weight depends on attention to intrauterine growth retardation--a result of poor maternal health and nutrition . Recommended are measures such as iron and chloroquine prophylaxis, tetanus toxoid vaccination, and improved nutrition during pregnancy .

Dent Update, 1997 Sep, 24(7), 271 - 6
Antibiotic prophylaxis in dental surgery; Walters H; Prevention of infection can be a minefield of uncertainty . There is little consensus of opinion on the objective criteria for diagnosing wound infection, and experts disagree on whether antibiotics should be routinely provided as prophylaxis in dental surgery . This article sets out the arguments for and against the prophylactic use of antibiotics in dental procedures.

J Clin Oncol, 1998 Mar, 16(3), 1167 - 73
Randomized, placebo-controlled, multicenter trial of granulocyte-macrophage colony-stimulating factor as infection prophylaxis in oncologic surgery . Leukine Surgical Prophylaxis Research Group; Meropol NJ et al.; PURPOSE: Postoperative infections are a frequent source of preventable morbidity and mortality in the oncologic population . Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a potent modulator of immune effector cells in vitro and in vivo . This study was conducted to determine whether GM-CSF, when administered perioperatively, could reduce the incidence of surgical infections in cancer patients . METHODS: This was a prospective, randomized, placebo-controlled, multicenter study . Cancer patients at high risk of infectious surgical morbidity were randomized to receive GM-CSF 125 microg/m2 per day or placebo subcutaneously for 8 days beginning 3 days preoperatively . Routine antibiotic prophylaxis was administered to all patients . RESULTS: Three hundred ninety-nine patients were enrolled, with 198 randomized to receive GM-CSF . Twenty-one percent of patients experienced infections during the first 2 weeks postoperatively, and there was no difference in infection rate between the study groups . The most common sites of infection were respiratory tract (53%) and surgical wound (25%) . The duration of operation and American Society of Anesthesiology (ASA) physical status classification were the most significant predictors of infection in multivariate analysis . GM-CSF was well tolerated and was not associated with fever . CONCLUSION: The eligibility criteria for this study were successful at defining a patient subgroup at high risk for postoperative infections . At an immunomodulatory dose of 125 microg/m2 per day, GM-CSF was safe and well tolerated, but did not reduce the incidence of postoperative infections in this high-risk oncologic population . Infectious morbidity in surgical oncology remains an important subject for continued clinical investigation.

Indian J Dent Res, 1995 Jul-Sep, 6(3), 83 - 93
Infective endocarditis, the conundrum of antibiotic prophylaxis; Anupama P et al.; Infective endocarditis (I.E.) is a common bacterial infection of the endocardium, which before the advent of antibiotics, had a high mortality rate . Endocarditis has been described as a serious and a potentially fatal condition in which the heart beats in a muffled march towards the grave, in quick time in the acute form and with a slower, but as deadly rhythm, in the subacute form . I.E . can occur at any period of life, but presently, there has been a shift towards younger individuals due to intravenous drug abuse . Thus the overall incidence since the pre-antibiotic era has remained constant . This has been the situation in spite of the periodic revisions made by the American Heart Association (AHA) for the guidelines for antibiotic prophylaxis . In India there are no guidelines issued by any professional organisations and hence the decision to use antibiotic prophylaxis depends on the dentist's awareness of the patient's predisposition, the standard regime learnt from a textbook, the patient's economic status and belief to comply with the advice and the choice of antibiotic, route of administration and dose . In this paper, an attempt is made to collect data on the incidence of I.E . from two large teaching hospitals and use it to decide whether antibiotic prophylaxis of patients predisposed to I.E . should be followed or not.

Am Ind Hyg Assoc J, 1998 Feb, 59(2), 104 - 12
A risk/cost analysis of alternative screening intervals for occupational tuberculosis infection; Nicas M; The Centers for Disease Control and Prevention (CDC) recommends that new health care employees receive a baseline skin test for Mycobacterium tuberculosis (M . tb) infection and that testing be repeated periodically . However, CDC does not explain the quantitative basis for its suggested screening intervals . This article examines the efficacy of alternative screening intervals for workers subject to different annual rates of M . tb infection and estimates the costs . An equation is developed for the cumulative risk of tuberculosis (TB) at 12 years given a specified annual rate of infection (ARI), screening interval, and a combined proportion (p) of successful skin testing and antibiotic prophylaxis . Equations for total cost of screening and cost per disease case prevented are provided . Results assume: (a) costs of $10 per skin test and $10,000 per TB disease case; (b) p = 0.88; and (c) and acceptable cumulative TB risk of 1 per 1000 . For ARIs that might be deemed low (0.2% to 0.5%) and medium (1%), CDC screening intervals of 12 months and 6-12 months, respectively, minimize the cost per disease case prevented but permit residual disease risks greater than 1 per 1000 . Recommended screening intervals are (i) 6 months for low-risk employee groups and (ii) 3 months for medium- and high-risk (e.g., ARIs of > or = 5%) groups . Interval (i) limits risk to 1 per 1000 and is approximately 50% shorter than the CDC interval for a low-risk group . Interval (ii), which is 67% shorter than the CDC interval for medium-risk groups but equal to that recommended for high-risk groups, permits a risk above 1 per 1000, but is likely the shortest feasible interval.

Przegl Lek, 1997, 54(7-8), 551 - 3
{Results of prophylactic and curative antibiotic therapy in biliary surgery}; Kosowski K et al.; Prophylactic antibiotic regimen (gentamicin, clindamycin) was assessed in a group of 104 patients operated electively on biliary lithiasis (cholecysto- and choledocholithiasis) . Antibiotic prophylaxis was performed in group of 20 patients, in 6 of them antibiotics were continued postoperatively . Intraoperatively antibiotics were given in a group of 20 patients--curative treatment . Control group consisted of 58 patients . We concluded that "one shoot" antibiotic therapy is valuable in controlling of wound infections . But the most effective method of reducing local septic complications rate combines prophylaxis with prolonged antibiotic administration.

Jt Comm J Qual Improv, 1997 Dec, 23(12), 636 - 52
Collaborative use of informatics among hospitals to benchmark medication use processes; Libby D et al.; BACKGROUND: In spring 1995 pharmacists representing each of the 23 member hospitals in Synernet, a hospital cooperative in Maine, decided to collaborate in developing a multihospital medication use evaluation (MUE) program . The committee set up task forces for adverse drug reaction reporting and prevention, MUE plans, and medication error reporting and prevention, for exploration of opportunities to eliminate duplication of efforts, compare performance, and share best practices . PLANNING THE PROGRAM: The members retained a consulting firm to manage the SynRx medication use program from conceptualization through implementation . Modules--on individual drug dosing, switching from intravenous to oral administration, pharmacists' clinical recommendations, and surgical antibiotic prophylaxis--were designed so that participants could adopt the entire plan as a turnkey procedure by inserting their hospital name in the appropriate blanks, modify it to more closely fit their own organizations, use portions of it for inclusion in their current plans, or not use it at all . The goal was to build in maximum flexibility to accommodate the variations in the participating hospital pharmacies and their respective hospitals . RESULTS: Early program benefits include improvements in medication event reporting, documentation of the measured aspects of medication use, delivery of care processes, and administrative efficiency . LESSONS LEARNED AND CONCLUSIONS: The participants, consultants, and programmers involved in the SynRx program learned firsthand the complexity and magnitude of hospital medication use processes . Yet it is possible to overcome the wide variability in systems among hospitals to create standards that allow for more meaningful comparisons of medication use.

Cathet Cardiovasc Diagn, 1998 Jan, 43(1), 60 - 2
Coarctation of the aorta following coil occlusion of a patent ductus arteriosus; Moore JD et al.; A case is described in which coarctation of the aorta develops following coil occlusion of a patent ductus arteriosus with a single Gianturco coil . This finding has yet to be reported in children undergoing this procedure and demonstrates the possibility of its occurrence and brings into question the need for and the duration of antibiotic prophylaxis following coil deployment.

J Dent Assoc S Afr, 1996 Dec, 51(12), 806 - 9
Antibiotic prophylaxis in periodontal surgery . A retrospective study; Callis S et al.; Antibiotics are frequently used in periodontal and minor oral surgery to prevent complications . The potential disadvantages of antibiotic prophylaxis are well documented . This study compares the incidence of complications for procedures performed with and without antibiotic prophylaxis . The clinical records of 1499 patients who received treatment at a university teaching hospital were reviewed . 1078 surgical procedures were done on 596 patients . 895 surgical procedures were done without prophylactic antibiotics, with 17 complications (1.9 per cent) . 183 procedures were done using antibiotic prophylaxis, with 1 complication (0.55 per cent) . The difference between the incidences of complications in the two groups was not statistically significant (P < 0.001) . In view of the questionable benefits and potential disadvantages of using antibiotics, their routine use during or following periodontal surgery must be questioned.

J Cardiovasc Surg (Torino), 1997 Dec, 38(6), 605 - 10
Antibiotic prophylaxis in cardiac surgery; Kriaras I et al.; BACKGROUND: A prospective, randomised study was conducted among 1009 cardiac surgery patients in order to compare the prophylactic efficacy of a second generation cephalosporin (cefuroxime) given as single shot, versus a broad spectrum double regimen (amoxycillin-netilmicin) . METHODS: Cefuroxime received 501 patients (Group A), while a 4-day combination of amoxycillin-netilimicin 508 patients (Group B) . RESULTS: There were found no statistically significant differences either in infection rate or the kind of infection between the two groups . Single shot cefuroxime prophylaxis was just as effective, as a 4-day combination of amoxycillin and netilmicin . Total infection rate was 5.6% (n=28) in Group A and 5.7% (n=29) in Group B . Respiratory tract infection was the most frequently registered in both groups; 2.6% in Group A and 2.9% in Group B . Sternal wound and catheter-related infection rates were 0.6% and 1% in both groups, respectively . There were no side effects due to the given antibiotics . CONCLUSIONS: A single shot of cefuroxime prophylaxis is equally effective and safe as a 4-day regimen with amoxycillin and netilmicin.

Dermatol Clin, 1998 Jan, 16(1), 25 - 47
Dressing the part; Cho CY et al.; Wound care after cutaneous surgery can play an integral role in wound healing . Wound care regimens have changed dramatically over the last 35 years as the physiology of wound healing has become better understood . Foremost is the improvement in wound healing achieved by keeping the wound occluded and moist . This observation has led to an explosion of a whole new category of occlusive dressings at the surgeon's disposal in healing postoperative wounds . These dressings have numerous applications as discussed previously . Generally, for acute surgical wounds, occlusive dressings are most useful for split-thickness wounds, such as graft donor sites and after dermabrasion, chemical peel, or laser treatment, and full-thickness wounds allowed to heal by secondary intention . Occlusive dressings may have greater benefit for the treatment of chronic ulcers of varying etiologies . The different categories of dressings share the common disadvantage of being relatively expensive . For routine sutured wounds, the authors prefer the readily available and inexpensive Telfa-type dressing combined with a topical antibiotic ointment . Topical antiseptics are useful for reducing bacterial counts on intact skin in preparation for surgery . Povidone-iodine (Betadine) and chlorhexidine gluconate (Hibiclens) have emerged as the two agents of choice . However, antiseptics have been shown to be toxic to healing tissue, and should not be used on open wounds . In contrast, topical antibiotic ointments are safe to use on open wounds, effective in preventing wound infections, and promote wound healing by maintaining a moist wound environment . The authors prefer the combination antibiotic ointment Polysporin for routine postoperative wound care . Antibiotic prophylaxis in dermatologic surgery to prevent wound infection is appropriate in certain cases . Surgery performed on grossly contaminated or infected skin requires a full 7 to 10 day course of antibiotics . Procedures in anatomic areas considered contaminated as well as in clean areas with significant environmental or patient risk factors may benefit from antibiotic prophylaxis . The choice of antibiotics should be based on the organism most likely to cause wound infection at the particular surgical site . Evidence supports giving a single preoperative dose 1 hour before surgery with a second dose possible 6 hours later if the procedure is prolonged or delayed . The risk of bacterial endocarditis after dermatologic surgery is not known . Antibiotics are indicated for any procedure on obviously infected skin, but are not routinely required for very minor procedures, such as small biopsies, on intact skin . Antibiotic prophylaxis may be prudent for those patients classified as high risk by the (AHA) . The antibiotic chosen should again cover the organism most likely to cause infection . One dose can be given 1 hour before surgery and repeated 6 hours postoperatively . Finally, wound healing can be greatly impacted by what the patient does or does not do after leaving the office . Therefore, wound care instructions should be clear, detailed, and provided in both oral and written form . Information should also be provided about what to expect as the wound heals.

J Laparoendosc Adv Surg Tech A, 1997 Apr, 7(2), 99 - 109
Longitudinal cholecystectomy study: patterns of care in a total community experience; Mcgee JM et al.; The purpose of this study was to determine outcomes and safety of laparoscopic cholecystectomy (LC) versus open cholecystectomy (OC) in a community setting at multiple open staff hospitals with multiple surgeons . This second-year study retrospectively examined all cholecystectomy records in one city at each of five hospitals over a 1-year period beginning in April 1991 through March 1992 . All charts were examined for type of surgery, rate of conversion to open procedure, sex, weight, previous abdominal surgery, surgeon, hospital, preoperative workup, operative time, antibiotic prophylaxis, cholangiograms, concurrent procedures, drains, hospital stay, common duct stones and their follow-up, pathology, reoperations, complications, and mortality . One thousand eight hundred one gallbladders were removed . One thousand three hundred four (72.4%) were successfully removed at LC . One hundred eighty-three (10.2%) others were attempted laparoscopically and converted to open cholecystectomy (CC), which represented 12.3% of the attempted LCs . Three hundred fourteen (17.4%) were removed via a standard OC . The mean operative times were 72.3 minutes for LC, 100.1 minutes for CC, and 86.2 minutes for OC . Cholangiography was attempted in 916 (70.3%) LCs, 144 (78.7%) CCs, and 250 (79.6%) OCs, with similar operative times, except in LC, when done via the GB, operative time was 65.2 versus 73.4 minutes when done via the cystic duct . Diagnosis of acute cholecystitis occurred in 306 (23.5%) LCs, 119 (65.0%) CCs, and 145 (46.2%) OCs . Complications requiring reoperation occurred in 30 (2.3%) LCs, 5 (2.7%) CCs, and 5 (1.6%) OCs . Common bile duct (CBD) injuries occurred in 5 (34%) LCs, with 4 converted to CC and 1 repaired 5 days later . Trocar site hernias occurred in 11 (0.8%) LCs . Thirty-nine surgeons participated in the study with mean numbers of 33.4 LC cases, 5.5 CC cases, and 7.2 OC cases, with ranges of 1 to 165 LC cases, 1 to 17 CC cases, and 1 to 24 OC cases . Death occurred in 12 (0.9%) LC cases, 4 (2.2%) CC cases, and 25 (8.0%) OC cases . The mean hospital stay was 39.6 hours for LC, 156.5 hours for CC, and 198.3 hours for OC.

Z Orthop Ihre Grenzgeb, 1997 Sep-Oct, 135(5), 417 - 21
{Prevention of periarticular ossification--with results of a randomized, double-blind study comparing acemetacin versus indomethacin}; Gierse H et al.; We examined the effect of NSAR in the prophylaxis of heterotopic ossifications after hip arthroplasty . During a randomized doubleblind study 59 patients took Indometacin and 60 patients Acemetacin for three weeks after the operation . All of them got a thrombosis prophylaxis with Heparin and a short term antibiotic prophylaxis . The range of ossifications was checked three months after the operation according to Arcq . The proportion of patients with no clinical symptoms (grade 0 or 1) was 92.3% in the indometacin group and 98.2% in the acemetacin group . Because of side effects (mainly gastrointestinal) 7 patients (11.9%) in the indometacin group and 5 patients (8.3%) in the acemetacin group stopped the study . In a previous study we had examined the effect of thrombosis prophylaxis by Heparin on the heterotopic ossifications . These results could now be taken for comparison . According to these results the examined NSAR Indometacin and Acemetacin raised the group of low grade heterotopic ossifications . The higher grades (2 degrees and 3 degrees according to Arcq) were only be seen in less than 5% . That is why we recommend the NSAR (Acemetacin or Indometacin) generally after hip arthroplasty as prophylaxis of heterotopic ossifications.

Laryngoscope, 1998 Jan, 108(1 Pt 1), 107 - 10
Use of antibiotic prophylaxis in ear surgery; Govaerts PJ et al.; A prospective, double-blind, randomized, placebo-controlled study was performed to evaluate the effect of antibiotic prophylaxis in ear surgery . The present study reports on the results of 750 patients, half of whom received cefuroxime for 1 day, the other half, placebo . All postoperative infections occurring within 2 weeks after the intervention were recorded, together with several preoperative and perioperative parameters . It is concluded that exploratory tympanoplasties (including stapedotomy) and "dry perforation" tympanoplasties should be considered "clean" operations according to the American National Research Council and do not benefit from antibiotic prophylaxis . On the other hand, tympanoplasties performed on draining ears and on ears with cholesteatoma should be considered "dirty" operations for which antibiotic prophylaxis may decrease the postoperative infection rate by factor 3 . All postoperative infections healed without sequels under proper treatment, except for three that resulted in graft necrosis--one in the placebo group and two in the cefuroxime group . In consequence, prophylaxis may not be mandatory in the dirty group, although the authors advocate its use for the sake of patient and surgeon comfort.

Ann Emerg Med, 1998 Jan, 31(1), 73 - 7
Irrigation in facial and scalp lacerations: does it alter outcome?
Hollander JE, Richman PB, Werblud M, Miller T, Huggler J, Singer AJ.
STUDY OBJECTIVE: Animal and human studies suggest that irrigation lowers the infection rate in contaminated wounds, but there is no evidence that this common practice is beneficial for "clean" lacerations . We tested the null hypothesis that there is no difference in the infection rate for noncontaminated lacerations to the face and scalp that are irrigated before primary closure compared with similar wounds that are closed primarily without irrigation . METHODS: We performed a cross-sectional study of consecutive patients presenting to a suburban, academic emergency department between October 1992 and August 1996 . Patients with nonbite, noncontaminated facial skin or scalp lacerations who presented less than 6 hours after injury were included . Structured, closed-question data collection instruments were completed at the time of laceration repair and at suture removal . The primary outcome parameters were the incidence of wound infection and the short-term cosmetic appearance of lacerations in patients who did or did not receive irrigation . RESULTS: A total of 1,923 patients were included in the study group; 1,090 patients received saline irrigation, and 833 patients did not . The irrigation and nonirrigation groups were similar with regard to time from injury to presentation (1.56 versus 1.42 hours, respectively), frequency of linear wound morphology (82% versus 88%), frequency of smooth wound margins (72% versus 82%), number of layers of closure (1.14 versus 1.26), number of skin sutures applied (4.98 versus 4.65), number of deep sutures applied (.70 versus 1.05), and use of oral antibiotic prophylaxis (2.8% versus 4.0%) . With respect to outcomes, the incidence of wound infection was not significantly different between the two treatment groups (.9% versus 1.4%, respectively; P = .28) . Likewise, the percentage of patients who had an "optimal" cosmetic appearance was similar in the two groups (75.9% versus 81.7%, respectively; P = .07) . CONCLUSION: Irrigation before primary closure did not significantly alter the rate of infection or the cosmetic appearance in our study population with clean, noncontaminated facial and scalp lacerations.

Chir Organi Mov, 1997 Apr-Jun, 82(2), 165 - 76
Antibiotic and antithromboembolic prophylaxis in hip arthroplasty (a review of 700 primary implants); Busanelli L et al.; The authors report the results obtained with antibiotic and antithromboembolic prophylaxis used in 700 consecutive primary total hip arthroplasties . As for antibiotic prophylaxis (5 cases of infection: 0.7%) the various types of antibiotic used always kept the infection rate under 1%, confirming the effectiveness of the preventive use of antibioticotherapy . The incidence of deep venous thrombosis and pulmonary embolia were 3.7% and 0.7%, respectively (26 cases of DVT and 5 of PET) . The incidence of DVT rose to 34.4% in a selected group of cases in which phlebography had been carried out even in the absence of symptoms of DVT . This confirms that the routine use of this method would without a doubt be useful in preventing complications with a high risk for the life of the patient (pulmonary embolia) . As for pharmacological prophylaxis, indobufene and calcium heparin were the drugs used most: their effectiveness was nearly similar, despite the fact that the use of calcium heparin in patients considered to be at a higher risk for thromboembolic complications should be made clear.

J Hosp Infect, 1997 Nov, 37(3), 237 - 47
Is single-dose antibiotic prophylaxis sufficient for coronary artery bypass surgery? An analysis of peri- and postoperative serum cefuroxime and vancomycin levels; Vuorisalo S et al.; Preliminary findings have suggested that a single intravenous dose of antibiotic is effective for infection prophylaxis in cardiac surgery . However there are still insufficient data on this proposed regimen . We measured serum cefuroxime and vancomycin levels after three different dosage regimens, in patients undergoing coronary artery bypass grafting (CABG) . Sixty patients were randomized into three cefuroxime and three vancomycin groups with 10 patients in each: a group given a one-day course, or an additional dose during cardiopulmonary bypass or a single dose . Serum levels of the antibiotics were measured at various times throughout the operative procedure and until 48 h after the start of prophylaxis . Each of the six dosage regimens maintained serum levels adequate for infection prophylaxis throughout the operative procedure . Serum levels remained above 2 mg/L for more than 8 h postoperatively, even in the single-dose cefuroxime group and above 4 mg/L for more than 24 h with all the vancomycin dosage regimens . Thus a single dose of cefuroxime (3 g or 1.5 g) or vancomycin (1.5 g) seems to achieve and maintain serum levels sufficient for infection prophylaxis several hours after CABG procedures.

J Infect Dis, 1998 Jan, 177(1), 161 - 6
Enhanced control of an outbreak of Mycoplasma pneumoniae pneumonia with azithromycin prophylaxis; Klausner JD et al.; There are currently no recommended epidemic-control measures for Mycoplasma pneumoniae pneumonia outbreaks in closed communities . Previous studies have suggested the usefulness of chemoprophylaxis administered to close contacts of case-patients . To evaluate the effectiveness of various epidemic-control measures during an institutional outbreak, an observational study was undertaken during a very large outbreak of M . pneumoniae pneumonia at a facility for developmentally disabled residents (n = 142 cases) . Control measures evaluated included no control, standard epidemic-control measures, and targeted azithromycin prophylaxis (500 mg on day 1, 250 mg/day on days 2-5) plus standard epidemic-control measures . The combined use of azithromycin prophylaxis and standard epidemic-control measures was associated with a significant reduction in the secondary attack rate . This study suggests that the addition of antibiotic prophylaxis to standard epidemic-control measures can be useful during institutional outbreaks of M . pneumoniae pneumonia.

Tidsskr Nor Laegeforen, 1997 Sep 20, 117(22), 3230 - 3
{Weight and weight gain in pregnancy}; Haram K et al.; This article reviews different aspects of maternal weight before and during pregnancy and weight gain in pregnancy, e.g . causes of undernourishment (hyperemesis, anorexia nervosa and bulimia nervosa) . Physiological weight gain during pregnancy is normally between 10 and 16 kg, representing 20% of the body weight before pregnancy . The increase in weight is usually lowest during the 1st trimester and greatest between the 17th and the 24th week of pregnancy . Low maternal weight at conception may cause low birthweight . Undernourishment may cause premature delivery or low birthweight, or both . There is an increased risk of gestational diabetes and macrosomia, as well as preterm delivery and hypertension in pregnant women who are overweight . There is also an increased risk of complications arising during general anaesthesia and operative delivery in severely overweight women . These women should be offered heparin or dextran as thrombosis prophylaxis where a caesarean section is to be performed . They should also be given antibiotic prophylaxis . A weight gain of between 7 and 12 kg reduces the risk of complications in overweight patients.

Zentralbl Hyg Umweltmed, 1995 Oct, 198(1), 57 - 71
{Analysis and conclusions regarding the epidemic spread of methicillin resistant S . aureus}; Heuck D et al.; Increasing dissemination of Methicillin-resistant S . aureus (MRSA) calls for a more consequent examination of the causal mechanisms . Experiences and results of analysis of three different outbreaks caused by MRSA are described . In summary it is shown that MRSA are especially epidemic virulent and persist over a long range of time in a care unit . Main reasons for these outbreaks obviously were mistakes in hospital hygiene and an inappropriate antibiotic prophylaxis . Predisposed inpatients suffer from severe infections . Interregional dissemination of MRSA observed is mainly due to the transfer of patients between hospitals . Optimization of hospital hygiene especially isolated or cohort nursing of affected patients as well as restriction of antibiotic prophylaxis and therapy are crucial measures against the dissemination of MRSA . For success of these measures information and motivation of staff are necessary.

Orthopedics, 1997 Oct, 20(10), 967 - 72
Low-velocity civilian gunshot wounds of the spine; Isiklar ZU et al.; This article describes a retrospective study on patients admitted to a level I trauma center between 1989 and 1993 with low-velocity gunshot wounds to the spine . Medical records and imaging studies were reviewed to determine patient demographics, neurologic deficit, prophylactic antibiotic administration, and rate of infection, spine stability, and principle associated injuries . A total of 37 patients with low-velocity gunshot wounds to the spine were identified and comprised 34% of all spinal injury patients . Neurologic outcome of the low-velocity gunshot wound to the spine depended on the level of the injury and the presenting neurologic deficit, as improvement of one or two Frankel grades occurred in only seven patients . Prophylactic antibiotics were given to 20 patients, and one infection occurred and was associated with colon perforation . In the absence of hollow viscus perforation, antibiotic prophylaxis did not appear beneficial . Spinal instability was noted in three patients with cervical injury and one patient with lumbar injury, and neurologic deficit was variable despite the presence of instability . The major associated injury was vascular occlusion or disruption in 8 of 12 (66%) cervical low-velocity gunshot wounds to the spine.

Neurosurgery, 1997 Nov, 41(5), 1073 - 9; discussion 1079-81
Risk factors for neurosurgical site infections after craniotomy: a prospective multicenter study of 2944 patients . The French Study Group of Neurosurgical Infections, the SEHP, and the C-CLIN Paris-Nord . Service Epidémiologie Hygiène et Prévention; Korinek AM; OBJECTIVE: To determine the incidence and risk factors of surgical site infections (SSIs) after craniotomy and to test the risk index score proposed by the National Nosocomial Infections Surveillance (NNIS) system, which, to our knowledge, has not been validated in neurosurgery to date . METHODS: During a 15-month period, every adult patient undergoing craniotomy in 10 neurosurgical units was prospectively evaluated for development and risk factors of SSI . The follow-up period was at least 30 days . SSIs were defined according to the Center for Disease Control definitions . Incidence was calculated per patient . Multivariate analyses were conducted at first to include all significant risk factors of univariate analysis and then only those known preoperatively . Finally, the NNIS risk index was tested in this population . RESULTS: Of a total of 2944 patients, 117 patients (4%) with SSIs were observed, including 30 with wound infections, 14 with bone flap osteitis, 56 with meningitis, and 17 with brain abscesses . Independent risk factors for SSIs were postoperative cerebrospinal fluid leakage (odds ratio, 145; 95% confidence interval, 72-293) and subsequent operation (odds ratio, 7; 95% confidence interval, 4-12) . Independent predictive risk factors were emergency surgery, clean-contaminated and dirty surgery, an operative time longer than 4 hours, and recent neurosurgery . Absence of antibiotic prophylaxis was not a risk factor . The NNIS risk index was effective in identifying at-risk patients . CONCLUSION: Independent risk factors for SSIs after craniotomy involve postoperative events . However, the NNIS risk index is effective in identifying at-risk patients.

World J Surg, 1997 Oct, 21(8), 811 - 4; discussion 814-5
Antibiotic prophylaxis and open groin hernia repair; Taylor EW et al.; Antibiotic prophylaxis is not routinely given for nonimplant, clean operations, although this view has recently been challenged . We have conducted a randomized multicenter, double-blind prospective trial to compare co-amoxiclav with placebo in 619 patients undergoing open groin hernia repair . Altogether 563 (91%) patients fulfilled the protocol; 283 received co-amoxiclav and 280 placebo . There was no difference between the groups in the number of patients receiving local or general anesthetic, the type of repair performed, the use of a subcutaneous fat suture, the type of skin closure used, the use of wound analgesia, or the use of a wound drain . Patients were given a card to return to the hospital in the event of their wound discharging or their needing to see their general practitioner . All patients were reviewed at approximately 6 weeks after operation . Fifty (8.9%) patients sustained a wound infection, 25 in the co-amoxiclav group and 25 in the placebo group . We conclude that antibiotic prophylaxis is of no benefit to patients undergoing open groin hernia repair.

Pediatr Clin North Am, 1997 Oct, 44(5), 1299 - 321
Antenatal hydronephrosis . Fetal and neonatal management; Elder JS; As many as 1% of newborn infants have a prenatal diagnosis of hydronephrosis or significant renal pelvic dilation . Hydronephrosis often is caused by nonobstructive conditions . The likelihood of significant urologic pathology is directly related to the size of the fetal renal pelvis, and 90% with an anteroposterior diameter more than 2 cm need surgery or long-term urologic medical care . Following delivery, antibiotic prophylaxis should be administered and a renal sonogram and voiding cystourethrogram should be obtained . If there is grade 3 or 4 hydronephrosis, usually a diuretic renogram is recommended also . Pediatric urologic or pediatric nephrologic consultation usually is helpful in planing evaluation and treatment . Prenatal recognition of hydronephrosis allows neonatal diagnosis and treatment of urologic pathology, preventing complications of pyelonephritis and obstruction.

HNO, 1997 Jun, 45(6), 448 - 52
{Antibiotic prophylaxis in laterobasal fractures}; Steidtmann K et al.; A retrospective study over 5 years evaluated the medical records of 78 patients who had suffered lateral skull base fractures . The purpose of the present study was to answer the question of whether antibiotic prophylaxis reduced the risk of meningitis . Fifty-five of 78 patients (71%) were given no antibiotics, among whom four developed meningitis . In 29% of patients treated with antibiotics, two developed meningitis . This difference was not significant . Even when cases with uncomplicated ("simple") lateral skull base fractures were separated from those with severe additional lesions related to their injuries, no significant correlation was found in the occurrence of meningitis despite the use of an antibiotic . Eight of 14 patients with initial otoliquorrheas were treated with antibiotics, with two of these 8 patients developing meningitis . None of the patients who did not receive antibiotics developed meningitis . Our findings shows that it is not advisable to treat patients who have suffered from lateral skull base fractures with prophylactic antibiotics . Instead, these patients should be examined frequently and appropriate antibiotic therapy prescribed at the first clinical symptoms of meningitis.

Zentralbl Gynakol, 1997, 119(8), 390 - 3
{Prolongation of a bi-amniotic twin pregnancy after premature rupture of fetal membranes and umbilical cord prolapse of the first twin during the 23rd week of pregnancy}; Honigl W et al.; A 41-year old woman had a premature rupture of the membranes of the first twin with prolapse of the umbilical cord and the left foot in the 24th gestational week (23 + 4) . The treatment consisted of bed rest in the Trendelenburg position, antibiotic prophylaxis and glucocorticoids for lung maturation . After 7 days the first twin was delivered vaginally from breech position . He died 10 hours later due to intraventricular hemorrhage . Tocolysis was administered and the umbilical cord was ligated and cut as high as possible . Seven days later a premature rupture of the membranes of the second twin and a prolapse of the fetal hand occurred . The second twin (birth weight 750 g) was delivered by cesarean section in the 26th gestational week (25 + 4) and survived without neurologic sequelae . Prolongation of pregnancy after a very premature delivery of the first twin of a biamniotic twin pregnancy can improve the neonatal outcome.

Rozhl Chir, 1997 Jun, 76(6), 281 - 3
{Antibiotic prophylaxis in thoracic surgery}; Janik M et al.; On a group of patients operated during the last three months under standard precautions the authors explain their views as regards antibiotic prophylaxis in thoracic surgery . They justify not only "short-term prophylactic administration of antibiotics" but also prolonged prophylaxis with antibiotics . Useful in this respect proved Mandol, cefalosporin of the 2nd generation, which is used as a standard drug without preoperative examination of the bacterial flora in sputum . Their patients did not develop infectious complications.

Gastroenterology, 1997 Oct, 113(4), 1289 - 94
Cost-analysis of prophylactic antibiotics in spontaneous bacterial peritonitis; Inadomi J et al.; BACKGROUND & AIMS: Antibiotic prophylaxis has been shown to decrease the incidence of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and ascites . The aim of this study was to test whether antibiotic prophylaxis for SBP is cost-effective and to compare the costs associated with different patient groups and treatment strategies . METHODS: A cost-effectiveness analysis was performed using a Markov chain model . The costs incurred during 1-year treatment with prophylactic antibiotics vs . no prophylaxis in patients with cirrhosis and ascites were calculated . The incidence rates of primary and recurrent SBP and the mortality rate of SBP were obtained from the literature . Total direct costs of SBP treatment were determined from the wholesale price of drugs and from disbursements by the Health Care Financing Administration . RESULTS: Norfloxacin prophylaxis resulted in savings between $2216 and $8545 per patient per year, depending on the patient group studied . Trimethoprim-sulfamethoxazole prophylaxis resulted in savings between $2934 and $9251 per patient per year . The groups that benefited most from prophylaxis were patients with an ascitic fluid total protein concentration of < or = 1 g/dL and those with a previous history of SBP . CONCLUSIONS: The use of prophylactic antibiotics to decrease the incidence of SBP is a cost-saving strategy in patients with cirrhosis and ascites.

Spine, 1997 Sep 15, 22(18), 2191 - 3
Epidural abscess after lumbar discography . A case report; Junila J et al.; STUDY DESIGN: The patient who suffered from pain in both lower legs and in whom discography was performed experienced a rare complication after discography . The findings and method of discography is described, as is usefulness of magnetic resonance imaging to image this rare complication . OBJECTIVES: To establish the possibility of getting a spinal epidural abscess after discography, how to make the diagnosis, and how to treat the complication . SUMMARY OF BACKGROUND DATA: Discitis after discography is a well-known complication, but epidural abscess is rare . METHODS: C-reactive protein concentration was measured and was more than 100 mg/L . Infection was suspected, and antibiotic therapy was started immediately . Magnetic resonance imaging was performed, and the diagnosis became clear . A laminotomy was performed . RESULTS: Symptoms due to epidural abscess disappeared soon after laminotomy . CONCLUSIONS: Some harmful and unpleasant complications are possible after discography . Antibiotic prophylaxis and stiletted needles should be used . Magnetic resonance imaging is the best radiologic procedure to image the complication, and surgery must be performed as soon as possible.

J South Orthop Assoc, 1997 Fall, 6(3), 180 - 5
Antibiotic prophylaxis and infection resistance of massive tumor endoprostheses during chemotherapy; Ward WG et al.; Fifty-five consecutively treated patients with malignant bone tumors had preoperative and postoperative chemotherapy by one oncologist . These same patients had massive bone resection and cemented endoprosthetic bone replacement by one orthopaedic oncologist . Despite 143 instances of documented fever and/or neutropenia in 45 of these 55 patients, no known deep periprosthetic infections developed in any patient during follow-up (mean, 29.4 months; median, 25 months; range, 5 months to 62 months) . Broad spectrum antibiotics had been administered in at least 118 instances to these patients (intravenously in hospital, 9 times to 7 patients; intravenously at home, 38 times to 18 patients; and orally at home, 71 times to 26 patients) . This study confirms the low infection rate of these massive endoprostheses, despite neutropenic and/or febrile episodes if the patient is given prophylactic broad spectrum antibiotics during the episodes . We support the continued use of massive endoprostheses for bone reconstruction in patients requiring chemotherapy.

Tidsskr Nor Laegeforen, 1997 Aug 20, 117(19), 2762 - 4
{Follow-up of a procedure of antibiotic prophylaxis in cesarean section}; Larsen A et al.; In order to assess the quality of the treatment given in our department, we studied the use of antibiotic prophylaxis in cases of cesarean section in relation to the implementation of a standard protocol . The records of 606 patients who underwent a cesarean section in 1989 and 1992 were studied retrospectively with regard to risk factors for postoperative infection, antibiotic prophylaxis and infections during hospitalisation . While the use of the antibiotic prophylaxis increased from 1989 to 1992, the number of postoperative infections remained relatively stable, 17% in 1989 and 14% in 1992 . 55% of patients who were regarded as candidates for prophylaxis in this study were given antibiotic prophylaxis in 1992 (93 of 169 patients) . 49 (53%) of these patients received an antibiotic prophylaxis in accordance with the protocol, whereas 44 (47%) were given other antibiotic regimens . The effect of treatment, as assessed by the number of postoperative infections, remained unchanged, while the use of antibiotic prophylaxis increased in the period after the protocol was implemented . The protocol was not followed as intended.

Am Fam Physician, 1997 Sep 15, 56(4), 1121 - 8
Pertussis: an update on primary prevention and outbreak control; Scott PT et al.; Pertussis is a highly contagious respiratory disease . Infected adolescents and adults with mild illness are the source of potentially life-threatening illness in infants and young children . The incidence of pertussis has been rising steadily in recent years . Primary vaccination is 80 percent effective, but protection is transient . Pertussis can be difficult to diagnose because classic whooping cough is uncommon, disease manifestations are often atypical, and laboratory and radiologic aids are frequently nonspecific . Diagnosis is usually based on the clinical picture, but culture, direct fluorescent antibody tests and serology can be helpful . Antibiotic therapy can decrease the duration and severity of illness, and prevents secondary spread if started early . Effective management of pertussis outbreaks requires early diagnosis and treatment of cases, antibiotic prophylaxis of contacts and accelerated vaccination of susceptible infants and children . Acellular pertussis vaccine preparations have recently been recommended for the entire primary vaccination series.

Ann Chir, 1997, 51(3), 272 - 87
{Anaerobic infections of the soft tissues}; Mathieu D et al.; Anaerobic soft tissue infections are still life threatening infections . Although their frequency is actually moderate; they remain severe because physicians are often insufficiently aware of them . Although the classification between myonecrosis and necrotizing fasciitis is still valid, these infections share so many points in common that they can be considered together . Their origin is often traumatic or surgical but may also be secondary to an ulcer or a small wound in a high-risk patient: arteriosclerotic, diabetic . Hypoxia, traumatic muscle crush, heavy bacterial contamination as well as incorrect antibiotic prophylaxis are the major reasons for their occurrence . Management consists of antibiotics adapted to both anaerobic and associated aerobic bacteria, large and early surgical debridement, but with conservative excision, and intensive hyperbaric oxygen therapy . Strict prevention measures must be applied to avoid their occurrence.

Br Dent J, 1997 Aug 9, 183(3), 101 - 5
Bacterial endocarditis: results of a survey in a children's hospital in France; Droz D et al.; OBJECTIVE: To identify and analyse the risk factors for infective endocarditis . DESIGN: Retrospective survey over a 12-year period . SETTING: Department of Paediatric Cardiology, Nancy, France . SUBJECTS: 43 children attending during 1970-1992 who were diagnosed with infective endocarditis in accordance with Von Reyn's classification . RESULTS: 45 episodes of infective endocarditis were recorded (2 children had 2 episodes) . Congenital cardiac disease was the most frequent predisposing factor for infective endocarditis . The causes of bacteraemia found were frequently, but not exclusively, of dental origin (30.5%) . Among the dental causes were: poor oral health, inappropriate treatments and lack of antibiotic prophylaxis . CONCLUSIONS: Children diagnosed with a cardiac disorder should be examined by a dentist . Modern principles of antibiotic therapy and accepted dental procedures must be performed as soon as possible and parents informed of the current preventive recommendations.

J Hepatol, 1997 Aug, 27(2), 295 - 8
An economic analysis of norfloxacin prophylaxis against spontaneous bacterial peritonitis; Younossi ZM et al.; BACKGROUND/AIMS/METHODS: Spontaneous bacterial peritonitis (SBP) is a frequent complication of advanced liver disease and in high-risk patients, it is associated with a mean (per episode) mortality of 29% and a mean 1-year mortality of 82% . The 1-year recurrence rate of SBP can be as high as 30-70% . Selective intestinal decontamination with antibiotic prophylaxis has been shown to significantly reduce the incidence of recurrent SBP . The aim of this study was to perform an economic analysis of norfloxacin prophylaxis to prevent SBP recurrence . RESULTS: This analysis showed that norfloxacin prophylaxis in high-risk patients with cirrhosis resulted in USD 4632 savings per patient per year by avoiding SBP and its associated expense . A sensitivity analysis showed that the norfloxacin prophylaxis remained cost-saving, even if it resulted in only a modest reduction in the SBP recurrence rate . CONCLUSIONS: Selective gut decontamination with norfloxacin is not only efficacious in preventing SBP, but can also be cost-saving by avoiding the resource utilization associated with its treatment.

J Burn Care Rehabil, 1997 Jul-Aug, 18(4), 342 - 6
Study of antibiotic prophylaxis during burn wound debridement in children; Rodgers GL et al.; Twenty-three children completed a randomized, prospective, partially blinded study performed to assess the need and effectiveness of antibiotic prophylaxis at the time of burn wound debridement and grafting . Patients with a total body surface area (TBSA) burn less than 35% were randomized to receive cefazolin or placebo . Patients with burns of 35% or more TBSA were randomized to receive cefazolin or targeted antibiotics based on surveillance cultures . Blood cultures were obtained at commencement, immediately after, and 24 hours after surgical debridement . Quantitative cultures and histologic examination of biopsied burn wounds were performed . Burn wound infection occurred in three patients with burns of less than 35% TBSA, two in the cefazolin group and one in the placebo group . Quantitative tissue cultures and histologic examination did not predict either infection . During the four procedures in three patients with 35% or more TBSA, three were randomized to receive cefazolin, and one targeted antibiotics . All receiving cefazolin developed burn wound infection . Quantitative tissue culture was more than 10(5) colony-forming units per gram in all, whereas histologic examination was positive in one . In our patients with less than 35% burn, cefazolin was not necessary, and in those with 35% or more burn, it was not effective.

Hepatogastroenterology, 1997 Jul-Aug, 44(16), 959 - 67
Septic complications after biliary tract stone surgery: a review and report of the European prospective study; Cainzos M et al.; We report a prospective, controlled study of the incidence of septic complications following biliary tract stone surgery . This study included a total of 280 patients operated on in eight hospitals in various European countries . In this study the computer program "Surgery" was used . Of 280 patients, 77 (27.5%) were male and 203 (72.5%) were female . The age ranged from 20 to 92 years (mean 54.8 years); 78.9% of the cases corresponded to clean-contaminated surgery; 85% of the patients received antibiotic prophylaxis with cefazolin . Twenty-one patients developed postoperative septic complications (7.5%) of which 12 (4.3%) were wound infections; five patients (1.8%) had intra-abdominal infections . The wound infection rate was 3.2% in clean-contaminated surgery, 7.7% in contaminated and 20% in dirty (p < 0.02) . In laparoscopic cholecystectomy the global rate of septic complications was 3.6% vs . 12.6% in open cholecystectomy (p < 0.01); 2.4% and 6.3% wound infection respectively . The mean age of patients who developed postoperative septic complications was 61.5 years and 54.2 years old who did not develop any complications (p < 0.03) . The duration of the postoperative period was 5 days in patients without infection and 13 days in patients with infection (p < 0.0001) . Two patients died, one of them (0.4%) caused by sepsis . In addition to the European prospective study, a review of the problems of sepsis in biliary surgery was carried out.

Can J Cardiol, 1997 Jul, 13(7), 641 - 5
Adult patients' knowledge about their congenital heart disease; Kantoch MJ et al.; OBJECTIVE: To assess patient knowledge about their congenital cardiovascular disease . DESIGN: Fifty consecutive patients (25 women) attending the Adult Congenital Heart Disease Clinic, University of Alberta, Edmonton, Alberta, filled out a questionnaire that tested knowledge about their heart defect and endocarditis prophylaxis . The patients ranged in age from 18 to 60 years (mean 25) . The most frequent cardiovascular anomalies were obstruction of the left ventricular outflow tract (13), coarctation of the aorta (10), tetralogy of Fallot (six), transposition of the great arteries (five) and Marfan syndrome (four) . Patients had been seen on average by three cardiologists (range one to six) and had made an average of seven clinic visits (range one to 22) since the age of 17 years . Eight patients had been followed at other clinics in the past . MAIN RESULTS: Fifty-four per cent of patients knew their diagnosis . Forty-four per cent could explain the defect in lay language, and another 48% made an attempt . When given a heart diagram, 26% marked their defect correctly and 28% made an attempt . Terms 'endocarditis' and 'antibiotic prophylaxis' were known to 16% and 22% of patients, respectively . Fifty-eight per cent could name at least one situation that carries a risk of 'infection in the heart' . CONCLUSION: Adults with congenital heart disease have poor knowledge of their heart defects and the importance of endocarditis and antibiotic prophylaxis . Although time consuming, patient education should be a part of every clinic visit . Repetitive and structured patient education may improve patients' knowledge and, hence, participation in their health care.

J Bone Joint Surg Br, 1997 Jul, 79(4), 590 - 5
Antibiotic prophylaxis in total hip arthroplasty . Review of 10,905 primary cemented total hip replacements reported to the Norwegian arthroplasty register, 1987 to 1995; Espehaug B et al.; We have assessed the effect of different regimes of antibiotic prophylaxis on the survival of total hip implants, comparing antibiotics administered both systemically and in the bone cement, systemically only, in the bone cement only and with no antibiotics given . We studied 10,905 primary cemented total hip replacements, performed for osteoarthritis of the hip and reported to the Norwegian arthroplasty register between 1987 and 1995 . Cox-estimated failure-rate ratios (FRR) are presented with adjustment for gender, age, the brand of cement, the prosthesis, the type of operating theatre and the operating time . For revisions performed for infection (39 operations), the lowest rate of revision was found among patients receiving antibiotic-containing cement plus systemic antibiotics (n = 5804) . The revision rate for the 4586 patients receiving systemic antibiotics only was 4.3 times greater (95% CI 1.7 to 11.0, p = 0.001); in 239 with antibiotics in the bone cement only it was 6.3 times greater (CI 1.6 to 25.0, p = 0.003); and in the 276 who did not receive antibiotics it was by 11.5 times greater (CI 2.1 to 63.0, p = 0.002) . Adjustment for the total amount of systemic antibiotic administered did not change the results . We also observed an increased revision rate for aseptic loosening (109 operations) comparing the systemic-only (FRR = 1.8, CI 1.1 to 2.9, p = 0.01) and the cement-only regimes (FRR = 2.6, CI 1.2 to 5.9, p = 0.02) with the combined dosage . Our findings show that systemic antibiotics combined with antibiotic-containing bone cement led to fewer revisions than the other methods.

J Am Dent Assoc, 1997 Jul, 128(7), 1004 - 8
Advisory statement . Antibiotic prophylaxis for dental patients with total joint replacements . American Dental Association; American Academy of Orthopaedic Surgeons; Infective endocarditis and the dental practitioner: a review of 53 cases involving litigation; Department of Clinical Dental Sciences, University of LiverpoolOBJECTIVE: To review episodes of infective endocarditis involving dental procedures that have resulted in litigation and to determine if any clinical recommendations can be obtained . DESIGN: 13-year retrospective study . INTERVENTION: Patient records were analysed to identify the probable cause of infective endocarditis . All were judged to be caused by dental manipulations on the basis of dental procedure, cardiac pathology, infecting micro-organism and time between onset of infection and dental manipulation . MAIN OUTCOME MEASURES: Cases were analysed to check if appropriate national guidelines on antibiotic prophylaxis were followed . Status of patient dental records was also evaluated . RESULTS: Dental procedures implicated in infective endocarditis were exodontia (23), scaling (21), root canal therapy with extra-canal instrumentation (7) and minor oral surgery (2) . No medical history was recorded in 10 patients . In a further 31 medical history was inadequate or out of date . Dentists involved with these cases failed to give prophylactic antibiotics (48), prescribed incorrect antibiotics (2), or gave antibiotics at inappropriate times (2) . There was one episode of prophylaxis with amoxycillin failing despite it being given correctly . CONCLUSIONS: If litigation is to be avoided dental practitioners must keep accurate dental records, take an appropriate medical history that is kept up to date and adhere to national guidelines on antibiotic prophylaxis.

Arch Dis Child, 1997 Jun, 76(6), 539 - 40
Dental attitudes, knowledge, and health practices of parents of children with congenital heart disease; Saunders CP et al.; A total of 60 children with severe congenital cardiac disease from the Great Ormond Street Hospital for Children and Guy's Hospital children's department were matched for age, gender, social class, and ethnic origin with 60 healthy children from the trauma clinic of the Department of Orthodontics and Paediatric Dentistry at Guy's Dental Hospital, London . The parents' attitude, knowledge, and dental health practices were assessed by questionnaire . The cardiac group had significantly poorer dental health practices than the healthy group . Of the cardiac children 18% had never visited the dentist compared with only 3% for the healthy group . It is difficult to assess the importance of this in terms of a serious health hazard . Current practice of cardiac physicians is to recommend that children with heart disease seek out and attend a dentist, the advice usually being accompanied by the presentation of a 'heart card' detailing antibiotic prophylaxis regimens if extractions are required . The data presented here shows that this strategy has failed.

Arch Ital Urol Androl, 1997 Jun, 69(3), 181 - 3
Ureteroscopy and stone lithotripsy with lithoclast: personal experience; Leidi GL et al.; Ureteroscopy has become a common technique in the diagnosis and treatment of ureteral pathologies, but this procedure is quite invasive and some complications have been reported in literature . In our Institute 49 patients underwent ureteroscopy and ballistic lithotripsy with lithoclast for ureteral stones . The stones were localized both in the middle and distal part of the ureter . We used a small caliber 7-8.5 Wolf ureteroscope . The treatments were performed under antibiotic prophylaxis . Direct access to the ureter without dilation of the meatus was obtained in 97.96% of patients . The stones were easily reached in 93.88% of the cases and satisfactory fragmentation was obtained in 90.7% . In 4 patients (9.3%) one or more large stone fragments escaped into the kidney, requiring the patients to be treated with ESWL . No major complications occurred: no ureteral perforations, no important bleeding and no severe or persistent infections . All patients were discharged in one to four days postoperatively . The authors conclude that ureteroscopy using small caliber instruments with Lithoclast is a safe and satisfactory alternative to ESWL in the treatment of ureteral stones.

Clin Cardiol, 1997 Jun, 20(6), 547 - 52
Routine arterial oxygen saturation monitoring is not necessary during transesophageal echocardiography; Kassimatis A et al.; BACKGROUND: Transesophageal echocardiography (TEE) is now an established adjunct to routine echocardiography, its diagnostic impact making it an invaluable first-line diagnostic procedure in many cardiac conditions . However, there is no unanimity in the way the transesophageal procedure is carried out, especially with regard to the need for antibiotic prophylaxis, sedation, and the monitoring of oxygen saturation . HYPOTHESIS: This study was prospectively undertaken (1) to determine the presence and magnitude of oxygen desaturation and (2) the changes in heart rate and blood pressure following sedation for routine TEE in an unselected and consecutive group of patients to identify those at high risk . METHODS: Arterial oxygen saturation, heart rate, and systolic, diastolic, and mean blood pressure were monitored in 106 consecutive patients undergoing routine transesophageal echocardiography . Ninety-four (89%) patients received intravenous sedation with midazolam . RESULTS: Three min after midazolam administration there was a drop in oxygen saturation from 97 +/- 2.5 to 95 +/- 2.9 (p < 0.001), in systolic blood pressure from 139 +/- 19.5 to 124.8 +/- 22.2 mmHg (p < 0.001), in diastolic blood pressure from 86.6 +/- 19.9 to 77.5 +/- 17.7 mmHg (p < 0.001), and in mean blood pressure from 108.3 +/- 18 to 95.6 +/- 28.8 mmHg (p < 0.001) . After introduction of the transesophageal probe and during the examination, there was a further drop in oxygen saturation with a maximum drop at the 15th min of the examination (93.7 +/- 3.7 vs . 97 +/- 2.5, p < 0.001) . The maximum blood pressure drop occurred at the 12th min into recovery: systolic blood pressure dropped from 139 +/- 19.5 to 118 +/- 20.8 mmHg (p < 0.001), diastolic blood pressure from 86.6 +/- 16.9 to 75.8 +/- 17.9 mmHg (p < 0.005), and mean blood pressure from 108.3 +/- 18 to 92.5 +/- 19.4 mmHg (p < 0.01) . Patients with congestive heart failure had a greater drop in oxygen saturation compared with patients who were not in heart failure (p < 0.01) . Twelve patients did not receive any sedation; however, they all showed a drop in oxygen saturation from 97.8 +/- 2.3 to 94.6 +/- 3.4 (p < 0.001), with a maximum drop at the 15th min during the transesophageal examination . CONCLUSION: In patients with no chronic obstructive airway disease who are not in congestive heart failure, routine oxygen saturation monitoring is not deemed necessary during transesophageal examination . The cause of hypoxemia during the procedure is not only related to sedation but also to esophageal intubation.

Am J Gastroenterol, 1997 Jun, 92(6), 989 - 91
Antibiotic prophylaxis for orthopedic prostheses and GI procedures: report of a survey; Meyer GW et al.; OBJECTIVE: To determine the practice recommendations of Program Directors of infectious disease training programs with regard to infection prophylaxis for patients with prosthetic orthopedic devices who undergo gastrointestinal procedures . METHODS: We surveyed Program Directors of infectious disease training programs to determine what they recommend when asked about antibiotic prophylaxis for patients with orthopedic prostheses who undergo gastrointestinal procedures . RESULTS: More than 50% of the respondents agreed that prophylaxis is not indicated at any time for these procedures, although there was an almost even split when confronted with colonoscopy and polypectomy within 6 months of prosthesis insertion . CONCLUSIONS: Most Program Directors agree with the recommendations of the American Society for Gastrointestinal Endoscopy and do not recommend prophylactic antibiotics for these patients . If antibiotics are chosen, they should be the same ones that are recommended for infectious endocarditis by The American Heart Association.

Am J Obstet Gynecol, 1997 May, 176(5), 1030 - 8
A prospective, double-blind, randomized, controlled clinical trial of ampicillin-sulbactam for preterm premature rupture of membranes in women receiving antenatal corticosteroid therapy; Lovett SM et al.; OBJECTIVE: Our purpose was to test the efficacy of antibiotic prophylaxis in women with preterm premature rupture of the membranes who receive antenatal corticosteroids . STUDY DESIGN: A total of 112 women received one of three regimens in a double-blind randomized controlled trial: (1) ampicillin-sulbactam for 72 hours followed by amoxicillin-clavulanate, (2) ampicillin for 72 hours followed by amoxicillin, or (3) placebo . RESULTS: A total of 48.6% of neonates in the placebo group either died or had sepsis or respiratory distress syndrome versus 29.3% in the pooled antibiotic group (p < 0.05) and 26.3% in the ampicillin-sulbactam/amoxicillin-clavulanate subgroup (p < 0.05) . All three neonatal deaths occurred in the placebo group (p = 0.03 versus pooled antibiotics) . Mean birth weight was significantly greater in the pooled antibiotic group (1773 gm, p = 0.04) and in the ampicillin-sulbactam/amoxicillin-clavulanate subgroup (1870 gm, p = 0.02) than in the placebo group (1543 gm) . Antibiotic prophylaxis reduced the need for prolonged ventilation (p = 0.05) . CONCLUSIONS: Antibiotic prophylaxis in combination with corticosteroids in preterm premature rupture of membranes significantly lowered the total frequency of neonatal mortality, sepsis, and respiratory distress syndrome and significantly increased birth weight compared with corticosteroids alone.

Arch Surg, 1997 May, 132(5), 487 - 92; discussion 492-3
The role of antibiotic prophylaxis in severe acute pancreatitis; Ho HS et al.; OBJECTIVE: To assess the impact of intravenous (IV) antibiotic prophylaxis on the incidence of pancreatic infection and the mortality rate in severe acute pancreatitis . DESIGN: Restropective review of a cohort of 180 patients with severe acute pancreatitis . SETTING: A tertiary referral center in Sacramento, Calif . INTERVENTION: The use of IV antibiotic prophylaxis evolved during 3 periods from no antibiotics in 50 patients (1982-1989), to nonprotocol use in 55 patients (1990-1992), to a 4-week course of imipenem-cilastatin sodium (1993-1996) given to 75 patients having Acute Physiology and Chronic Health Evaluation (APACHE) II scores greater than 6 and pancreatic necrosis (> 15% of the gland), peripancreatic necrosis, or peripancreatic collection . MAIN OUTCOME MEASURES: Pancreatic infection and mortality . RESULTS: Without antibiotic prophylaxis, the incidence of pancreatic infection was 76% (38/50) . Intravenous antibiotic prophylaxis reduced the infection rate of 45% (25/55) (P = .03) . The imipenem-cilastatin protocol further reduced the infection rate to 27% (20/75) (P = .04) . The mortality rates showed only a decreasing trend, from 16% (1982-1989) to 7% (1990-1992) to 5% (1993-1996) (P = .11) . Patients with sterile severe acute pancreatitis had a mortality rate of 2% (2/97); whereas 17% (14/83) of patients with infection succumbed to the disease . Patients developing infection within the first 4 weeks from the onset of illness had mortality rates ranging from 19% to 40%, compared with 0% to 8% for those who became infected after 4 weeks . No patient with pancreatic infection developing after 4 weeks died with the imipenem-cilastatin protocol . CONCLUSIONS: Intravenous antibiotic prophylaxis significantly reduced the infection rate in severe acute pancreatitis, with only a trend toward improved survival . A prospective, randomized, double-blind multicenter trial comparing the efficacy of different types and/or combinations of antibiotic prophylaxis in severe acute pancreatitis is indicated.

Head Neck, 1997 May, 19(3), 188 - 93
Comparison of three prophylactic antibiotic regimens in clean-contaminated head and neck surgery; Rodrigo JP et al.; BACKGROUND: Although appropriate perioperative antibiotic prophylaxis has significantly reduced wound infection rates in clean-contaminated head and neck surgical procedures, controversy still remains regarding the optimal antibiotic regimen . METHODS: In this prospective, double-blind clinical trial, 159 patients were randomized to receive amoxicillin-clavulanate, clindamycin plus gentamicin, or cefazolin intravenously up to 1/2 hour before surgery and at 6-hour intervals for an additional three doses . RESULTS: An overall wound infection rate of 23% was observed . Thirteen (22.8%) infections occurred in the amoxicillin-clavulanate-treated group, 11 (21.2%) in the clindamycin plus gentamicin-treated group, and 13 (26%) in the cefazolin-treated group, which was not statistically significant . Only prior medical illnesses, such as chronic obstructive pulmonary disease and diabetes mellitus, correlated with an increased wound infection rate (p = 0.018) . CONCLUSIONS: Amoxicillin-clavulanate, clindamycin plus gentamicin, and cefazolin seem to have similar efficacy when administered prophylactically in clean-contaminated head and neck surgical procedures.

Am J Med, 1997 Apr, 102(4), 337 - 43
The clinical impact of echocardiography on antibiotic prophylaxis use in patients with suspected mitral valve prolapse; Heidenreich PA et al.; PURPOSE: To determine the impact of echocardiography on the use of antibiotic prophylaxis in patients with suspected mitral valve prolapse (MVP) . PATIENTS AND METHODS: We evaluated 147 consecutive patients who were referred for "rule out mitral valve prolapse" to a university hospital echocardiography laboratory . Chart review and phone contact were used to determine the demographic characteristics of the patients; past diagnosis of MVP, symptoms, and exam at referral; practice specialty of referring MD; echocardiographic findings; and change in prophylaxis usage as a result of the echocardiogram (ECHO) . Prophylaxis was considered to be indicated if the echocardiogram demonstrated MVP with at least mild regurgitation or abnormal thickening of at least one mitral leaflet . RESULTS: Based on the ECHO a change in antibiotic prophylaxis was indicated in 20 of 147 (14%) patients including initiation of prophylaxis in 6, and discontinuation of prophylaxis in 14 . However, only 4 of 20 patients (20%) actually changed their prophylaxis habits leading to an actual yield of 4 management changes per 131 ECHOs ordered (3%) . This corresponded to 1 change in management per $36,250 in hospital and physician costs . Younger age, female gender, and presence of symptoms were associated with a benign ECHO . Indications for a change in management were not significantly different between physician specialities: 18% for generalists (internal medicine and family practice), 12% for cardiologists, and 7% for other specialists, P = 0.3 . CONCLUSIONS: In patients referred for evaluation of MVP, echocardiography infrequently resulted in changes in antibiotic prophylaxis management and was associated with significant expense.

Br J Oral Maxillofac Surg, 1997 Apr, 35(2), 133 - 6
The appropriateness of referral of medically compromised dental patients to hospital; Absi EG et al.; Hospital departments of oral and maxillofacial surgery make a substantial contribution to both managing and treating medically-compromised dental patients . Contracting arrangements should take account of this . Demographic data suggest that the treatment of medically-compromised elderly dentate patients will become increasingly important in the General Dental Service (GDS) . To determine the medical conditions and treatment requirements prompting referral of these patients to hospital, a prospective study was undertaken of 75 consecutive adults referred for hospital treatment specifically because of a medical condition which prevented delivery of routine dental care in the GDS . Patients (mean age: 56 years) were referred mainly from general medical (33%) and dental (62%) practitioners . Cardiovascular disease was the most frequently cited medical condition requiring referral (43%; n = 32 cases) . Forty-eight patients (64%) were symptomatic on presentation and on average had attended on 2.3 occasions before definitive treatment was instituted . Fifty-two patients (70%) had no special treatment requirements other than those available in the GDS, 11 patients (15%) simply required antibiotic prophylaxis and 81% were treated by undergraduates or junior staff . These data suggest that many patients referred for dental hospital treatment because of underlying medical condition are not in fact medically-compromised and may be treated in the primary care setting.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1997 Apr, 83(4), 423 - 6
Comparison of ceftriaxone with penicillin for antibiotic prophylaxis for compound mandible fractures; Heit JM et al.; PURPOSE: The purpose of the study was to compare the efficacy and cost of two antibiotic regimens for prophylaxis of compound mandible fractures: 1 gm/day ceftriaxone and 2 million U penicillin G every 4 hours . DESIGN: A prospective study of 90 patients with compound mandible fractures was performed . The patients were randomized to the two antibiotic regimens . The surgical procedures were performed by oral/maxillofacial surgery residents at a large urban training center . Standard treatment consisted of open reduction with either bone plates or wires, with all patients receiving 6 weeks of maxillomandibular fixation . The patients were monitored at 2-week intervals for 8 weeks by two of the authors, who were blinded to which antibiotic regimen the patient was assigned . RESULTS: Two patients in each group had postoperative infections within the first 2 weeks of treatment . The infections resolved with local wound care, removal of internal fixation devices, and oral antibiotics . After resolution of the infection each patient had a malunion, which was managed without additional complications . The cost difference between the two treatment regimens was approximately $350 per day . CONCLUSION: Ceftriaxone was noted to be an efficacious and cost-effective treatment alternative to penicillin G for compound mandible fracture antibiotic prophylaxis.

J Infect Dis, 1997 Apr, 175(4), 996 - 9
Duration of tick attachment as a predictor of the risk of Lyme disease in an area in which Lyme disease is endemic; Sood SK et al.; Animal studies have shown an exponential increase in the risk of Borrelia burgdorferi infection after 48-72 h of deer tick attachment . Persons with tick bites were prospectively studied to determine if those with prolonged tick attachment constitute a high-risk group for infection . Ticks were identified, measured for engorgement, and assayed by polymerase chain reaction (PCR) for B . burgdorferi DNA . Duration of attachment was determined from the scutal index of engorgement . Of 316 submissions, 229 were deer ticks; 14% were positive by PCR . Paired sera and an intact tick for determination of duration of attachment were available for 105 subjects (109 bites) . There were 4 human cases (3.7% of bites) of B . burgdorferi infection . The incidence was significantly higher for duration of attachment > or =72 h than for <72 h: 3 (20%) of 15 vs . 1 (1.1%) of 94 (P = .008; odds ratio, 23.3; 95% confidence interval, 2.2-242) . PCR was an unreliable predictor of infection . Tick identification and measurement of engorgement can be used to identify a small, high-risk subset of persons who may benefit from antibiotic prophylaxis.

An Med Interna, 1997 Mar, 14(3), 111 - 3
{Scheduled biliary surgery and antibiotic prophylaxis . Is its use always justified?}; Blanco JR et al.; AIM: Evaluate the need to give prophylactic antibiotic therapy in patients that undergo elective surgery for cholelithiasis . METHODS: Prospective study in 35 patients the underwent surgery for cholelithiasis, without infectious risk factors . All of them, the hemocultives, endotoxin and Tumor Necrosis Factor has been evaluated along the surgical process . RESULTS: The hemocultives were in all the patients negatives . The levels of Tumor Necrosis Factor decreased along the surgical process, without modifications of endotoxin levels . There were no significant differences in either of the points of the analysis . CONCLUSIONS: Biliary surgery in patients that undergo elective surgery for cholelithiasis, without infectious risk factors, is a clean surgery, and so, in this patients is not indicated systematically an antibiotic prophylaxis.

Ned Tijdschr Geneeskd, 1997 Mar 1, 141(9), 412 - 3
{No routine antibiotic prophylaxis necessary in endoscopic retrograde cholangiopancreatography}; van de Meeberg PC et al.; Acute cholangitis is a serious complication and cause of death in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) . Some centres have adopted a policy of administering antibiotics before every ERCP procedure . The results of a recent clinical trial failed to support this policy . Antibiotic prophylaxis should be restricted to patients expected to develop incomplete drainage of the bile duct and to endocarditis prophylaxis.

Infect Dis Clin North Am, 1997 Mar, 11(1), 203 - 22
Chorioamnionitis and endometritis; Casey BM et al.; Chorioamnionitis complicates 1% to 2% of all pregnancies and may affect 10% of women with certain risk factors . Intraamnionic infection may result in devastating morbidity for both the fetus and the mother . Also, chorioamnionitis is associated with higher cesarean section rates . As demonstrated earlier, endometritis is a common complication of cesarean delivery alone . Nevertheless, antibiotic prophylaxis has been shown to reduce postpartum morbidity . In the face of chorioamnionitis and a cesarean delivery, the risk of developing endometritis increases exponentially . However, if appropriate antibiotic therapy is instituted at the time of diagnosis, fetal and maternal outcomes improve dramatically . Similar to chorioamnionitis, endometritis is usually polymicrobial in nature . The preponderance of the organisms isolated are anaerobic . Established risk factors include operative delivery, prolonged ruptured fetal membranes, and prolonged labor . The diagnosis is based primarily on clinical examination with fever and the exclusion of other sources of extrapelvic infection . Once the diagnosis is established, appropriate empiric antibiotics are instituted . Antibiotic therapy should be continued until the patient is afebrile and asymptomatic for 24 to 36 hours . Over the past 20 years, the use of single-agent therapy in these serious infections has been shown to be safe as well as effective . Once successful therapy is completed, the patient is discharged home with no oral antibiotics.

Ann Thorac Surg, 1997 Mar, 63(3), 829 - 30
Endaortitis of coarctation of the aorta after invasive diagnostics; Bohm JO et al.; We report the case of a young woman in whom endaortitis developed at the site of a coarctation of the aorta after the invasive investigation of right fossa iliac pain . The organism responsible suggests a causal relationship to the investigations without antibiotic prophylaxis, and we emphasize the need for antibiotic prophylaxis in these cases . Invasive investigation of isolated coarctation in a young adult or adolescent is probably superfluous.

Ugeskr Laeger, 1997 Feb 24, 159(9), 1265 - 7
{Antibiotic prophylaxis in cesarean section}; Pedersen TK et al.; We investigated the guidelines for patient selection and drug regimens for use of antibiotic prophylaxis in relation to Caesarean section in the maternity clinics in Denmark . A questionnaire was sent to all the Danish maternity clinics that perform Caesarean section, concerning indications for use of antibiotic prophylaxis and antibiotic regimens to patients undergoing acute and elective Caesarean section . All departments (n = 48) returned the questionnaire . Twenty departments (46%) provided written guidelines for antibiotic prophylaxis . Four departments (8%) used antibiotic prophylaxis in elective Caesarean sections, 25 departments (52%) used antibiotics in all emergency sections . In the presence of rupture of the membranes or prolongation of labour (> 12 hrs) 58 and 63% of the departments used antibiotic prophylaxis, respectively . The most frequent first choice drug was cefuroxim, employed by 27 departments (56%) . Concerning timing, 21 departments (44%) gave antibiotics after cord clamping and 13 departments (27%) before incision . We propose a nation-wide prospective investigation on the rate of infections associated with Caesarean section to set up rational guidelines for antibiotic prophylaxis.

Prog Urol, 1997 Feb, 7(1), 42 - 7
{Biopsy of the seminal vesicles in the staging of localized cancer of the prostate: technic and results}; Vallancien G et al.; OBJECTIVE: To allow the diagnosis of pathological stage C prostatic cancer before deciding on treatment . METHOD: Seminal vesicle biopsy was performed as an outpatient procedure without anaesthesia . An identical antibiotic prophylaxis to that used for prostatic biopsy was performed . Biopsies were performed by longitudinal vision using a transrectal probe . A seminal vesicle needle biopsy was performed lateral to the prostate in the medial third of the seminal vesicle . RESULT: When seminal vesicle biopsies are positive, the final pathology report after radical prostatectomy confirmed the diagnosis in 100% of cases . When seminal vesicle biopsies were negative, seminal vesicle invasion was detected on the final pathology examination in one third of cases, mostly corresponding to exclusively intraprostatic involvement of the seminal vesicle . Biopsies are useful when at least one of the two prostatic bases is involved . In the series of the last 42 radical prostatectomies performed because of negative seminal vesicle biopsies, we detected only 11% of capsular lesions, almost always less than 1 mm, and 0% of ilio-obturator lymph node invasion . CONCLUSION: Although the digital rectal examination findings, the PSA level, the Gleason score, and the number of positive biopsies and their length, allow an approach to preoperative staging, only seminal vesicle biopsies can provide a better preoperative staging of prostatic cancer for a given patient and no longer just statistically.

Endoscopy, 1997 Feb, 29(2), 114 - 9
Antibiotic prophylaxis in gastrointestinal endoscopy: a report by a Working Party for the British Society of Gastroenterology Endoscopy Committee; Mani V et al.; Antibiotic prophylaxis is recommended for endoscopic procedures if the patient is at high risk of endocarditis or of symptomatic bacteraemia as a consequence of immunosuppression or neutropenia . In most circumstances parenteral amoxycillin and gentamicin are recommended . The addition of parenteral metronidazole is recommended in patients with neutropenia . Vancomycin or teicoplanin are recommended in patients allergic to penicillin . Antibiotic prophylaxis is recommended for all patients undergoing ERCP with evidence of biliary stasis or pancreatic pseudocyst . Oral ciprofloxacin or parenteral gentamicin (or parenteral quinolone, cephalosporin or ureidopenicillin) are recommended for ERCP.

Eur J Gastroenterol Hepatol, 1997 Feb, 9(2), 131 - 6
The role of surgery in the major early complications of severe acute pancreatitis; Bassi C et al.; The early complications of severe acute pancreatitis may constitute a dramatic clinical dilemma in the first 2 weeks of the disease, when the surgical approach is made even more difficult by failure to define the precise extent of the necrotic component of the disease . Moreover, the surgical indication itself is not always based on clear guidelines to which the clinician can refer, and this is due to factors of two types: (i) the intrinsic complexity of the pancreatitis syndrome in its early toxic stages and (ii) the difficulty in understanding the relevant information reported in the literature in this connection, which is often incomplete and based on confused terminology . While the surgical indication is universally accepted in the case of infection of the necrotic tissue (an event, however, which is by no means frequent in the early stages of severe pancreatitis), the development of multi-organ failure despite adequate intensive care is a potential indication which not all specialists go along with, at least not as regards the ideal timing of the intervention . Other surgical indications which have emerged are evidence of complete rupture of the main pancreatic duct and the presence of very extensive sterile necrosis . As things stand at present, however, we are witnessing a general tendency to postpone surgery, since delayed surgery is associated with a lower incidence of complications than is the case with early surgery . If, as is known, the role of surgery is aimed mainly at the treatment of superinfections and severe multi-organ failures, targeted antibiotic prophylaxis and earlier, more complete anti-enzymatic therapy may, as suggested by a number of pilot studies, offer a promising alternative to invasive procedures which are sometimes risky, though indispensable, in an attempt to save patients who would otherwise have no chance of survival.

Akush Ginekol (Sofiia), 1997, 36(1), 9 - 11
{Antibiotic prophylaxis in cesarean section with cefoxitin (Mefoxin)}; Stoikov S et al.; The ain of this presentation is to show the advantages and disadvantages of a single prophylactic dose of Mefoxin, in comparison to the classical antibiotic prophylaxis with penicillin and gentamicin . The authors conclude that: single dose prophylaxis with Mefoxin significantly reduces the rate of infection morbidity after caesarean section; a single application of 2 g Mefoxin after clamping of the umbilicus is enough for prophylaxis of infectious complications after caesarean section.

Eur J Surg Suppl, 1997, (578), 31 - 5
Prevention of wound infection in elective colorectal surgery by local application of a gentamicin-containing collagen sponge; Rutten HJ et al.; Preoperative antibiotic prophylaxis is known to significantly reduce the incidence of postoperative wound infection in elective colorectal surgery, and is a recognized part of surgical management . Antibiotics are usually given systemically or orally, or by a combination of the two routes . Local antibiotic delivery to the wound site using an implanted, reabsorbable, gentamicin-containing collagen sponge is a novel concept . We compared postoperative wound infection rates in 221 colorectal surgery patients randomized to receive systemic gentamicin/metronidazole with (Group I, n = 107) or without (Group II, n = 114) the gentamicin-collagen sponge . The two patient groups were identical on the basis of demographics and operations undergone . The postoperative wound infection rate was significantly lower in Group I patients than Group II 5.6% (6/107) and 18.4% (21/ 114), respectively (p < 0.01) . The mean duration of hospital stay was 13.8 days in Group I and 16.3 days in Group II, which did not represent a statistically significant difference . The gentamicin collagen sponge was well tolerated and no adverse events were reported that were attributable to its use . This new method for delivering gentamicin directly to the operative site may represent a significant method for reducing postoperative wound infection rates to levels lower than those currently achieved with systemic antibiotics alone.

Zentralbl Chir, 1997, 122(1), 25 - 8
{Perioperative standards for prevention of anastomotic insufficiency}; Waldner H et al.; Anastomotic leakage is a major cause of morbidity and mortality in gastrointestinal surgery . Its incidence varies in the different segments of the GI tract being highest in the distal rectum . The rate of anastomotic leakages was reduced considerably within the last 20 years . Perioperative measures have contributed to this reduction in addition to improvements and standardization in operative technique . Perioperative nutrition, perioperative antibiotic prophylaxis and mechanical bowel preparation are widely used in colorectal surgery . Therefore they can be considered as standards . High-caloric parenteral feeding is used commonly perioperative . Its efficiency to reduce postoperative septic complications has been proven until now only for malnourished patients . The aim of perioperative antibiotic prophylaxis is to reduce the bacterial count after intraoperative contamination . Therefore tissue levels must be in the therapeutic range to cover for the expected bacteria . The efficiency to reduce postoperative wound infection has been proven, however the influence on the rate of anastomotic leakages is still controversial . Mechanical bowel preparation can reduce the bowel load but not bacterial concentration inside the bowel . Orthograde lavage with polyethylenglycol solution is feasible unless bowel obstruction is present, but its influence on anastomotic healing is still under discussion . Although all of these procedures are widely used, their influence on anastomotic healing has still to be proven by prospective, controlled trials.

Am J Rhinol, 1997 Jan-Feb, 11(1), 55 - 62
Hereditary hemorrhagic telangiectasia: what the otolaryngologist should know; Byahatti SV et al.; Hereditary hemorrhagic telangiectasia (HHT) or Rendu-Osler-Weber disease is a systemic autosomal dominant disorder involving blood vessels . Phenotypically, the disease presents with telangiectases that involve all areas of the body . Ninety percent of patients experience epistaxis and are referred to the otolaryngologist for evaluation . Because otolaryngologists may be the primary physicians caring for these patients, it is critical they be knowledgeable about high risk groups, screening protocols for arteriovenous malformations, antibiotic prophylaxis, and genetic screening . It is important that they be aware of the many therapeutic modalities available for the treatment of epistaxis . In this article, the diagnosis, screening, treatment, and molecular genetics of HHT will be discussed . In addition, our experience with 20 patients treated with the Nd:YAG laser for recurrent epistaxis will be reviewed.

Public Health Rep, 1997 Jan-Feb, 112(1), 52 - 8
Geographic differences in mortality of young children with sickle cell disease in the United States; Davis H et al.; OBJECTIVES: Because geographic differences in health care have been found for many diseases, including those affecting children, there are probably geographic differences in the health care of young children with sickle cell disease . Consequently, survival of young children with sickle cell disease might differ among geographic areas . This study's objective was to identify areas in the United States where young children with sickle cell disease are at especially high and low risk of dying . METHODS: Using U.S . death certificate data from 1968 through 1992, the authors calculated the mortality rates of 1- through 4-year-old black children with sickle cell disease for states, counties, and cities . Deaths from trauma, congenital anomalies, and perinatal conditions were excluded . RESULTS: From 1968 through 1980 and from 1981 through 1992, 1- through 4-year-old black children with sickle cell disease in Florida had a markedly higher risk of dying, and those in Pennsylvania had a markedly lower risk of dying, than the average 1- through 4-year-old black child with the disease in the United States . From 1981 through 1992, 1- through 4-year-old black children with sickle cell disease in Maryland had the lowest mortality rate in the nation . During the same time period, 1- through 4-year-old black children with sickle cell disease in five counties in Florida were at especially high risk, while in Baltimore no young black children with the disease died . These geographic differences in mortality of black children with sickle cell disease greatly exceeded geographic differences in mortality of black children without the disease . CONCLUSIONS: Marked differences exist across the United States in mortality of young black children with sickle cell disease . To improve survival for children with the disease in high mortality areas, evaluations should be made of the accessibility and quality of medical care, and of parents' health care seeking behavior and compliance with antibiotic prophylaxis . In addition, efforts should be made to understand and duplicate the success of treatment programs in low mortality areas.

Postgrad Med, 1997 Jan, 101(1), 191 - 2, 195-200
Management of ascites . Paracentesis as a guide; Habeeb KS et al.; All patients with new-onset ascites or with known ascites and any change in their condition, such as the appearance of fever, abdominal pain, renal insufficiency, or encephalopathy, should undergo diagnostic paracentesis to characterize the ascitic fluid, detect infection, and aid differential diagnosis . A serum-ascites albumin gradient greater than 1.1 g/dL indicates portal hypertension . Spontaneous bacterial peritonitis is a common and serious complication of ascites and is best diagnosed by the number of neutrophils in the ascitic fluid . Patients with the condition should be treated with parenteral antibiotics, and response to therapy should be assessed with repeated paracentesis . Hospitalized patients with low-protein ascites should receive antibiotic prophylaxis . Sodium restriction and diuretics are the cornerstones of therapy for ascites . In refractory cases, alternative forms of therapy, such as large-volume paracentesis, peritoneovenous shunting, or transjugular intrahepatic portosystemic shunting, may be of benefit . Patients with refractory ascites should be considered for liver transplantation.

Chemotherapy, 1997 Jan-Feb, 43(1), 54 - 9
Low-dose, single-shot perioperative antibiotic prophylaxis in colorectal surgery; Peiper C et al.; Reductions of frequency of administration and dosage of antibiotic agents used in colorectal surgery may lower costs and the occurrence of adverse side effects . In a prospective randomized trial we evaluated two single-short regimens, a low dose of 1 g cefotiam against a standard dose of 2 g cefotiam, both in combination with 500 mg metronidazole . The low-dose group had twice the number of patients with wound sepsis (4 of 30) than the group receiving the standard antibiotic regimen (2 of 30) . Two hours after infusion, the antibiotic concentrations in samples of serum, subcutaneous fatty tissue, and colonic wall of those patients receiving 1 g cefotiam were < 1 mg/l . The concentrations after administration of 2 g cefotiam were higher, as expected, and without any adverse side effects . In conclusion, we prefer infection prophylaxis by the standard dose of 2 g cefotiam plus 500 mg metronidazole in colorectal surgery.

Ceylon Med J, 1996 Dec, 41(4), 141 - 3
Fetal hydronephrosis, a one year follow up; Senanayake M et al.; OBJECTIVE: To determine the underlying urological anomalies and the outcome during the first year, in babies with antenatally diagnosed hydronephrosis . DESIGN: A prospective descriptive study . SETTING: Southlands and Worthing Hospitals, Worthing, UK . METHOD: From January 1991 to December 1992, in the Worthing District Health Region, UK all babies with hydronephrosis persisting postnatally (69) were prospectively assessed for renal growth and function, general well-being, and complications if any . The diagnoses, treatment and complications occurring during the first year were analysed . RESULTS: Of the 69 babies 4 were lost to follow up . The 65 fetuses assessed had the following underlying causes: transient in utero hydronephrosis 34 (52.3%), idiopathic hydronephrosis 9 (13.8%), isolated vesico-ureteric reflux 5 (7.6%), vesico-ureteric reflux with other urological abnormalities 2 (3.1%), pelvi-ureteric junction obstruction 2 (3.1%), equivocal pelvi-ureteric junction obstruction/idiopathic hydronephrosis 4 (6.2%), multicystic dysplastic kidney 4 (6.2%), polycystic kidneys 1 (1.5%) and patulous extrarenal pelvis 4 (6.2%) . During one year of follow up 4 (6%) of babies needed surgical intervention and further 6 (9%) needed antibiotic prophylaxis . CONCLUSION: The majority of fetal hydronephroses is were self-limiting or benign . Vesico-ureteric reflux was the commonest urological abnormality . 23 (33%) apparently normal neonates detected on prenatal screening needed aggressive management or close monitoring.

Rev Esp Enferm Dig, 1996 Dec, 88(12), 847 - 50
{Surgery of benign obstruction of the bile tract . Current opinion status}; Moles JR et al.; Treatment of the benign obstruction of the main bile duct remains controversial . A questionnaire, containing the different aspects of the treatment, was mailed in order to learn the general opinion about its management in our country; 140 specialists were surveyed with the following results: 35% gave valid answers . Most of those surveyed (85%) use antibiotic prophylaxis, preferably (79%) pre and postoperatively . Ultrasonography is used in 100% of the cases, and the second most common examination is endoscopic retrograde colangiopan-creatography . Among the intraopreoperative examinations, colangiography is the most used (100%), followed by choledochoscopy . A majority (90.4%) of those surveyed employ the T-tube and 67.5% prefer choledochoduodenostomy if an internal bile drainage must be performed . In obstructive jaundice, only 27.5% recommend preoperative percutaneous drainage . Endoscopic sphinterotomy is the elective technique for suppurative cholangitis and for patients with choledocholitiasis and previous cholecystectomy.

Curr Opin Pediatr, 1996 Dec, 8(6), 606 - 14
Pediatric HIV infection; Lambert JS; Our ability to diagnose, treat, and prevent HIV infection in pregnant women and in children has changed dramatically over the last few years . Recent developments include "early diagnostic" techniques such as polymerase chain reaction, quantitative viral load measurements to assist in estimating disease status and prognosis, newer antiretroviral therapies (including combinations) and effective antibiotic prophylaxis for HIV-infected children, and a better understanding of maternal-fetal factors that may mediate transmission of HIV . As children with long-term immunosuppression live longer, we are diagnosing new diseases and unusual clinical manifestations of common diseases . Children are living into their teenage years with perinatally acquired HIV infection, and we now find ourselves dealing with many of the complex medical and psychosocial issues that have confronted clients with other chronic diseases (e.g., diabetes, cancer): issues of growth failure; nutrition; depression' disclosure of illness to school, friends, and family; and death and dying . What separates HIV from other chronic diseases is its ability to infect and affect so many other family members, not just the child.

Am J Surg, 1996 Dec, 172(6A), 38S - 43S
A critical review of antibiotic prophylaxis in severe acute pancreatitis; Barie PS; The close association between infection and poor outcome in severe pancreatitis has led many investigators to hypothesize that antibiotic prophylaxis might reduce infection and thereby reduce mortality . However, despite this possible relationship, few studies of good quality have been performed in humans . Comprehensive searches using Medline and reviewing relevant published bibliographies of English-language human and experimental literature concerning acute pancreatitis or pancreatic tissue and antibiotic therapy or pharmacokinetics were conducted . Ample experimental evidence indicates that aminoglycosides penetrate pancreatic tissue poorly and that penetration of penicillins is variable, although the relevance of this is debatable, because most tissue that requires debridement in severe pancreatitis is necrotic peripancreatic retroperitoneal fat, not the pancreas itself . Although several animal studies suggest that antibiotic prophylaxis would be beneficial in severe pancreatitis, two recent randomized studies of intravenous antibiotics in humans provide conflicting data . There are insufficient data to recommend the use of selective digestive decontamination . Some justification exists for the use of intravenous antibiotic prophylaxis in severe pancreatitis, but the data are insufficient to mandate prophylaxis or to elevate it to the standard of care . If chosen, prophylaxis with the combination of a fluoroquinolone plus metronidazole, or monotherapy with a carbapenem antibiotic, would be most appropriate . Several other questions-including the minimum degree of severity that will benefit, the validity of endpoints other than mortality, and reduction of the need for surgical drainage-require additional trials.

Am J Surg, 1996 Dec, 172(6A), 26S - 32S
Let us shorten antibiotic prophylaxis and therapy in surgery; Wittmann DH et al.; Excessive duration of antibiotics for prophylaxis and treatment of surgical infection appears to be the principal reason for "inappropriate" administration in current surgical practice . The main factors to blame are the inability of the clinician to distinguish between contamination, infection, and inflammation . Failure to distinguish between contamination and infection is the reason that prophylaxis is unnecessarily carried through into the postoperative phase for prolonged periods . Failure to distinguish between infection and inflammation misguides surgeons to continue antibiotics for unnecessarily long treatment periods . The concept for shortening courses of antibiotic administration is supported by a forum of experts . The majority of experts also favored a trend away from the use of therapeutic courses of fixed duration, by tailoring the duration of administration to the intraoperative findings to shorten treatment courses . Specific recommendations are (1) contamination: single dose prophylaxis (gastroduodenal peptic perforations operated within 12 hours, traumatic enteric perforations operated within 12 hours, peritoneal contamination with bowel contents during elective or emergency procedures, early or phlegmonous appendicitis, or phlegmonous cholecystitis); (2) resectable infection: 24-hour postoperative antibiotics (appendectomy for gangrenous appendicitis, cholecystectomy for gangrenous cholecystitis, bowel resection for ischemic or strangulated "dead" bowel without frank perforation); (3) advanced infection: 48 hours to 5 days, based on operative findings and patient's condition (intra-abdominal infection from diverse sources); (4) severe infection with the source not easily controllable: longer administration periods may be necessary (e.g., infected pancreatic necrosis).

Eur J Surg, 1996 Dec, 162(12), 945 - 8; discussion 949
Antibiotic prophylaxis in umbilical and incisional hernia repair: a prospective randomised study; Abramov D et al.; OBJECTIVE: To find out if preoperative prophylaxis would reduce infection rates after umbilical and incisional hernia repair . DESIGN: Randomised controlled trial . SETTING: Teaching hospital, Israel . SUBJECTS: 35 Patients who presented with umbilical (n = 19) or incisional (n = 16) hernias during a period of 8 months . INTERVENTIONS: Cefonicid 1 g was given by intravenous infusion to alternate patients 30 minutes before the operation . MAIN OUTCOME MEASURES: Wound infection . RESULTS: The groups were comparable for age, body mass index, grade of surgeon, operating time, and size of hernial ring . The wound infection rates were 0/8 compared with 4/8 for incisional hernia repairs (p = 0.08) and 1/9 compared with 4/10 for umbilical hernia repairs (p = 0.3) . The overall rate was 1/17 compared with 8/18 (p = 0.02) . CONCLUSIONS: Single dose antibiotic puphylaxis seems to exert a beneficial effect on the wound infection rate after umbilical and incisional hernia repair.

Ann Trop Paediatr, 1996 Dec, 16(4), 307 - 17
Clinical problems in measles case management; Hussey GD et al.; Measles remains one of the leading causes of childhood morbidity and mortality in developing countries . The World Health Organization has identified effective case management as one of the specific strategies to reduce the burden of this disease . The purpose of this article is to review the aetiology, natural history, treatment and outcome of the common clinical problems associated with measles with a view to identifying possible deficiencies in case management . Complications such as pneumonia, diarrhoea, croup and malnutrition have been well defined in terms of their relative contribution to morbidity and mortality . However, there are few published data on the aetiology and natural history of these specific complications . Such data are crucial for rational case management strategies . Data on treatment of measles and its complications are limited and the role of antibiotic prophylaxis and therapy is unclear . The only specific research focus on case management during the last decade has been vitamin A therapy . There is a continuing need for community and hospital-based studies on the natural history of measles and its complications, the aetiology of these complications and intervention strategies that will improve measles case management.

Pediatr Nephrol, 1996 Dec, 10(6), 789 - 94
Vesicoureteral reflux: practical aspects of evaluation and management; Greenfield SP et al.; The efficacy of both medical and surgical therapy for vesicoureteral reflux (VUR) has been well established . Controversy remains, however, regarding who should be evaluated for the presence of VUR, who should undergo corrective surgery, who should be treated medically and for how long . Medical treatment requires many years of continuous antibiotic prophylaxis, so compliance with therapy is essential . Many children are lost to followup, however, and remain untreated after a medical regimen is started . This large number of untreated children raises issues of the appropriateness of blanket therapeutic recommendations for all children with VUR and challenges the clinician to devise more effective treatment strategies.

Artif Organs, 1996 Dec, 20(12), 1278 - 81
Clinical use of omniflow vascular graft as arteriovenous bridging graft for hemodialysis; Wang SS et al.; From April 1992 to November 1995, 109 bridging arteriovenous fistulas were performed in 89 patients for hemodialysis at National Taiwan University Hospital . These included 61 Omniflow vascular grafts (OVG) in 47 patients and 48 GoreTex polytetrafluoroethylene (PTFE) grafts in 42 patients . There were 36 male and 53 female patients, whose ages ranged from 24 to 84 years with a mean of 59 +/- 2 years . The operation was performed under lidocaine local anesthesia with antibiotic prophylaxis . The anatomic configurations included 50 (45.9%) forearm loop grafts, 19 (17.4%) forearm straight grafts, and 40 (36.7%) thigh loop grafts . Hemodialysis via the bridging graft was started 2 weeks after the operation . The patients received hemodialysis 3 times a week or more when indicated . No patients suffered from limb loss . Pseudoaneurysm and graft infection requiring operation occurred 0.96% and 1.92% per patient year, respectively, in the OVG group, and pseudoaneurysm and graft infection both occurred 2.38% per patient in the PTFE group . In the OVG group, the thigh loop graft had better patency than the forearm straight graft . The forearm loop graft had a better patency rate than the forearm straight graft . In the OVG group, the 1 to 4 year patency rate was 77 +/- 6 % 58 +/- 8%, 48 +/- 9%, and 34 +/- 13%, respectively, whereas in the PTFE group, the 1 to 4 year patency rate was 69 +/- 7%, 50 +/- 9%, 43 +/- 10%, and 26 +/- 15%, respectively . Therefore, the Omniflow is a good alternative bridging graft for hemodialysis.

Actas Urol Esp, 1996 Nov-Dec, 20(10), 858 - 66
{Morbidity of and tolerance to ultrasonography-guided transrectal biopsy of the prostate}; Herranz Amo F et al.; OBJECTIVE: The objective of the study is to evaluate the infectious complications of the ultrasound-guided prostate transrectal biopsy using two different antibiotic prophylactic regimes . Also, patient tolerance to ultrasound-guided transrectal biopsy is assessed . METHODS: Prospective study in 100 patients randomized to antibiotic prophylaxis with Pefloxacin (800 mg as single dose) versus Ciprofloxacin (250 mg/8 h/72 h) . Tolerance data collection was done through completion of a questionnaire immediately after biopsy . RESULTS: Out of the 92 patients eligible for the study, 44 (48%) were assigned to Pefloxacin and 28 (52%) to Ciprofloxacin . In-house validation indicated both groups were matched . 90% patients showed good tolerance to the ultrasound technique and 81.5% patients to the transrectal biopsy . 31.5% patients presented no post-biopsy events; among the remaining only one patient (1%) required medical care and hospitalization . No patient had infectious complications . CONCLUSIONS: Prostate transrectal ultrasound and transrectal prostate biopsy was an approach well tolerated by most (81.5%) patients studied . Percentage of major complications was very small (1%), while post-biopsy events (haematuria, rectorrhage, etc) which do not require medical care should be considered not as complications but as effects intrinsic to the approach itself . Antibiotic prophylaxis whether with Pefloxacin or Ciprofloxacine was highly effective, although Pefloxacin is preferred due to its single dose administration and lower cost.

Chirurg, 1996 Nov, 67(11), 1123 - 8
{What is prevention of perioperative infection? Overview exemplified by trauma surgery}; Hansis M; The prevention of perioperative infection requires an interplay of technical equipment, good surgical technique and proper attention to hygiene . The basis for this is a well-structured and well-organized department using well-known, generally practised routine procedures and solid, realistic time planning . The most important technique for supervising and optimizing behaviour (with regard to both operative technique and hygiene) is the example of "being there" ("inter-esse") . In this way, mistakes regarding details are noticed immediately . Moreover, the best form of quality control is a long-term, honest survey of infection statistics that is managed by one responsible person only . Above all, the infection statistics should detect factors predisposing to infection that can be modified by everyday staff attention . The protection of staff against infection is equally as important as the protection of patients . The question of whether routine perioperative antibiotic prophylaxis or treatment in trauma surgery is useful under the present conditions has not yet been answered.

J Formos Med Assoc, 1996 Nov, 95(11), 881 - 4
Delayed delivery of surviving triplet after fetal reduction and spontaneous abortion; Chang HC et al.; In multiple pregnancies, survival of remaining fetuses after premature death and delivery of one fetus is uncommon . We report a case of a triplet pregnancy that was reduced to twins at the 14th gestational week and then had preterm premature rupture of membranes and intrauterine fetal death of one twin at the 17th gestational week . To save the surviving fetus, delivery of the dead fetus and ligation of the umbilical cord at the cervical level were performed . We also performed McDonald cervical cerclage to keep the placenta of the dead fetus as well as that of the surviving one in the uterine cavity . After a series of aggressive procedures, including immediate administration of tocolytic agents, and antibiotic prophylaxis to prevent infection and preterm labor, the surviving fetus was delivered vaginally 73 days later due to intractable uterine contractions . After a 10-week hospital stay, the infant boy, weighing 2,500 g, was discharged without any sequelae . To our knowledge, this was the longest interval between deliveries in a triplet pregnancy reported in Taiwan . With adequate intensive management, a satisfactory outcome of the fetus and mother in such cases is possible.

Arch Dis Child, 1996 Nov, 75(5), 436 - 9
Intravenous immunoglobulin, splenectomy, and antibiotic prophylaxis in Wiskott-Aldrich syndrome; Litzman J et al.; AIM: To assess the results of supportive treatment with intravenous immunoglobulin (IVIG) and antibiotic prophylaxis in combination with splenectomy in patients with Wiskott-Aldrich syndrome . STUDY DESIGN: Retrospective review of case records of 21 patients from March 1984 to February 1996 . RESULTS: Thrombocytopenia was cured in 14 of 15 patients who had splenectomy, but it recurred intermittently in three . Mean platelet volume (MPV) was normal transiently in some patients, but all MPV values were subnormal 8-23 months after splenectomy . Antibiotic and IVIG prophylaxis may have contributed to the lack of a detectable increase in the number of severe acute bacterial infections in the 451 months after splenectomy . Four patients died in 2205 months of observation before and after splenectomy (median 82, range 16-248): two of cerebral B cell lymphoma, one of progressive multifocal leucoencephalopathy, and one with severe chronic chest disease of pneumonia . CONCLUSION: Adequate supportive treatment with IVIG and antibiotic prophylaxis together with splenectomy enables good survival and quality of life in the short and medium term in patients with Wiskott-Aldrich syndrome . Persistence of infection, bleeding, and vasculitic and allergic symptoms in a significant minority and the risk of development of lymphoma, however, suggest that bone marrow transplantation may be indicated if an HLA identical donor is available.

Aust N Z J Surg, 1996 Nov, 66(11), 738 - 42
Australian multicentre evaluation of a new polyurethane vascular access graft; Allen RD et al.; BACKGROUND: A new three-layered cast polyurethane vascular access graft (Thoratec VAG) is the most recent addition to the list of materials used in the search for the perfect prosthetic graft material for haemodialysis vascular access . Despite its use in 23 countries, a clinical assessment has not been published . METHODS: An independent retrospective evaluation by questionnaire was obtained for 145 implantation procedures performed by 30 surgeons . RESULTS: Ninety-two per cent of procedures were performed for an acute need for vascular access and 73% had prior failed vascular access surgery . Patients were hospitalized for a median of 4 days and the graft was initially used at a median of 3 days . Median follow-up was 306 days . Thoratec VAG had a problem-free (primary) patency of 44.9% and a functional (secondary) patency 64.5% at 1 year . Major causes of graft loss were thrombosis (17%) and infection (11%) . Intra-operative thrombosis was the only significant risk factor for subsequent thrombosis (P = 0.013) . Infection was less in patients with antibiotic prophylaxis that included vancomycin (P = 0.02) . CONCLUSION: The ability to use the graft soon after surgery is a major advance for patients who urgently need reliable medium to long-term haemodialysis access.

Tidsskr Nor Laegeforen, 1996 Oct 20, 116(25), 3025 - 7
{The hip registry . Good economy for society}; Engesaeter LB et al.; As many as 33,656 total hip arthroplasties (THA) have been recorded in the Norwegian Arthtroplasty Register from the start in September 1987 until January 1994 . The annual costs for the about 5,500 THA performed in Norway (4.2 million inhabitants) are 72 million USD . We have documented before that some types of uncemented prostheses (Ti-Fit/ Bio-Fit (cup/stem) and Coxa/Femora) and types of cements (low-viscosity and Boneloc) show higher revision rates than others do . In this paper the costs of these "inferior" implants are estimated . The "inferior" implants were compared with a reference-THA (the Charnley prosthesis with antibiotic-containing high viscosity cement and with systemic antibiotic-prophylaxis (n = 4,970)) . In addition, based on data in the literature, comparisons have been made for two earlier commonly used prostheses in Norway: The Christiansen prosthesis (n = 6,500) and the Wagner double-cup prosthesis (n = 2,200) . For the period 1987-93, the annual over-all extra cost of using other implants than the reference-THA was 1.71 mill . USD for the first 3-5 years postoperatively . For the Christiansen and the Wagner prostheses the annual extra costs were estimated to 2.65 and 2.38 mill . USD respectively . By documenting poor results early the Register helps to stop the use of the inferior prostheses and cements, and thus reduce both the number of revisions, and, most important, the suffering of the patients.

Endod Dent Traumatol, 1996 Oct, 12(5), 209 - 14
Is antibiotic prophylaxis required for endodontic treatment?
Lavelle CL.
The stable prevalence of infective endocarditis since the advent of antibiotic prophylaxis for patients at-risk reflects the increasing polymicrobial etiology of such infections not associated with dental procedures . In addition to concerns for the growing crisis for antibiotic-resistant bacteria, the need for controlled clinical trials to determine the continued efficacy of prophylactic regimens for endodontic and other dental procedures cannot be overstated.

Minerva Stomatol, 1996 Oct, 45(10), 431 - 9
{The dental assessment of the patient waiting for a liver transplant}; Barbero P et al.; Until the last several years liver transplantation was considered an experimental treatment procedure . Nowadays virtually any disease process, that is in terminal stage, is treatable with transplantation . The introduction of cyclosporine in 1980 and the recent use of OKT3 monoclonal antibody now allows a 5-year survival rate of 60-70% . The causes of early death of patients who survive after surgery are infective complications, multiorgan failure and acute rejection of the allograft . In the literature and in our experience, bacterial sepsis is the most common cause of deaths occurring during the first postoperative months while most deaths after one year are generally related to chronic rejection of the allograft . The risk of infection is also increased by the over-immunosuppression of these patients always treated with a high dose of immunosuppressive agents when evidence of acute graft rejection is found . Regarding these problems, patients being prepared for liver transplantation should be evaluated for their dental health . The medical indications of 80 transplant recipients and the current status of liver transplantation are reviewed in this article . We describe the dental status of these patients that should receive indicated dental care before surgery . Most patients (90%) were affected by chronic active hepatitis while the number of primitive cirrhosis was significantly lower . Very poor dental hygiene was found in 85% of patients while 45% were affected by advanced periodontal disease and 12% by a chronic gingivitis . Dental caries were observed in 67% while in 20% of cases endodontic periapical lesions were found and only 2% of these resulted as radicular cysts . Indicated dental care consisted in 87% of cases in dental hygiene instructions, in 85% in scaling and root planing, in 63% in conservative restorations and in 40% in endodontic treatments . Dental treatment guidelines before transplantation are described with particular attention to prevent risk of infection using antibiotic prophylaxis for invasive dental procedures . Dentists, after surgery must be also prepared to deal with excessive bleeding related to a severe liver disfunction; for this purpose an appropriate protocol is also described . The monitoring of oral and general health conditions and the achievement of specific protocols of prophylaxis are helpful in the prevention of complications and are fundamental to obtain the best results with liver transplantation improving the quality of life of these patients.

J Gastroenterol Hepatol, 1996 Oct, 11(10), 938 - 41
Preventing endoscopic retrograde cholangiopancreatography related sepsis: a randomized controlled trial comparing two antibiotic regimes; Smith BC et al.; Current antibiotic prophylaxis for endoscopic retrograde cholangiopancreatography (ERCP) is not standardized and may be inadequate . We aimed to evaluate the efficacy of 3 days of additional oral antibiotics in the prevention of ERCP-related sepsis . One hundred and fifty-six patients were randomized prospectively to receive either intravenous ticarcillin and clavulinic acid (Timentin; SmithKline Beecham, Dandenong, Victoria, Australia), pre-ERCP (group I) or Timentin and 3 days of oral amoxycillin and clavulinic acid (Augmentin; SmithKline Beecham, Dandenong, Victoria, Australia), group II) . Blood cultures were taken 30 min after the procedure . The occurrence of sepsis, defined as a temperature over 38 degrees C, occurring in the first 7 days was recorded and the risk factors for the development of sepsis were evaluated . Four patients had significant positive blood cultures despite the prior administration of Timentin . Sepsis occurred in 10% of group I patients, but only 3% of group II patients (relative risk 3.30; 95% confidence intervals 0.74-14.8) . The performance of sphincterotomy and the presence of common bile duct stones were significant risk factors for the development of sepsis . We would recommend 3 days of additional oral Augmentin after a single dose of intravenous antibiotics in patients at increased risk of sepsis, which would include those with bile duct stones and/or those undergoing a therapeutic procedure.

J R Coll Surg Edinb, 1996 Oct, 41(5), 321 - 2
Antibiotic prophylaxis: theory and reality in orthopaedics; Dougall TW et al.; Marked differences were found when prophylactic antibiotic regimens and accuracy of administration were compared in the orthopaedic trauma and elective surgery units of one city . Consultants carrying out elective, primary joint replacements advocated similar antibiotic policies . There was 100% compliance in correct prescription and over 99% in administration of antibiotic doses . An audit of eight surgeons who undertook emergency surgery on adult hip fractures found three different prophylactic antibiotic regimens and that half of the consultants wished no antibiotics to be given . Only 33% of the patients were prescribed the schedule that their consultant wished and there were frequent inaccuracies in dose administration . Of 48 doses prescribed, five were omitted and in addition, four were recorded as having been given although they were unprescribed . Whilst antibiotic prophylaxis is universally accepted and the drugs are prescribed and administered accurately in cases of elective joint arthroplasty, the converse is true for emergency hip surgery.

World J Surg, 1996 Oct, 20(8), 1006 - 8; discussion 1108-9
Experiences with percutaneous endoscopic gastrostomy; Gutt CN et al.; Today the procedure of choice for long-term enteral tube feeding in patients with prolonged swallowing difficulties or inabilities is percutaneous endoscopic gastrostomy (PEG) . The primary indications are head and neck cancers, neurologic dysphagia, cancer cachexia, and obstruction of the esophagus and pharynx with enough space for an endoscopic procedure . This technique requires no general anesthesia and is possible in patients with contraindications to surgical gastrostomy . Between September 1994 and April 1995 a total of 115 patients underwent PEG placement attempts . We employed the pull-technique with 15-Freka PEG tubes . The average procedure time, including esophagogastroduodenoscopy, was 17 minutes . In nine cases PEG insertion was impossible owing to severe obstruction of the esophagus . In 46 (40%) patients local abdominal pains started on the first or second postoperative day; 7 of these patients required surgical consultation, and no further intervention was needed . In only one patient was there a serious complication that required surgical intervention: a presumed perforation that turned out to have no correlate upon review . All patients received single-shot antibiotic prophylaxis; and only in those patients with abdominal symptoms do we recommend a prolonged antibiosis . The abdominal symptoms reported were due to a slight leak of gastric fluid causing a topical peritonitis, which required no further treatment . In our experience PEG is a useful alternative to surgical gastrostomy . The simplicity of this procedure leads to low complication rates, short hospitalization, and is possible on an outpatient basis . It is cost-efficient and has a much better psychological tolerance than nasogastric tubes.

Minerva Chir, 1996 Sep, 51(9), 691 - 6
A new approach to the problem of surgical wound infections in clean operations; Porcu A et al.; A study was made of the risk factors causing a high incidence of surgical wound infections in clean operations . Identification of these factors in the preoperative stage allows the patients to be divided into two categories: a high risk (about 10% of patients for surgery) and low risk . By giving antibiotic prophylaxis only to patients at high risk, the incidence of postoperative infections can be reduced, decreasing the number of extra days in hospital and consequently lowering costs . This is a new approach to the problem of surgical wound infections since not only is it based on the usual classification of operations into clean, clean-contaminated, contaminated and dirty, but it also takes into account the defensive capacity of the target of the infection: the patient.

Arch Phys Med Rehabil, 1996 Sep, 77(9), 900 - 2
Prospective evaluation of antibiotic prophylaxis prior to cystometrogram and/or cystogram studies: oral versus intramuscular routes; Fried GW et al.; OBJECTIVE: To compare empiric single-dose gentamicin versus culture-specific oral antibiotics as prophylaxis before cystometrogram and/or cystogram . Comparisons with regards to infection, patient preference, and cost were made . DESIGN: Prospective randomized control trial . SETTING: Inpatient and outpatient rehabilitation hospital . PATIENTS: Seventy received oral antibiotics and 72 received intramuscular gentamicin . INTERVENTION: Cystometrograms and/or cystograms were performed . MAIN OUTCOME MEASURE: Patient interviewed and chart reviewed for infection . Convenience and comfort were rated by patient . RESULTS: Oral antibiotics and gentamicin have similar efficacy . Patients rated the gentamicin more convenient (p < .001) and comfortable (p < .01) than oral antibiotics . Gentamicin is less expensive . CONCLUSION: Gentamicin should be used as the method of choice for cystometrogram/cystogram prophylaxis.

Am J Gastroenterol, 1996 Sep, 91(9), 1804 - 8
Colonic tattooing with India ink: benefits, risks, and alternatives; Nizam R et al.; OBJECTIVE: To provide comprehensive information on key issues concerning colonic tattooing with India ink in reported literature . METHODS: A total of 735 citations on India ink alone were present in the English literature (1966-1995), including 16 on India ink and colonic tattooing . Nine major studies were identified and reviewed for 1) preparation before tattooing (type of ink used, sterilization process, colonic preparation, and antibiotic prophylaxis), 2) the tattooing process (technique and volume injected), 3) success in localization, and 4) complications . RESULTS: A'total of 447 cases of colonic tattooing with India ink have been reported . Major indication was preoperative marking of tumor site . Various India ink preparations were used . Ink was unsterilized in 57% (255/447), autoclaved in 42% (187/447), and gas sterilized in 1% (5/447) of cases . Colonic preparation varied similarly . Prophylactic antibiotics were used in 1% (5/447) of cases . Dilution of India ink varied from undiluted to 1:100 (with 0.9% saline) . The volume injected ranged from 0.1 to 2 ml per site injected, commonly with tangential needle insertion and delivery of ink into the submucosa in the majority of the cases . Intraoperative localization was easier with multiple tattoo injections . Five reports of complications have been made . In only one instance did overt clinical complications develop . Risk of a clinical complication with colonic tattooing with India ink is 0.22% . CONCLUSION: Marked variability in technique, as well as potential for reporting bias, limit the quantitative conclusions . In general, colonic tattooing with India ink is a safe, accurate, and inexpensive method for preoperative marking and prospective study of colonic lesions.

J Urol, 1996 Sep, 156(3), 885 - 8
Transplantation into the long-term defunctionalized bladder; Serrano DP et al.; PURPOSE: We evaluated the outcome of transplantation into a long-term defunctionalized bladder . MATERIALS AND METHODS: Since 1985 we performed transplantation in 5 dialysis dependent patients after excision of the ileal conduit and native kidneys . The bladder was evaluated before transplantation with cystoscopy, voiding cystography, urodynamics and demonstration of continence . Bladder rehabilitation was accomplished by cycling through a suprapubic tube or urethral catheter, and no bladder augmentation was done . All patients received antibiotic prophylaxis for several years . RESULTS: Five male recipients underwent transplantation at ages 22, 29, 30, 31 and 55 years, and they had had a defunctionalized bladder for 15, 17, 23, 25 and 26 years . All patients were alive with a functioning allograft at 6, 84, 90, 112 and 120 months after transplantation . Current serum creatinine values are 1.2, 1.6, 1.8, 2.3 and 2.5 mg./dl . Median urodynamic values before and after transplantation were bladder capacity 60 and 300 cc, respectively, peak flow rate 5 and 18 cc per second, respectively, and post-void residual 20 and 15 cc, respectively . One patient required self-catheterization . CONCLUSIONS: Renal transplantation into a long-term defunctionalized bladder can be performed safely in carefully selected patients . Bladder function and continence should be confirmed before transplantation using a program of progressive bladder rehabilitation.

Gastroenterol Hepatol, 1996 Aug-Sep, 19(7), 339 - 43
{Endoscopic ligation with elastic bands in the prevention of hemorrhage recurrence caused by esophageal varices . Study of 45 patients}; Brullet E et al.; The aim of the present study was to determine the usefulness of elastic band ligation in the prevention of hemorrhage recurrence by esophageal varices . Forty-five patients without known hepatocarcinoma who had survived a hemorrhagic variceal episode were included in the study . Seventeen patients (38%) were Child-Pugh A, 22 (49%) B, and 6 (13%) C, with the hepatitis C virus and alcohol being the etiology of cirrosis in 55 and 20% of the cases, respectively . The first ligation session was performed between the third and fifth days after the hemorrhagic episode and the posterior sessions were carried out at intervals of 2-4 weeks . The ligation sessions were performed without antibiotic prophylaxis and with placement of an overtube . A mean of 4 +/- 2 bands were placed per session (range, 1-8) and the mean number of sessions required per patient to achieve erradication of the varices was 3.5 +/- 1.5 (range, 2-8) . The rate of bleeding recurrence was 17.7% (9 episodes, five by variceal rupture and four by ulcer secondary to ligation) . All the episodes of bleeding recurrence occurred between the sessions, with the mortality being 11% (5/45 patients) . In the 40 remaining patients the varices were erradicated although 19 (47.5%) required one or two additional sessions of sclerotherapy . The accumulated percentage of patients free of bleeding recurrence was 82% during a mean follow-up of 10.2 +/- 6.7 months . Ten lesions of dislaceration of the esophageal mucosa caused by placement of the were observed overtube . In conclusion, endoscopic elastic band ligation is a useful technique for the erradication of esophageal varices an in the prevention of bleeding recurrence.

Infect Control Hosp Epidemiol, 1996 Aug, 17(8), 539 - 44
Local antibiotic prophylaxis in surgery; Martin C et al.; The perioperative use of antibiotics is an established and accepted technique for the prevention of postoperative infection . Intravenous administration often is preferred, and intramuscular administration is possible, although it has certain drawbacks . This article examines a variety of other routes of administration for delivering antibiotics locally to the surgical site . These techniques merit further study in prospectively randomized trials.

J Urol, 1996 Aug, 156(2 Pt 2), 812 - 5
Bilateral anterior pubic osteotomy in bladder exstrophy closure; Frey P; PURPOSE: We report our clinical experience with anterior pelvic osteotomy in 16 patients who underwent surgery for bladder exstrophy . The technique and its difficulties are discussed . MATERIALS AND METHODS: Anterior pelvic osteotomy of the superior ramus of the public bone is a simple and efficient method to facilitate symphyseal approximation and abdominal wall closure without or with low tension on the suture lines in neonates who undergo surgery for bladder exstrophy . Older children in whom surgery has been delayed can also benefit from this method . Compared to other methods of osteotomy in exstrophy surgery it does not require additional incisions, nor does the patient need to be repositioned on the operating table . A successful operation does not depend on any particular orthopedic skills and it can easily be done by the pediatric urologist . RESULTS: Immediate postoperative results regarding abdominal wall closure were excellent in all 16 patients . However, major postoperative complications developed in 2 patients . Despite antibiotic prophylaxis a severe soft tissue infection developed in 1 child, resulting in complete bladder dehiscence . In another patient an obturator nerve injury resulted in transient palsy, which resolved completely . While the first complication was not related to osteotomy, the second was osteotomy related . CONCLUSIONS: Bilateral superior ramotomy of the pubic bones is a new alternative, easily performed technique to optimize bladder exstrophy surgery in children.

J Urol, 1996 Aug, 156(2 Pt 2), 668 - 72
An analysis of social and economic factors associated with followup of patients with vesicoureteral reflux; Wan J et al.; PURPOSE: Nonsurgical treatment of vesicoureteral reflux requires antibiotic prophylaxis and long-term surveillance . We examined factors that affect followup compliance and influence quality of care in these children . MATERIALS AND METHODS: We retrospectively reviewed the records of 288 boys and 742 girls with vesicoureteral reflux . RESULTS: Of the children treated nonsurgically for vesicoureteral reflux 34% were lost to followup and the majority (80%) were not monitored beyond the 1-year followup appointment . Older maternal age (36 years or older) was significantly associated with improved followup compliance . Paternal age, primary physician type, medical insurance type, income, education level and environment (urban, suburban or rural) were not significant . CONCLUSIONS: Approximately a third of children treated nonsurgically for vesicoureteral reflux will be lost to followup . Only older maternal age predicts for good compliance . Preconceptions about compliance on the basis of other factors, such as socioeconomic status and primary physician type, may be incorrect . Furthermore, the notion that certain forms of medical insurance plans may help to promote followup may also be unsupported . These children would benefit from efforts to improve compliance with a medical regimen or early correction of reflux.

Br Dent J, 1996 Jul 20, 181(2), 64 - 5
Infective endocarditis in children following dental extraction and appropriate antibiotic prophylaxis; O'Sullivan J et al.; Infective endocarditis is a rare but important complication of certain types of dental treatment . Antibiotic prophylaxis is routinely prescribed for patients with known congenital heart disease . In this report we describe two patients in whom endocarditis developed within 3 months of the dental procedure, despite appropriate antibiotics . Endocarditis should be actively excluded if patients develop a fever associated with non-specific symptoms following an 'at risk' dental procedure.

Bone Marrow Transplant, 1996 Jul, 18(1), 171 - 6
Hepatic dysfunction following busulfan and cyclophosphamide myeloablation: a retrospective, multicenter analysis; Styler MJ et al.; Veno-occlusive disease continues to be a significant cause of morbidity and early mortality following bone marrow transplantation . This study retrospectively analyzes the incidence and risk factors for severe VOD in 350 patients treated with 4 days of busulfan (total 16 mg/kg) and 2 days of cyclophosphamide (120 mg/kg) at four marrow transplant centers . Using the criteria defined by McDonald et al (Hepatology 1984; 4: 116-122), 93/350 (27%) developed VOD (11% mild, 5% moderate and 11% severe) . Multivariate analysis revealed the following risk factors to be significantly associated with severe VOD: pretransplant transaminase and alkaline phosphatase elevation, ciprofloxacin antibiotic prophylaxis, use of estrogen/progestins or vancomycin during the peritransplant period and methotrexate for GVHD prophylaxis . Mild to moderate grades of VOD were not associated with significantly increased mortality but mortality was higher in patients with severe VOD (31%, P = 0.0013) . These data suggest that risk factors for VOD may depend on the preparative regimen used and suggest that use of these risk factors may identify a subgroup of patients that can be targetted for studies of prevention of VOD.

Acta Obstet Gynecol Scand, 1996 Jul, 75(6), 537 - 9
Antibiotic prophylaxis in cesarean section; Pedersen TK et al.; BACKGROUND . To investigate the guidelines for patient selection and drug regimens for application of antibiotic prophylaxis in relation to cesarean section in the maternity clinics in Denmark . METHODS . A questionnaire to all the Danish maternity clinics that perform cesarean section, concerning indications for application of antibiotic prophylaxis and antibiotic regimens to patients undergoing acute and elective cesarean section . RESULTS . All departments (n = 48) returned the questionnaire . Twenty departments (46%) provided written guidelines for antibiotic prophylaxis . Four departments (8%) used antibiotic prophylaxis to elective cesarean sections, 25 departments (52%) applied antibiotics to all emergency sections . In the presence of the rupture of membranes or prolongation of labor (> 12 hrs) 58% and 63% of the departments applied antibiotic prophylaxis, respectively . The most infrequent first choice drug was cefuroxim, employed by 27 departments (56%) . Concerning timing, 21 departments (44%) applied antibiotics after cord clamping and 13 departments (27%) before incision . CONCLUSION . We propose a nation-wide prospective investigation on the rate of infections associated with cesarean section to set up rational guidelines for antibiotic prophylaxis.

Tidsskr Nor Laegeforen, 1996 Jun 10, 116(15), 1777 - 81
{Quality control of prosthetic replacements of knee, ankle, toe, shoulder, elbow and finger joints in Norway 1994 . A report after the first year of registration of joint prostheses in the national registry}; Furnes A et al.; Total hip replacements have been recorded in the Norwegian Arthroplasty Register since 1987, and recording of the other joint arthroplasties was started in January 1994 . After 12 months 1,589 primary arthroplasties had been registered; these referred to 962 knees, 11 ankles, 76 toes, 113 shoulders, 69 elbows, 12 wrists, 335 fingers and 11 carpometacarpal 1 joints . Median age of the patients was 70 years . 80% were women . Rheumatoid arthritis was the predominant reason for joint replacement, except in the case of the knees where the dominant cause was osteoarthrosis (71%) and of shoulders, 28% of which were replaced because of fractures . Cement was used in 83% of the primary arthroplasties in knee, ankle, shoulder, and elbow joints . 74% of the cement types used contained antibiotics . 9% were uncemented and 8% hybrids . 97% were given systemic antibiotic prophylaxis, most commonly first generation cephalosporins . 114 reoperations were reported . The reason was aseptic loosening in 56%, and infection in 15% . The cooperation with Norwegian orthopaedic surgeons is good . The Register thus provides a reliable picture of implants of Norway, and a good basis for future follow-up studies.

Int J Impot Res, 1996 Jun, 8(2), 87 - 9
Antibiotic prophylaxis in prosthetic penile surgery: critical assessment of results in 75 consecutive patients; Maffezzini M et al.; OBJECTIVE: Antibiotic prophylaxis in prosthetic surgery was administered prospectively according an original protocol . Routine pre-operative preparation included also scrupulous, repeated disinfection of the skin of the genital and perineal region . METHODS: Vancomycin 500 mg i.v . every 6 h on the day of surgery and gentamicin 1 mg/kg i.v . every 8 h on the day of surgery and for the following 48 h were administered to 75 consecutive patients . Overall 87 prosthetic devices were implanted . The patients were evaluated at 6 weeks and at 6 months after surgery . RESULTS: No infection was observed . CONCLUSION: Support from this study to antibiotic prophylaxis in penile prosthetic surgery is uncertain . The importance of scrupulous routine pre-operative preparation is probably underestimated.

J Gen Intern Med, 1996 Jun, 11(6), 329 - 33
Efficacy of antibiotic prophylaxis for prevention of Lyme disease; Warshafsky S et al.; OBJECTIVE: To determine if antibiotic prophylaxis following a dear tick bite is effective in reducing the risk of developing Lyme disease . DESIGN: Meta-analysis of published trials . DATA IDENTIFICATION: Clinical trials were identified by a computerised literature search of MEDLINE and by an assessment of the bibliographies of published studies . STUDY SELECTION: Trials were included in the analysis if their patients were randomly allocated to a treatment or control group, enrolled within 72 hours following an Ixodes tick bite, and had no clinical evidence of Lyme disease at enrollment . Three trials were selected for review after inclusion criteria were applied . DATA EXTRACTION: Data were extracted for details of study design, patient characteristics, interventions, duration of therapy, and number of adverse events in each arm of therapy . RESULTS OF DATA SYNTHESIS: Among the 600 patients with Ixodes tick bites, the rate of infection in the placebo group was 1.4% . In contrast, patients who received antibiotic prophylaxis had a 0% infection rate . The pooled odds ratio, comparing prophylaxis to placebo, was 0.0 (95% confidence interval 0.0, 1.5) (p = .12) . CONCLUSIONS: The available evidence to date suggests that the routine use of antibiotic prophylaxis for the prevention of Lyme disease remains uncertain . Meta-analysis of the controlled trials failed to establish definitive treatment efficacy owing to the small sample size of the combined trials and the low rates of infection following a deer tick bite . A larger randomized trial is needed to demonstrate definitively that prophylaxis is more effective than placebo in reducing the risk of early Lyme disease in endemic areas.

J R Coll Surg Edinb, 1996 Jun, 41(3), 178 - 80
Antibiotic prophylaxis for infantile pyloromyotomy; Nour S et al.; A retrospective study of 50 patients with infantile hypertrophic pyloric stenosis (IHPS) showed wound infection in six patients . In an attempt to assess the value of antibiotic prophylaxis in infantile pyloromyotomy 150 patients with infantile hypertrophic pyloric stenosis were entered in a prospective randomized controlled study . The infants were allocated to receive a dose of Cefuroxime (30 mg/kg) at induction of anaesthesia or no antibiotic . Eight infants developed wound infection, five in the control group and three in the antibiotic prophylaxis group . Although the difference between the two groups was not statistically significant there was an overall reduction of wound infection (6.5%) compared with pre-trial figures (12%) . In order to study the bacterial flora in the umbilicus in these infants, culture swabs were taken from the umbilicus on admission, immediately prior to surgery and from the wound prior to skin closure . It was shown that the umbilicus was not the source of infection.

Arch Mal Coeur Vaiss, 1996 Jun, 89(6), 713 - 8
{Survey on the practice of antibiotic prophylaxis of infective endocarditis by dentists}; Bennis A et al.; The authors undertook an enquiry among 287 dentists to assess their practice of prophylactic antibiotic therapy against infectious endocarditis . Of the 227 dentists who replied, most (90%) knew that a dental extraction required prophylactic antibiotic therapy . They correctly prescribed antibiotics to prosthetic valve patients (84%) and to those with post-rheumatic cardiac disease (87%) . Many dentists considered that coronary bypass (66%), mitral valve prolapse without mitral regurgitation (65%) or chronic myocardial infarction (68%) also required antibiotic prophylaxis, contrary to published recommendations . Only 21% of dentists used the recommended 3 gram dose of amoxicillin; the others prescribed a lower dose or another antibiotic . Approximately half the dentists started treatment 1 to 3 days too soon and less than 5% used the recommended single dose of antibiotic . These results show that dentists do not adhere strictly to the rules of prophylaxis on infectious endocarditis defined by different working groups . The authors make several suggestions to improve the prevention of infectious endocarditis and to remedy the problems shown up by this study.

Am J Surg, 1996 Jun, 171(6), 548 - 52
Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures . The Antibiotic Prophylaxis Study Group; Silver A et al.; BACKGROUND: Twenty-five percent of all nosocomial infections are wound infections . Professional guidelines support the timely use of preoperative prophylaxis for prevention of postoperative wound infections . Barriers exist in implementing this practice . IPRO, the New York State peer review organization, as part of the Health Care Financing Administration's Health Care Quality Improvement Program, sought to determine the proportion of patients receiving timely antibiotic prophylaxis for aortic grafts, hip replacements and colon resections in 44 hospitals in New York State . METHODS: IPRO conducted a retrospective medical record review of 44 hospitals through out New York State stratified for teaching, nonteaching status . A sample was drawn of 2651 patients, 2256 from Medicare and 395 from Medicaid, undergoing either abdominal aortic aneurysm repair, partial or total hip replacement or large bowel resection . The study determined the proportion of patients who had documentation of receiving antibiotics and those who received antibiotics timely, that is less than or equal to 2 hours preoperatively . RESULTS: Eighty-six percent of patients had documentation of receiving an antibiotic . Forty-six percent of aneurysm repairs and 60% of hip replacements had evidence of receiving timely antibiotic prophylaxis, that is within 2 hours prior to surgery . For colon resections, 73% of cases had either oral prophylaxis or timely parenteral therapy . An increased proportion of patients had received parenteral antibiotics prematurely as the surgical start time occurred later in the day . A total of 44 different antibiotics were recorded for prophylaxis . CONCLUSIONS: Antibiotic prophylaxis was performed in 81% to 94% of cases, however, anywhere from 27% to 54% of all cases did not receive antibiotics in a timely fashion . By delegating implementation of ordered antibiotic prophylaxis to the anesthesia team, timing may be improved and the incidence of postoperative wound infections may decrease.

Orv Hetil, 1996 Apr 28, 137(17), 927 - 30
{Milestones in the fight against nosocomial infections in Hungary}; Losonczy G; The world-wide struggle against nosocomial infections began with the work of the well known Hungarian physician, Ignac Semmelweis, in the middle of the 19th century . His activity is the milestone in the fight against the nosocomial infections not only in Hungary but internationally, as well . The recognition made in the 1950-s, of more than sixty different sorts of hospital-acquired infections frequently occurring in almost all departments of Hungarian hospitals formed a major momentum . The acknowledgement of this situation by the highest National medical professional council, with all the favourable consequences for future solutions, can be taken as the third historical continuation . The next important step was the recognition that the immunocompromised state of the hospitalized patients is the basis of becoming a victim of a nosocomial infection . The epidemiology of these diseases should be called "clinical epidemiology" and may be considered as an independent discipline . The major step against the struggle of nosocomial infections was the introduction of antibiotic prophylaxis . The following step was the construction of a special informatical, preventive and control system, collectively called "surveillance" . The institutional and professional bases of all these activities were provided by the Central Municipal Hospital for Infectious Diseases and the National Institute of Traumatology at Budapest.

Ned Tijdschr Geneeskd, 1996 Apr 6, 140(14), 781 - 4
{Registration of postoperative complications to improve the results of surgery}; Roukema JA et al.; OBJECTIVE . To analyse the consequences of postoperative complications in 1418 surgical patients . DESIGN . Prospective descriptive study . SETTING . St . Elisabeth Hospital in Tilburg, The Netherlands . METHOD . In the period 1986-1992 all postoperative complications and their consequences occurring during or after the clinical treatment of surgical patients were registered . RESULTS . In 5% of the 28,485 surgical procedures (= 1418 patients) postoperative complications were found . To treat these complications, 577 patients had to be reoperated on, 233 patients several times, and generally because of postoperative infections . Readmission after discharge was necessary in 310 patients for treatment of their complications . Mean hospital stay for all patients was 10 days, as against 21 days in patients with postoperative complications . On the basis of the figures recorded, quality enhancing measures were taken, e.g . regarding antibiotic prophylaxis and wound treatment . CONCLUSION . The consequences of postoperative complications are considerable . With respect to quality control in health care it is important to develop national registration and documentation of surgical complications.

Acta Orthop Scand, 1996 Apr, 67(2), 115 - 21
The economic impact of failures in total hip replacement surgery: 28,997 cases from the Norwegian Arthroplasty Register, 1987-1993; Furnes A et al.; The Norwegian Arthroplasty Register was established in 1987 . Until January 1994, approximately 200 different implant combinations had been used in total hip replacements (THR) in Norway . About 5,500 THR were performed each year in this period with a total cost of 70 million USD per year . We analyzed the economic consequences related to the use of some inferior primary hip arthroplasties in this period . As the reference arthroplasty, we chose the most commonly used prosthesis in Norway, i.e., the Charnley prosthesis fixed with high viscosity cement containing antibiotic and with systemic antibiotic prophylaxis (n 4,970) . We compared this reference group to all other primary THR registered in the same time period (n 24,027), and to the following sub-groups of primary THR: 1) uncemented Ti-Fit/ Bio-Fit (acetabulum/femur) combination (n 173), 2) uncemented Coxa/Femora combination (n 153), 3) THR with low-viscosity cement (n 1,807) and 4) THR with Boneloc cement (n 1,250) . We estimated the number of additional revisions compared to the reference arthroplasty after a follow-up of 3-5 years in the different groups, with adjustment for age, sex and diagnosis . The direct extra revision costs were calculated . Compared to the reference arthroplasty, the group of all other primary THR gave an extra revision cost estimated at about 1.7 million USD per year . About 1,000 uncemented Bio-Fit femoral prostheses have been applied in Norway, including those implanted before the registration started (1985-1987) . The extra revision costs the first postoperative years for these 1,000 prostheses amount to about 0.7 million USD per year . Corresponding figures in the Coxa/ Femora group were 0.08 million USD, in the group with low-viscosity cement, 0.3 million USD and in the Boneloc group, 0.4 million USD per year.

Postgrad Med, 1996 Apr, 99(4), 89 - 90, 95-8, 101-2
Acute exacerbations of chronic bronchitis: focusing management for optimum results; Aboussouan LS; Acute exacerbations of chronic bronchitis can be recognized clinically by (1) increased cough and dyspnea, (2) a change in character of sputum, and (3) an increase in quantity of sputum . Routine chest radiographs are probably not warranted in initial evaluation . Therapy is aimed at control of inflammation, infection, bronchoconstriction, and mucin production . Corticosteroids improve flow rates in patient with respiratory insufficiency . Antibiotic therapy appears to decrease hospital stay and improve flow rates in patients with bacterial infection, as determined by sputum examination or the presence of two of the following symptoms: increased dyspnea, increased sputum production, purulent sputum . Gram's stain of expectorated sputum often allows targeted and cost-effective therapy . Ipratropium bromide (Atrovent) is the bronchodilator of choice; concomitant use of beta agonists has additional benefit . Research on future therapy may focus on the role of corticosteroids, mucolytic agents, and drugs that counteract the effects of neutrophil elastase . Smoking cessation is the first step in prevention . Antibiotic prophylaxis is warranted only in patients with four or more exacerbations per year . Pneumoccoccal and influenza vaccinations are effective and safe; unfortunately, they are underutilized at present.

Cleve Clin J Med, 1996 Mar-Apr, 63(2), 94 - 100
Outpatient management of systemic lupus erythematosus; Sims GN Jr et al.; SUMMARY: Systemic lupus erythematosus (SLE) is often managed by primary care practitioners, who must coordinate the care with the support of subspecialists . The management of patients with such a serious and chronic disease can be both rewarding and challenging . This article reviews common problems and suggests management strategies . KEY POINTS: Measurement of serum antinuclear antibodies can lead to an erroneous diagnosis if used as the sole basis for diagnosis . Infections are the leading cause of death in lupus patients, and immunizations and antibiotic prophylaxis need to be considered . Acute cutaneous SLE is exacerbated by exposure to ultraviolet light . Patients should avoid sun exposure . Specific treatment of cutaneous SLE includes topical corticosteroids and antimalarial agents . Some of the most perplexing problems seen in SLE relate to neuropsychiatric features . NSAIDs, corticosteroids, and antimalarials are the most commonly used medications for SLE.

Minerva Ginecol, 1996 Mar, 48(3), 85 - 92
{Retrospective study of postoperative infectious morbidity following cesarean section}; Di Lieto A et al.; The increase of cesarean sections produced more postoperative infections . Several authors assessed the effectiveness of chemioantibiotic prophylaxis to reduce the postoperative infective morbidity . Although the family of antibiotics more frequently used is that of cephalosporin, the best single agent has not been found yet . The aim of our study, made in the Department of Obstetrics and Gynecology of University of Naples "Federico II", is to propose a retrospective analysis concerning the incidence of cesarean section (CS), the postoperative infective morbidity and the employment of antibiotic prophylaxis . Our sample is a group of 13285 pregnant women, 3171 (23.9%) of these patients underwent to CS from 1st January 1985 to 31st December 1994 . The group of 3171 women was divided in two subgroups, the first of 2748 patients un-derwent to antibiotic prophylaxis, the second of 423 was untreated due to their previous experience of allergy towards antibiotics or because there was no evidence of risk factors . The women we treated with antibiotics underwent a three days prophylactic therapy with cefazolin or ampicillin soon after the CS . The incidence of infective complications had a 21.2% rate over a total of 3171 women . Endometritis was the most common infectious complication following cesarean delivery . The rate was 53.3% in the case of primary cesarean section and 52.3% in the case of iterative cesarean section . The use of antibiotic prophylaxis gave us the opportunity to reduce the postoperative morbidity in the primary CS (23.4%) as well in the iterative CS (16.6%) . On the contrary the untreated group had an infective incidence with a 33.8% rate in the case of primary CS and with a 27.4% rate in the case of iterative CS . Our opinion is that the administration of antibiotics as cefazolin and ampicillin is able to reduce in a significant way the incidence of postoperative infective morbidity as well the period of hospitalization.

Br J Surg, 1996 Mar, 83(3), 356 - 9
Randomized study of antibiotic prophylaxis for general and gynaecological surgery from a single centre in rural Africa; Reggiori A et al.; In a district rural hospital in Uganda, 850 surgical patients were evaluated prospectively over a 3-year period to compare the clinical efficacy of conventional postoperative penicillin therapy with single-dose ampicillin prophylaxis for hernia repair and ectopic pregnancy, and with single-dose ampicillin-metronidazole prophylaxis for hysterectomy and caesarean section . The high rate of postoperative infection usually encountered in African hospitals after conventional treatment with penicillin for 7 days was significantly reduced with the new regimen: from 7.5 to 0 per cent in hernia repair and from 10.7 to 2.4 per cent in ectopic pregnancy; from 20.0 to 3.4 per cent in hysterectomy and from 38.2 to 15.2 per cent in caesarean section . Length of hospital stay and postoperative mortality rates were also significantly reduced . Single-dose ampicillin prophylaxis with or without metronidazole, although rarely used in developing countries, is more cost effective than standard penicillin treatment.

J Pediatr Surg, 1996 Feb, 31(2), 239 - 40
Heterotopic splenic autotransplantation in a neonate with splenic rupture, leading to normal splenic function; Yamataka A et al.; Loss of the spleen in infants and young children frequently results in overwhelming infection . To preserve splenic function, heterotopic splenic autotransplantation after splenectomy was performed on a newborn in whom the spleen was traumatized beyond repair because of birth trauma . Postoperatively, the percentage of pitted red blood cells that accurately reflects splenic reticuloendothelial function was normal . Splenic scintigrams obtained 3 weeks after the operation showed uptake by the reimplanted tissue . The otherwise mandatory long-term antibiotic prophylaxis could be reduced to 3 weeks in the newborn . At 7 years of age, the patient has not shown any increased susceptibility to infections.

Unfallchirurg, 1996 Feb, 99(2), 152 - 3
An unusual lawn mower injury; Logar M et al.; The authors report a case of foot trauma produced by a piece of the lawn mower blade, which was fired projectile-wise from the machine while it was in operation . At hit the calcaneous and remained trapped in the bone . The wound healed after removal of the foreign body, wound debridement and systemic and local antibiotic prophylaxis . In the professional literature available, no report has been found on a missile injury produced by a piece of rotating lawn mower knife.

Chirurg, 1996 Feb, 67(2), 99 - 109
{Anterior rectum resection}; Rosen HR et al.; Anterior resection is the method of choice for the treatment of rectal cancer situated in the upper or middle third of the rectum . Hand-sewn and stapled anastomosis methods have shown comparable results with regard to the rate of leakage . Standardized preoperative bowel preparation, antibiotic prophylaxis and a careful surgical technique will lead to a postoperative lethality of below 5% and a surgical complication rate below 15% . The main functional problems following anterior resection consist of incontinence and bladder and sexual dysfunction, but these can be partly avoided by careful surgical preparation . There is controversy in the literature concerning the positive effect of a protective ileostomy or colostomy . The major principles are: (1) radical resection of the tumor, with complete removal of the mesorectum, leaving a minimal distal margin of 2 cm, and (2) a meticulous anastomosis technique: tension-free, pulsation blood flow, tight.

Nippon Jibiinkoka Gakkai Kaiho, 1996 Feb, 99(2), 314 - 19
{Tonsillectomy in a boy liver transplant}; Yamaguchi K et al.; As of 1995, organ transplantation from cadaver donors is under debate in the Japanese Diet . Depending on what the Diet decides, more organ transplantations may be performed . Since cases of orthotopic liver transplantation (OLT) may increase, the need to perform surgical operations in post-OLT patients may arise . The purpose of this report is to enlighten Japanese otorhinolaryngologists on the post-transplant state . An 8-year-old boy who underwent OLT in Australia 7 years previously underwent successful tonsillectomy, adenoidectomy and insertion of ventilation tubes into both ears under general anesthesia (GA) to treat habitual angina, hypertrophy of the nasopharyngeal and palatine tonsils, and secretory otitis media . The optimal circumstances for operation require adequate but not excessive immunosuppression and a well-functioning graft . Vascular complications (VCs) such as hepatic artery thrombosis become rare after a few years post-OLT . However, once VCs occur the mortality rate of OLT patients is high, and excessive perioperative changes in circulation must be avoided . Immunosuppressive agents should be continued throughout the perioperative period and perioperative antibiotic prophylaxis should be employed, just as in non-transplant patients . Tonsillectomy is an effective means of prophylaxis for upper respiratory infection in habitual angina patients . Infection of an OLT patient may become critical because immunosuppressive agents to prevent rejection lower immune barriers and increase the risk of infection, and dose reduction may increase the risk of rejection . Tonsillectomy may also prevent a possible lympho-proliferative disorder (LPD) . Tonsillar hypertrophy in OLT patients may be due to life-threatening LPD . Thus, tonsillectomy serves both as a prophylactic and curative measure against possible complications OLT may cause later, and therefore may improve the outcome of OLT.

Gastrointest Endosc, 1996 Feb, 43(2 Pt 1), 127 - 31
Endoscopic sphincterotomy in patients with liver cirrhosis; Prat F et al.; BACKGROUND: Nonsurgical alternatives in biliary diseases have not been studied in large series of patients with cirrhosis . Our aim was to determine the indications and results of endoscopic treatment in this subset of patients . METHODS: Fifty-two patients (36 men, 16 women-Child-Pugh Class A, 18; B, 22; C, 12) aged 63 +/- 18 years underwent endoscopic sphincterotomy (ES) between 1988 and 1993 . Antibiotic prophylaxis was routinely carried out and coagulopathy was corrected before ES when required . The data were collected retrospectively up to 30 days after ES . RESULTS: ES succeeded in 98% of the patients (12 cases of needle-knife papillotomy) . Twenty-nine patients (55.7%) had choledocholithiasis, 18 had biliary strictures (12 malignant), and 5 had pancreatic or other biliary diseases . Five days after ES, morbidity was 13.5% and mortality was 7.7% . At 1 month, morbidity was 22.9% and mortality 12.5% . Only endoscopic procedures and Ineffective drainage were seen to be significant risk factors or morbidity . The results of the subgroup of cirrhotic patients with choledocholithiasis (n = 29) were compared with those of matched noncirrhotic patients (n = 58) . The cirrhotic and noncirrhotic patients treated for choledocholithiasis showed similar results for stone clearance, morbidity, and mortality . CONCLUSION: ES is a safe and effective procedure for treating choledocholithiasis in cirrhotic patients . ES can therefore be considered as an alternative to surgery in Child class A and B patients and must be preferred for Child class C patients with life-threatening biliary complications.

J Clin Epidemiol, 1996 Feb, 49(2), 251 - 4
Monitoring of antibiotic use in a primary and tertiary care hospital; Thomas M et al.; Prophylactic and curative use of antibiotics was studied prospectively in 87 consecutive medical and surgical cases of a tertiary care hospital and in 98 cases of a primary care hospital . Based on Kunins' criteria, antibiotic prophylaxis was found to be more inappropriate in the primary care hospital (49%) than in the tertiary care hospital (34%) . Antibiotic therapy, however, was more appropriate at the primary level; 67% as opposed to 60% at the tertiary level . This resulted in a similar overall level of inappropriate antibiotic use in the two hospitals . Surgical prophylaxis was started postoperatively in 68% of the primary care hospital cases . Though prophylaxis was always perioperative in the tertiary care hospital, the postoperative duration was more than 7 days in one third of the cases . The nosocomial infection rate in those given prolonged prophylaxis was higher than those who received antibiotics for less than 72 hours . Antibiotics were started empirically in 78% of tertiary hospital care cases and 100% of cases in the primary hospital . Though culture sensitivity was done in 80% of the tertiary care cases, more than half the specimens were sent after multiple doses of antibiotics were started . The choice of antibiotic did not always correlate with the sensitivity report . Though cost-effective drugs were chosen in 50% of cases, in more than 20% of cases expensive drugs were started . The study highlights the need for an antibiotic audit and suggests the necessity of having an ongoing peer audit.

Langenbecks Arch Chir, 1996, 381(6), 318 - 22
{Peritoneal and subcutaneous administration of cefazolin as perioperative antibiotic prophylaxis in colorectal operations . Prospective randomized comparative study of 200 patients}; Quendt J et al.; The prophylactic effect of a intraoperative intraperitoneal and subcutaneous application of cefazolin versus a single shot i.v . prophylaxis was investigated . Additionally, we registered the concentration of cefazolin in the serum and the peritoneal fluid in 22 patients . We randomized 200 patients of whom 189 were included in the study . Ninety-two patients received the prophylaxis i.v . (group 1) and 97 topically (group 2) . In 4 (2.1%) wound infections occurred {3(3.3%) group 1 and 1 (1.0%) in group 2} . The difference was not significant . The concentration of cefazolin in the serum was significantly higher at 1 h and 2 h postoperatively in group 2 . We conclude that a topical application of antibiotics is possible to prevent surgical wound infection.

Bull Hosp Jt Dis, 1996, 54(3), 175 - 9
Incidence of deep sepsis in uncemented total hip arthroplasty using clean air facility as a function of antibiotic prophylaxis; Hauser R et al.; Eight hundred and twenty two uncemented primary total hip arthroplasties (THAs) were performed between September 1980 and December 1992 . The population that underwent uncemented THA can be divided into two groups based on the perioperative antibiotic prophylaxis: group 1 contains 439 primary THAs from September 1980 to September 1987 without antibiotic prophylaxis; group 2 contains 383 primary THAs who received short-term cefamandole prophylaxis from October 1987 to December 1992 . Laminar air-flow and whole-body exhaust suits were used during the whole period of this study . Both groups consisted of relatively young patients with a mean age of 53.8 years in group 1, and 54.3 years in group 2 . Using Kaplan-Meier survivorship analysis, the estimated survival rate of sepsis-free hips in group 1 was 97.9% at one year, 97.6% at two years, and 97.4% at three and up to eleven years . In group 2 with antibiotic prophylaxis no deep infection occurred; the rate of sepsis-free hips at five years is 100% . Under clean air conditions, antibiotic prophylaxis significantly decreased the incidence of deep sepsis (p log-rank 0.004).

Clin Ther, 1996 Jan-Feb, 18(1), 84 - 94
Antibiotic prophylaxis during clean neurosurgery: a large, multicenter study using cefuroxime; Holloway KL et al.; Cefuroxime is a second-generation cephalosporin with in vitro activity against the organisms that are commonly associated with neurosurgical wound infections . Other properties of cefuroxime are an elimination half-life of 1.3 hours, which yields prolonged serum concentrations, and its ability to penetrate the blood-brain barrier in proportion to the degree of inflammation . A prospective, multicenter, open-label study was conducted to evaluate the efficacy and safety of cefuroxime for antibiotic prophylaxis in patients undergoing clean neurosurgery . Cefuroxime 1.5 g was given intravenously 25 to 60 minutes before surgery; for procedures lasting more than 3 hours, cefuroxime 750 mg was given intravenously 8 hours after the initial dose . Patients were examined before surgery, daily during hospitalization, and at 8 weeks after surgery . A total of 956 adults were enrolled in the study . The most common procedures in study patients were laminectomy (41.8% of patients) or craniotomy (24.3%), and the mean duration of surgery was 3.2 hours . Infection occurred in 2 (0.3%) of 592 assessable patients by the time of discharge and in 1 additional patient by the 8-week follow-up evaluation for a total of 3 (0.5%) of 560 assessable patients . Drug-related adverse events occurred in 5 (0.5%) of 956 patients . These results indicate that antibiotic prophylaxis with cefuroxime is associated with a low incidence of postoperative wound infection and is well tolerated in patients undergoing clean neurosurgery.

J Orthop Trauma, 1996, 10(5), 298 - 303
Reamed nailing of open tibial fractures: does the antibiotic bead pouch reduce the deep infection rate?
Keating JF, Blachut PA, O'Brien PJ, Meek RN, Broekhuyse H.
Eighty-one open tibial fractures were treated by reamed intramedullary nailing . There were 38 type II, 23 type IIIa and 20 type IIIb injuries . At the end of the nailing procedure the first 26 fractures (15 type II, five type IIIa, and six type IIIb) had antibiotic prophylaxis and delayed closure of the open wound . The subsequent 55 fractures (23 type II, 18 type IIIa, and 14 type IIIb) had identical management but in addition had an antibiotic bead pouch inserted into the open wound following debridement . Three amputations were performed: one (3.8%) in the group treated without a bead pouch and two (3.6%) in the bead pouch group in patients with grade IIIb fractures and severe crushing injuries . Of the remainder, there were four deep infections (16%) in the 25 fractures treated prior to the use of the bead pouch and two (4%) deep infections in the 53 fractures following introduction of the bead pouch . Addition of the bead pouch to the wound management protocol was associated with a worthwhile reduction of deep infection.

Zentralbl Gynakol, 1996, 118(5), 279 - 82
{Perioperative antibiotic prophylaxis in breast surgery: cefotiam versus clindamycin}; Bier UW et al.; 97 patients undergoing breast surgery received either 2 g cefotiam or 1200 mg clindamycin as i.v . singleshot application in the course of an open randomised comparison of parallel groups to evaluate the efficacy and tolerability of both antibiotic regimens . Both regimens proved to be well to-lerated and equally suitable for the prophylaxis of postoperative infections in breast surgery.

Thorac Cardiovasc Surg, 1995 Dec, 43(6), 352 - 4
Survival of acute intestinal infarction after cardiac transplantation; Aleksic I et al.; We report the case of a 52-year-old male who underwent total orthotopic heart transplantation for end-stage ischemic cardiomyopathy . The postoperative course was complicated by acute intestinal infarction which was diagnosed after surgical exploration, and treated with a subtotal colectomy with Brooke ileostomy and closure of the distal sigmoid three days posttransplant . The patient survived with nutritional support and broad antibiotic prophylaxis . Review of the literature on acute abdominal complications after operations involving cardiopulmonary bypass suggests that such complications are usually fatal . Detection and diagnosis may be obscured and treatment complicated by immunosuppression after cardiac transplantation . Because of the poor prognosis without appropriate management, a high level of suspicion, early and aggressive diagnostic measures, and swift surgical intervention are essential to survival.

Gastrointest Endosc, 1995 Dec, 42(6), 630 - 5
Antibiotic prophylaxis for gastrointestinal endoscopy . American Society for Gastrointestinal Endoscopy; Early revision among 12 et al.; Section for Medical Informatics and Statistics, University of Bergen, NorwayOn the basis of data from the Norwegian Arthroplasty Register during the period 1987-1993, we have compared times to revision for 10 different cemented total hip prostheses . A total of 11,169 patients, with 12,179 primary total hip replacements (THRs), performed with high viscosity cement for primary arthrosis and followed for a maximum of 6.4 years, were included in this study . The Kaplan-Meier estimate of the overall percentage revised after 5 years was 2.5 (95% Confidence Interval: 2.1-3.0) . For the Charnley prosthesis (n 6,694), 2.9% were revised after 5 years (95% CI: 2.3-3.4) . Using Cox regression to adjust for gender, age, type of cement and use of systemic antibiotic prophylaxis, the Charnley prosthesis was compared with the 9 other brands . The revision rate for the Spectron/ITH combination (Spectron acetabulum, ITH femur) (n 1,034) was only 0.35 (p 0.04) times that of the Charnley prostheses . The Elite/Charnley combination (Elite acetabulum, Charnley femur) (n 507) and the Muller Type prosthesis (n 116) showed poorer results with failure rates 2.3 (p 0.01) and 2.7 times (p 0.04) that of Charnley, respectively . Although the overall results for cemented THRs in general were good, clinically important differences in revision rates were demonstrated among the cemented prosthesis brands . Our findings underline the need for careful evaluation of different total hip replacements.

Blood, 1995 Nov 15, 86(10), 3979 - 86
Late infections after allogeneic bone marrow transplantations: comparison of incidence in related and unrelated donor transplant recipients; Ochs L et al.; Infectious complications are a major cause of morbidity and mortality after allogeneic bone marrow transplantation (BMT) . We have evaluated the incidence of late infections (beyond day +50) in recipients of related (RD) and unrelated donor (URD) allogeneic BMT, factors associated with increased risks of infection, and the impact of the late infections on survival . Between 1989 and 1991, 249 patients received an RD (n = 151) or URD (n = 98) allogeneic BMT at the University of Minnesota and all late infections were investigated . Three hundred sixty-seven late infectious events developed in 162 patients between 50 days and 2 years after BMT . The incidence of any late infection was greater in URD versus RD recipients (84.7% v 68.2%, respectively; P = .009) . In multivariate analysis, advanced graft-versus-host disease (GVHD) was significantly associated with late infections . The effect of GVHD was apparent only in RD recipients (relative risk {RR}, 2.29; P = .003), whereas URD recipients, with or without GVHD, had more late infections compared with RD recipients without GVHD . Multivariate analysis showed that late posttransplantation infections were the dominant independent factor associated with increased nonrelapse mortality (RR, 5.5; P = .0001), resulting in improved 3-year survival for RD versus URD recipients (49.9% +/- 8% v 34.4% +/- 10%; P = .004) . In this study, we observed that late infections are more frequent in URD recipients, resulting in substantially higher nonrelapse mortality . This prolonged period of increased infectious risk in URD recipients suggests the need for aggressive surveillance and therapy of late infections and perhaps prolonged antibiotic prophylaxis for all URD BMT recipients.

Dan Med Bull, 1995 Nov, 42(5), 485 - 8
Failure to detect a general reduction of surgical wound infections in Danish hospitals; Poulsen KB et al.; The aim of this study was to see if introduction of continuous monitoring of the incidence of surgical wound infections would result in a reduction in the cumulated infection rates . Data from a Danish sentinel system, including more than 65,000 operations, are shown to be sufficiently representative to be used as the basis of a national surveillance system for surgical wound infections . The overall infection rates increased with age and with contamination of the wound . Antibiotic prophylaxis was used in 36% of the operations, with a higher fraction among elderly patients, and in contaminated or major operations . The length of stay was significantly and equally extended for patients with superficial or deep infections, compared to patients without wound infections . The results from 13 departments could be followed at least two years from the beginning of the registration . No general preventive effects of the continuous monitoring were found in these surgical units.

Eur J Obstet Gynecol Reprod Biol, 1995 Nov, 63(1), 37 - 40
A prospective randomised study of the effects of prophylactic antibiotics on the incidence of bacteraemia following hysteroscopic surgery; Bhattacharya S et al.; OBJECTIVE: To study the effect of prophylactic antibiotics on the incidence of bacteraemia following hysteroscopic surgery . DESIGN: Prospective randomized study . SETTING: Aberdeen Royal Infirmary . SUBJECTS: One hundred and sixteen women about to undergo either endometrial laser ablation (ELA) or transcervical resection of the endometrium (TCRE) . INTERVENTION: Fifty-five women were randomised to receive 1.2 g of Augmentin (co-amoxiclav) i.v . at induction of anaesthesia . Sixty-one women received no antibiotic prophylaxis . Blood cultures were obtained at the end of the surgical procedure . RESULTS: Incidence of bacteraemia in the non-antibiotic group (16%) was significantly higher than that in the antibiotic group (2%) (95% confidence interval for difference from 5% to 25%) . The majority of organisms were of dubious clinical significance and contamination could not be excluded in 7 cases out of 10 . CONCLUSION: There is no convincing evidence that antibiotics are of value in this clinical setting.

West J Med, 1995 Nov, 163(5), 492 - 8
Congenital heart disease in adults; Foster E; Patients reaching adulthood with unoperated and operated congenital heart disease require attention to issues of exercise, antibiotic prophylaxis, contraception, and pregnancy . A careful clinical history is important to establish the degree of a person's disability, if any, and the symptoms responsible for the disability, whether due to heart failure, cyanosis, or both . The findings of a physical examination and a noninvasive evaluation, including electrocardiogram, chest x-ray film, and echocardiography, are often sufficient to establish a diagnosis and to assess the adequacy of a previous operation . Transesophageal echocardiography and magnetic resonance imaging are adjunctive procedures that are indicated when routine transthoracic echocardiography is limited . Cardiac catheterization may be necessary when the noninvasive data are ambiguous and to assess coronary artery disease (congenital and acquired) in patients considered for surgical therapy . Cardiac catheterization is increasingly therapeutic (such as percutaneous pulmonary balloon valvuloplasty) as well as diagnostic . Primary surgical repair or additional surgical palliative procedures should be considered in symptomatic adults . A patient with Eisenmenger's syndrome--severe pulmonary hypertension--is a special case that may be amenable only to transplantation.

Br J Hosp Med, 1995 Oct 4-17, 54(7), 341 - 7
Prevention of infective endocarditis: enthusiasm tempered by realism; Prasad A et al.; Infective endocarditis is a cause of substantial morbidity and mortality, and antibiotic prophylaxis may be appropriate in some circumstances . This article examines current British recommendations on prophylaxis, circumstances in which it may be beneficial and evidence for its efficacy.

J R Army Med Corps, 1995 Oct, 141(3), 129 - 33
Potential recruits referred for cardiac opinion review of 100 consecutive cases--a waste of time or an investment?
Ineson N, Stacey BS.
Eighty seven of 100 consecutive recruits referred for cardiac assessment of fitness to serve had heart murmurs . Seven of these were rejected as having significant cardiac disease . One with a diagnosis of hypertrophic cardiomyopathy would have been placed at considerable risk had he been exposed to the physical stress of military training . The remaining 6 rejected had conditions which could have been worsened by the stress of military training and/or required intensive cardiac follow-up . These included 3 individuals with aortic regurgitation, 1 with atrial septal defect, 1 with ventricular septal defect combined with a small atrial septal defect and 1 with post rheumatic fever mitral regurgitation . Thirteen patients we assessed because of other cardiac problems including repaired congenital heart disease and hypertension . The rejection rate in this group was high at 10 out of 13 . The majority of those referred (83/100) were found to be fit for military service . Five of these required advice on antibiotic prophylaxis but the majority had totally unrestricted service . Although most recruits who present with cardiac "problems" will be fit for service, important and potentially fatal conditions can be detected . Therefore vigilance must be high amongst examining doctors and suspect individuals referred for appropriate assessment.

Rev Esp Anestesiol Reanim, 1995 Oct, 42(8), 336 - 40
{Patient with tricuspid atresia undergoing orthopedic surgery: anesthetic considerations}; Vidal Marcos A et al.; We describe a 52-year-old patient with rheumatoid arthritis, interventricular communication and pulmonary stenosis . After an accidental fall she was scheduled for total hip replacement . The main objective of anesthetic management was to preserve pulmonary blood circulation at arterial pressures that would assure adequate tissue perfusion . Other objectives were to maintain hydration to prevent decreases in hematocrit levels, avoid systemic embolization and allow for antibiotic prophylaxis.

Otolaryngol Clin North Am, 1995 Oct, 28(5), 987 - 1001
The infected wound and its management; Bumpous JM et al.; The infected wound is one of the most frequent causes of delayed wound healing . Even in the face of appropriate antibiotic prophylaxis, infections can occur in 10% to 20% of clean-contaminated procedures in the head and neck . The authors describe their comprehensive approach to prevent and manage the infected wound at the head and neck area.

APMIS, 1995 Oct, 103(10), 689 - 92
Serodiagnosis of Helicobacter pylori infection in patients with human immunodeficiency virus infection; Nielsen H et al.; In contrast to the established role of Helicobacter pylori gastritis in gastritis and duodenal ulcer in general, conflicting results have been reported in patients with human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome . The seroprevalence during early HIV infection is unknown . We retrospectively studied 102 patients with HIV infection early during the infection and in most cases in asymptomatic patients . Serological IgG antibody response to H . pylori was assessed by ELISA . Compared with an age-matched control group the seroprevalence of H . pylori positivity was not significantly different (19% vs 25%) . We observed no association with CD4 counts, p24 antigen, antibiotic prophylaxis with sulfamethoxazole/trimethoprim or antiretroviral treatment . In 54 of 83 patients initially seronegative a second examination was performed after a median of 24 months (range 3-60 months) and 2 patients had H . pylori seroconverted, indicating an incidence of new infection of 2%/year . In conclusion, previous reports have underestimated the prevalence of H . pylori infection in HIV patients, which seems to be similar to that in an HIV-negative population.

Rev Clin Esp, 1995 Oct, 195(10), 669 - 73
{The effect of surgical antibiotic prophylaxis and the timing of its administration on the risk of surgical wound infection}; Munoz Platon E et al.; BACKGROUND: Clinical trials have demonstrated the efficacy of surgical prophylaxis (SP) . Nevertheless, how the timing of antibiotic administration influences the risk of infection in clinical praxis has scarcely been studied . In this study an assessment was made of whether the non administration of antibiotic, or its administration longer than 2 hours preoperatively, or only postoperatively, are associated with a higher rate of infection of the surgical wound (SWI) compared with antibiotic administration within the two hours prior to surgery in our setting . METHODS: Observational, longitudinal, pseudoretrospective study . It included 2,483 patients undergoing surgery in 1992, with clean-contaminated, contaminated and clean with prophylaxis indication, and without previous infection surgeries . Information on variables potentially associated with SWI and incidence of infection was monitored . A multivariate analysis was made by means of the logistic regression method to evaluate the association of prophylaxis and time of administration, controlling for the remaining variables . RESULTS: 754 patients received appropriate prophylaxis (within 2 hours prior to surgery); 28 of these patients (3.7%) developed SWI . Twenty-four of the 107 who received prophylaxis longer than 2 hours prior to surgery developed infection (22.4%; p < 0.001 compared with the first group; OD: 7.5, 95% CI: 3.94-14.1); in the group of patients non receiving preintervention doses 94 patients developed infection (7.7%; p = 0.001; OR: 2.16, 95% IC: 1.38-3.41) . Among patients who did not receive prophylaxis 24 infections were detected (6%; p = 0.10; OR: 1.66, 95% CI: 0.91-2.99) . In the multivariate analysis the administration of prophylaxis longer than 2 hours prior to surgery or postoperatively was confirmed to be associated with a higher SWI rate, as in the non-administration situation, controlling for the remaining variables (OR for longer than 2 hours: 5.82; for postoperative administration: 3.23, and for non-administration: 2.68) . CONCLUSIONS: The administration of SP is inappropriate in a high percentage of cases . The administration of SP within the 2 hours prior to surgery reduces the risk of SWI, compared with the administration 2 hours or longer prior to intervention or only postoperatively.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1995 Oct, 80(4), 409 - 13
Evaluation of medical consultations in a predoctoral dental clinic; Jainkittivong A et al.; OBJECTIVE . A patient's medical condition can affect the delivery of dental care . Medical consultation is indicated for dental patients whose medical history is uncertain or when physical assessment may indicate an untreated medical problem . The aims of this study were to evaluate the use of medical consultation and determine how it affects dental treatment plans in a predoctoral dental clinic program . STUDY DESIGN . Reviews of 147 medical consultation requests were performed . RESULTS . The main reasons for medical consultations were cardiovascular assessment (51.5%) and diabetic status determination (12.6%) . In the cardiovascular assessment category, hypertension (48.1%) and heart murmur (17.9%) were primary concerns . Main dental concerns were the need for preoperative antibiotic prophylaxis (33.3%) and the use of vasoconstrictors (20.4%) . Overall, 32.1% of medical consultations resulted in an alteration in dental treatment plans . As a result of medical consultations, 8% commenced their medical management . CONCLUSIONS . These results indicated that medical consultations could reduce the medical risk associated with dental procedures and unnecessary antibiotic prophylaxis . Therefore for many dental patients, good communication between dentists and physicians is essential for adequate care.

Surgery, 1995 Oct, 118(4), 742 - 6; discussion 746-7
Should antibiotic prophylaxis be used routinely in clean surgical procedures: a tentative yes; Lewis RT et al.; BACKGROUND . The incidence of surgical site infection (SSI) after clean surgical procedure has traditionally been regarded as too low for routine antibiotic prophylaxis . But we now know that host factors may increase the risk of SSI to as high as 20% . We assessed the value of prophylactic cefotaxime in patients stratified for risk of SSI in a randomized double-blind trial . METHODS . Patients admitted for clean elective operations were enrolled, stratified for risk by National Nosocomial Infection Survey criteria, and randomized to receive intravenous cefotaxime 2 gm or placebo on call for operation . They were followed for 4 to 6 weeks for SSI diagnosed by Centers for Disease Control and Prevention criteria . RESULTS . Analysis of 775 patients showed that the 378 evaluable patients who received cefotaxime had 70% fewer SSI than those who did not--Mantel-Haenszel risk ratio (MH-RR) 0.31; 95% confidence intervals (CI) 0.11 to 0.83 . Benefit was clear in the 616 low risk patients--0.97% versus 3.9% SSI (MH-RR 0.25, CI 0.07 to 0.87, p = 0.018), but only a trend was seen in 136 high risk patients--2.8% versus 6.1% SSI (MH-RR 0.48, CI 0.09 to 2.5) . CONCLUSIONS . The results indicate clear benefit for routine antibiotic prophylaxis in clean surgical procedures . High risk patients need more study.

Ann Ital Chir, 1995 Sep-Oct, 66(5), 665 - 9
{Significance of antibiotic prophylaxis in infection prevention in biliary surgery . Personal experience}; Zuccarini F et al.; Postoperative infections are one of the most frequent causes of morbidity in surgical patients . In biliary tract surgery the risk of septic complications is essentially increased by opening the bile ducts . Aim of this paper is to evaluate indications and effectiveness of short-term prophylaxis in preventing infective complications of biliary surgery . Authors report a personal six years review regarding 530 patients operated for biliary tract diseases . The patients were divided into two groups: the first one (n . 245) operated under short-term prophylaxis; the second one (n . 285) treated only postoperativelly with antibiotics . The results obtained show a significatively higher rate of infective complications in the second group of patients . There is a little difference between the groups in the case of elective cholecystectomy, whereas there is a great difference in case of non-elective surgery, bile ducts opening, external biliary drainages placement or sphincteropapillotomy . Authors furthermore emphasize how surgical results are conditioned by individual risk factors, especially obesity and diabetes.

Minerva Chir, 1995 Sep, 50(9), 827 - 9
{Antibiotic prophylaxis with ++vancomycin in corrective surgery with alloplastic material}; Massaioli N et al.; The authors report a controlled series of 40 patients treated for recidivating inguinal hernia and laparocele with the implant of alloplastic material . Short-term prophylaxis with vancomycin was performed in all cases . The antibiotic was found to be well tolerated at the doses used and this was associated with a good clinical success rate . The use of vancomycin in prophylaxis for this type of surgery is considered a rational choice and the use of short-term prophylaxis reduces the risks linked to possible collateral effects.

Am J Perinatol, 1995 Sep, 12(5), 322 - 4
Ampicillin/sulbactam versus ampicillin alone for cesarean section prophylaxis: a randomized double-blind trial; Rijhsinghani A et al.; To study the effectiveness of anaerobic coverage in prevention of postpartum endometritis in women undergoing nonelective cesarean sections, we conducted a randomized prospective double-blind study of women undergoing cesarean sections and requiring antibiotic prophylaxis from April 1, 1989, through December 31, 1990 . Ninety-four patients were enrolled in the study . Forty-five patients received ampicillin alone and 46 received ampicillin in conjunction with sulbactam . All patients were evaluated prior to surgery and in the postoperative period . Ninety-one patients completed the study and their records were analyzed . Patients were divided into two groups depending on the presence or absence of ruptured membranes . Seventy-five percent of patients had ruptured membranes . Failure of prophylaxis and subsequent endometritis was documented in 8.8% of patients who received ampicillin and sulbactam and 35.3% of patients who received ampicillin alone . This difference was statistically significant (p < 0.02) . In conclusion, single-dose ampicillin and sulbactam provides better prophylaxis than single-dose ampicillin in women undergoing cesarean section with rupture of membranes.

J Am Acad Dermatol, 1995 Sep, 33(3), 418 - 21
Dermatologists and antibiotic prophylaxis: a survey; George PM; BACKGROUND: Antibiotic prophylaxis is frequently used for the prevention of infection at a distant site such as the heart valve or prosthetic joint . However, there are no published data describing how dermatologists manage patients "at risk" . OBJECTIVE: The purpose of this study is to document prophylactic antibiotic use by dermatologists . METHODS: A total of 211 randomly selected community dermatologists and 69 academic dermatologic surgeons were surveyed by questionnaire to determine whether they would provide antibiotic prophylaxis in 20 different clinical situations . RESULTS: This survey showed that under certain circumstances, almost all dermatologists provide antibiotic prophylaxis to prevent infection at a distant site . However, many dermatologists use antibiotics in settings with relatively little or no indication and confuse a prophylactic regimen with treatment of a superficial infection . CONCLUSION: This survey underscores the need for education and research into the prophylactic management of patients "at risk" who undergo dermatologic surgical procedures.

Prim Care, 1995 Sep, 22(3), 445 - 50
Antibiotic prophylaxis for lower gastrointestinal endoscopy; Varma JR; Bacterial endocarditis is a preventable disease in most patients . It is a potentially fatal disease if left untreated . This article addresses issues related to bacterial endocarditis prophylaxis as related to lower gastrointestinal endoscopy and the recommendations of the American Heart Association.

Br J Hosp Med, 1995 Aug 16-Sep 5, 54(4), 147 - 9
Decision-making in surgery: splenectomy; Carroll A et al.; Interest in splenectomy is topical because of the need to develop protocols for the prevention of overwhelming systemic infections postsplenectomy . Partial splenectomy is possible in only a few patients undergoing splenectomy for trauma . In haematological disorders, total splenectomy is mandatory . All patients who have had a total splenectomy will require vaccination and antibiotic prophylaxis.

Pract Periodontics Aesthet Dent, 1995 Aug, 7(6), 29 - 36; quiz 37
Clinical issues in the prevention of dental-induced endocarditis and prosthetic joint infection; Wahl MJ; No issue in medicine or dentistry is the subject of more misunderstanding than the prevention of infective endocarditis and late prosthetic joint infections . To resolve some of the confusion, national medical groups have published guidelines for the prevention of these infections, including the use of antibiotic prophylaxis for certain dental procedures and certain at-risk patients . While these guidelines are helpful, there still are clinicians who either do not recommend antibiotics when indicated or recommend antibiotics without indication . An understanding of these issues helps to prevent not only the infections but also the adverse antibiotic effects and associated legal problems . The learning objective of this article is to educate clinicians on the prevention of dental-induced endocarditis and prosthetic joint infections.

Br J Surg, 1995 Aug, 82(8), 1136 - 7
Effective administration of heparin and antibiotic prophylaxis; Avery CM et al.; A prospective audit was performed to determine whether new departmental procedures had improved the administration of heparin and antibiotic prophylaxis in patients undergoing major surgery who were at risk of deep vein thrombosis, pulmonary embolism and postoperative wound infection . The results are compared with a previous retrospective audit of the same 'at-risk' groups . A significant improvement in prophylaxis administration is demonstrated.

Br J Surg, 1995 Aug, 82(8), 1046 - 8
Value of oral antibiotic prophylaxis in colorectal surgery; McArdle CS et al.; A total of 169 patients undergoing colorectal surgery were randomly allocated to receive either gentamicin plus metronidazole or oral ciprofloxacin plus metronidazole as prophylaxis; they were also allocated to receive cover for 1 or 3 days . Twenty-eight patients (17 per cent) developed postoperative wound infections . The proportion of patients with wound infections and other infective complications was significantly less (P < 0.02) in those receiving oral ciprofloxacin . Cover for 3 days was no better than that for only 1 day . Oral ciprofloxacin for prophylaxis may offer advantages in efficacy and ease of administration compared with parenteral antibiotics.

Am J Obstet Gynecol, 1995 Aug, 173(2), 465 - 9; discussion 469-71
Wound infection after abdominal hysterectomy: effect of the depth of subcutaneous tissue; Soper DE et al.; OBJECTIVE: Our purpose was to determine the effect of the depth of the subcutaneous tissue at the operative site on abdominal wound infection after hysterectomy . STUDY DESIGN: A prospective study was performed of women undergoing abdominal hysterectomy and not receiving antibiotic prophylaxis who underwent maximum vertical measurement of their subcutaneous incisions before the abdominal cavity was surgically entered . Additional demographic and perioperative data previously associated with wound infection were collected and analyzed . Surgical technique was standardized among the three attending surgeons involved . RESULTS: Wound infection occurred in 17 of 150 (11.3%) women undergoing abdominal hysterectomy . Univariate analysis identified the following risk factors as being significantly associated with wound infection: depth of subcutaneous tissue (p = 0.0004), preoperative serum albumin (0.0015), weight (p = 0.0029), and body mass index (p = 0.0032) . Logistic regression analysis confirmed the thickness of the subcutaneous tissue as the only significant risk factor for wound infection (p = 0.04) (odds ratio 1.37, 95% confidence interval 1.01 to 1.86) . No patients with a maximum depth of subcutaneous tissue < 3 cm had a wound infection . CONCLUSION: We conclude that the depth of subcutaneous tissue is the most significant risk factor associated with abdominal wound infection after hysterectomy.

Arch Pediatr Adolesc Med, 1995 Aug, 149(8), 839 - 44
Practice variations among pediatricians and family physicians in the management of otitis media; Roark R et al.; OBJECTIVES: To determine theoretical practice patterns and Medicaid practices in the management of persistent and recurrent otitis media by family physicians and pediatricians in Colorado . METHODS: Members of the Colorado chapters of the American Academy of Pediatrics and the Colorado Academy of Family Medicine were surveyed with the use of two hypothetical case management scenarios for which they were asked to indicate which International Classification of Diseases, Ninth Revision, Medicaid codes they would use . Physicians were presented with two case scenarios (one involving a persistent asymptomatic middle ear effusion and the second involving recurrent otitis media) and were asked to choose from a variety of management options, including observation, antibiotic therapy, decongestants, corticosteroids, antibiotic prophylaxis, and referral for ventilation tube surgery . RESULTS: Family physicians would have prescribed high-cost antibiotics (amoxicillin plus clavulanate potassium, cefaclor, or cefixime) to treat persistent middle ear effusions twice as often as pediatricians would have (P < .002) . At the 6-week visit, 50 family physicians (43%) would administer an oral decongestant either alone or in combination with other therapy as compared with 16 (14%) of pediatricians (P < .001) . Family physicians would refer patients for ventilating tube surgery three times more often than pediatricians at the 9-week visits (P < .001) . Recurrent episodes of acute otitis media would be managed similarly by both physician groups . Respondents reported a wide variety of International Classification of Diseases, Ninth Revision, coding, often coding persistent effusions as acute otitis or as unspecified otitis media . CONCLUSIONS: The findings of this survey document the wide variation in practice patterns for treating children with persistent otitis media and children with recurrent otitis media in Colorado.

J Am Coll Surg, 1995 Aug, 181(2), 138 - 44
Ranitidine reduces postoperative interleukin-6 induced C-reactive protein synthesis; Rasmussen LA et al.; BACKGROUND: The mechanism of post-traumatic immunosuppression is still not known in detail . However, histamine released during trauma and major surgery may play a significant role in the process . Previously, we showed that the histamine-2 receptor antagonist (H2RA), ranitidine, reduced trauma-induced suppression of certain immunological parameters . STUDY DESIGN: The effect of perioperative ranitidine on postoperative change in plasma interleukin-6 (IL-6) and serum C-reactive protein (CRP) levels was assessed in 23 women undergoing elective abdominal hysterectomy . The patients were randomized to receive intravenous ranitidine, 100 mg twice a day from skin incision, for two days, followed by oral ranitidine, 150 mg twice a day, for a further three days, or no ranitidine . Interleukin-6 and CRP were analyzed in plasma and serum, respectively, drawn preoperatively and six, 24, 48, and 120 hours after skin incision . RESULTS: Routine blood analyses, clinical data (except age), duration of surgery, anesthesia, antibiotic prophylaxis, blood loss, and perioperative blood transfusion were similar in the two groups . Interleukin-6 levels were significantly increased in all patients and without difference between the ranitidine-treated and non-ranitidine-treated patients after six, 24, and 48 hours compared to preoperative levels, respectively . C-reactive protein levels were also significantly increased in all patients after 24, 48, and 120 hours, respectively; however, at 48 hours, CRP was significantly reduced in ranitidine-treated patients compared with non-ranitidine-treated patients (p = 0.02) . CONCLUSIONS: These results suggest that histamine-2 receptor activation mechanisms may not be involved in postoperative IL-6 synthesis . However, the reduced CRP level in ranitidine-treated patients suggests that H2RAs modulate IL-6 signal transduction in hepatic cells.

Ann Ig, 1995 Jul-Aug, 7(4), 267 - 77
{Epidemiological analysis of nosocomial infections at the "Arcispedale St . Anna" in Ferrara between 1989 and 1991}; Gregorio P et al.; The Authors describe the results of an epidemiology project on nosocomial infection performed from 1989 through 1991 at the "Arcispedale S . Anna", Ferrara, Italy . Data are considered from 4.183 patients who were hospitalized for surgical treatment and intensive care: 301 patients (7.2%) developed 402 episodes of infection, namely 1.34 infections per patient . 8.2% of the patients who underwent surgery had at least one infection, while 3.9% of the those who did not have surgery showed at least one infection . The majority of infections came out higher among those submitted (11.4%) than among those not submitted (4.4%) to antibiotic prophylaxis . Infections were caused by both Gram+ and Gram- bacteria, and often the infections were polimicrobial.

Z Kardiol, 1995 Jul, 84(7), 532 - 41
{The management of adolescents and adults with congenital heart defects: 3 years experiences with interdisciplinary consultation}; Muhler EG et al.; Since September 1991, 204 patients (pts), 109 male and 95 female, mean age 27.3 +/- 10.6 years, were followed in a newly established interdisciplinary outpatient clinic combining both adult and pediatric cardiologists . 61 pts predominantly presented with left-to-right shunt congenital heart disease (CHD), 32 with valvar CHD, 20 with aortic coarctation, 23 with complex acyanotic, and 49 with cyanotic CHD . The population included 19 pts with Marfan syndrome . 106 pts had had previous cardiac surgery, 32 of them with up to three reoperations . Deficits and needs in medical and social care were analyzed in 100 pts using a standardized questionnaire at the time of first examination: One-third of pts were not or only incompletely informed about their CHD, previous surgical procedures and need for antibiotic prophylaxis of endocarditis . Only a minority of pts had had vocational advice (34%) or counseling concerning contraception (40%) or pregnancy (30%) . Cardiac catheterization was performed in 37 pts (18%) after being first seen in our outpatient clinic, followed by a primary surgical intervention in 19 and reoperation in eight cases . Overall, 30 pts (15%) underwent surgery (28) or interventional procedures (one closure of the arterial duct, one AV node ablation after Mustard-operation) as a consequence of admission to our unit . Successful late Fontan operations were performed in four adults aged 21 to 35 years . There was 1/30 postoperative death (M . Ebstein, thrombosis of the mechanical prosthesis) . The population includes five pts with severe pulmonary vascular disease (one waiting for lung transplantation) and two pts with pulmonary artery arborisation malformations not amenable to surgery . CONCLUSION: In a population of 204 adolescents and adults with CHD, we clearly found deficits in medical and social care and, in addition, an unexpected high percentage of necessary invasive investigations (18%) and surgical or interventional procedures (15%) . Interdisciplinary management of these patients is mandatory combining the special facilities of adult and pediatric cardiologists.

Ginecol Obstet Mex, 1995 Jul, 63, 302 - 7
{Ceftriaxone vs . cefazolin in obstetrical surgical prevention}; Figueroa Damian R et al.; The cesarean section is associated with a high incidence of puerperal infections . The antibiotic prophylaxis in obstetric surgery may reduce infectious complications, nevertheless antibiotic prophylaxis only has proved to be effective in women with risk factors for the occurrence of infection . We made a comparative study of the prophylactic efficacy of the ceftriaxone a single dose versus cefazolin three doses, in women with risk factor for infection . There were enrolled 100 patients, 50 in each group . Six percent of the ceftriaxone group patients developed puerperal infections while 12% of the cefazolin group women developed this complication . The statistic analysis don't show difference between the groups . We consider the single dose prophylactic schema is better because its application is easier, administration is safety and reduces the risk of adverse reactions.

Eur J Surg, 1995 Jul, 161(7), 509 - 11
Infection after laparoscopic cholecystectomy: are antibiotics really necessary?
Watkin DS, Wainwright AM, Thompson MH, Leaper DJ.
OBJECTIVE: To establish the incidence of infection after laparoscopic cholecystectomy, and assess the need for antibiotic prophylaxis . DESIGN: Prospective open study . SETTING: University teaching hospital, United Kingdom . SUBJECTS: 253 consecutive patients undergoing laparoscopic cholecystectomy between September 1990 and January 1993 . INTERVENTIONS: A single intravenous dose of cefuroxime 1.5 g at induction of general anaesthesia . MAIN OUTCOME MEASURES: Infective complications . RESULTS: Patients were reviewed at two weeks and 12 months . At two weeks there had been two wound infections (one resolved spontaneously and the other required removal of a gallstone from the subcutaneous tissue), two chest infections (treated with antibiotics orally and physiotherapy), and one subhepatic abscess (drained percutaneously under ultrasonographic control) . No other complications were reported at 12 months . CONCLUSIONS: Routine antibiotic prophylaxis may be unnecessary during elective laparoscopic cholecystectomy, but a randomised controlled trial is necessary to confirm this.

Rev Gastroenterol Mex, 1995 Jul-Sep, 60(3), 145 - 8
{Complications of splenectomy in the Sugiura-Futagawa procedure}; Mercado MA et al.; Evaluation of the complications of splenectomy in the Sugiura-Futawaga operation . BACKGROUND: Splenectomy in portal hypertension is a more difficult procedure and probably has a higher morbidity and mortality . METHOD: A retrospective study of 155 patients with hemorrhagic portal hypertension treated by means of the Sugiura-Futawaga operation was conducted to evaluate the complications related to splenectomy . RESULTS: Mean age of the patients was 42 years: 81 patients were male and 74 female . In 87 cases liver cirrhosis was shown, 39 cases with portal fibrosis, 23 cases with primary biliary cirrhosis and 6 cases with normal liver (idiopathic portal hypertension) . No patient received preoperative immunization against pneumococcus, but received antibiotic prophylaxis . Complications were found in 16 cases (10.3%): 13 of them related to the surgical procedure (peritonitis 3.9%, subphrenic collection 1.9%, pancreatic pseudocyst 1.9% and pancreatic fistula 0.6%) and three related to the absence of spleen (1.9%) with septic shock as manifestation . CONCLUSIONS: The complications related to splenectomy in the Sugiura-Futagawa procedure are low, as well as the overwhelming post-splenectomy infection rate . Splenectomy in the Sugiura-Futagawa operation has no important role in the post-operative morbidity.

Dermatol Surg, 1995 Jun, 21(6), 550 - 4
Antibiotic prophylaxis in cutaneous surgery; Rabb DC et al.; BACKGROUND . Postoperative wound infections, endocarditis, and late contamination of prosthetic implants are potential complications of cutaneous surgery . OBJECTIVE . To review current American Heart Association guidelines and their application to cutaneous surgery, and to determine how practicing physicians approach this problem . METHOD . Surveys were sent to dermatologists to determine what kind of preoperative screening was being done and how antibiotics were being used . RESULTS . The most common indications for prophylaxis were manipulation of infected tissue in patients undergoing any procedure, and any procedure in a patient with a prosthetic heart valve . Some respondents used antibiotic prophylaxis for all procedures, while others never used antibiotics in any surgical procedure . Cephalosporins and erythromycin were the most commonly used antibiotics and they were usually given orally, one dose before and one dose after surgery . CONCLUSION . Scientific literature supports the use of antibiotic prophylaxis for endocarditis in two situations: 1) surgical procedures on infected tissue in patients with a high risk cardiac lesion; and 2) any surgical procedure in a patient with a prosthetic heart valve . Our survey suggests that the majority of dermatologists obtain pertinent medical history and use appropriate antibiotic prophylaxis in these two situations . But the survey also suggests that antibiotic prophylaxis is used in a variety of situations where indications for use are not as clear, and sometimes prophylaxis is not used when it should be.

Drugs, 1995 Jun, 49(6), 897 - 911
Drug treatment associated with heart valve replacement; Coulshed DS et al.; This article reviews a number of specific pharmacological considerations for patients with prosthetic heart valves . All patients with mechanical heart valves should be anticoagulated . In the past, an International Normalised Ratio (INR) of 2.5 to 4.5 has been recommended . Recent nonrandomised studies have suggested that a patient with a prosthetic valve who is at low risk for thromboembolic events could have an INR ranging from 1.8 to 3.5 . The lower end of this range should only be used for patients at higher than average risk of haemorrhage, until randomised data show that levels below 2.5 may be applied universally . In high-risk patients (particularly those with previous thromboembolic events) low dose aspirin should be added . During noncardiac surgery, a patient at low risk for thromboembolic events could be managed by discontinuing anticoagulation 3 days before the operation, with warfarin recommenced as soon as possible afterwards . Perioperative heparinisation would be appropriate in a higher risk patient . Women with prosthetic heart valves wishing to become pregnant should be converted to the use of twice-daily subcutaneous heparin injections . Patients with bioprosthetic valves can be managed without anticoagulation unless they have some other reason to require it . Patients at high risk should be treated with aspirin or warfarin . Thrombolytic therapy for acute valve thrombosis should be used for those who are haemodynamically compromised and therefore have a high risk of mortality from operative intervention . All patients with prosthetic heart valves undergoing invasive procedures potentially causing bacteraemia should receive antibiotic prophylaxis for endocarditis . The actual drugs used depend on the likely nature of the bacteraemia, and any possible patient hypersensitivity.

J Trauma, 1995 Jun, 38(6), 895 - 8
Morbidity associated with nonoperative management of extraperitoneal bladder injuries; Kotkin L et al.; Foley catheter drainage alone has become routine management for extraperitoneal bladder ruptures in many medical centers, and few reports address treatment failures with this approach . Over the last 10 years, 70 patients with bladder ruptures were managed at our institution . Thirty-six of these had extraperitoneal injuries caused by blunt trauma, and 29 of these were treated by catheter drainage alone . Of those patients managed nonoperatively, 74% had spontaneous healing within 10 to 14 days; however, 26% had significant complications, including delayed healing, vesicocutaneous fistula, septic events, bladder calculi, or death . Although our results confirm previous reports in the literature that most patients with extraperitoneal bladder ruptures do well with nonoperative management, they also point out that a significant subset of patients do not . We were unable to identify presenting features that would predict an unfavorable outcome, although patients with multiple pelvic fractures seem to be at high risk . The maintenance of adequate catheter drainage and use of antibiotic prophylaxis seems to have a significant impact on outcome.

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