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 Rad