J Chemother, 1995 Jun, 7(3), 216 - 20 Clindamycin/cefonicid in head and neck oncologic surgery: one-day prophylaxis is as effective as a three-day schedule; Righi M et al.; The aim of our study was to evaluate the optimal duration of antibiotic prophylaxis in major oncologic surgery of the head and neck using a novel broad spectrum drug combination: clindamycin and cefonicid . A prospective randomized study was carried out on 126 evaluable patients undergoing clean-contaminated (skin to mucosa) surgery for cancer of larynx, pharynx or oral cavity . Cases at high surgical risk (because of need of pedicled or microvascular free flaps reconstruction), were excluded from the study . Within 20 days after surgery, only one case of wound infection was recorded among the 62 patients treated with the one-day schedule, versus three cases registered among the 64 subjects receiving three-day chemoprophylaxis . Episodes of systemic infections and eventual wound complications occurring in the first 20 days after surgery have also been recorded . The role of potential risk factors for postoperative complications has been evaluated . According to our findings, a three-day antibiotic regimen is not more effective than a short-term (one-day) schedule in preventing wound or systemic infection in clean-contaminated head and neck cancer surgery without flap reconstruction. J Hosp Infect, 1995 Jun, 30 Suppl, 127 - 39 Risk factors for surgical infection; Leaper DJ; In the last century remarkable advances have been made in surgery, associated with the lowest recorded rates of infection or sepsis . Many surgical practices are time honoured but have little scientific basis to prevent postoperative infection whereas some local and systemic factors are well recognized and can be modified to lower infection risks . Surgical skill is not easily measurable but shorter operations in experienced hands leaving the minimum of tissue damage, haematoma or dead space have the lowest infection rates in general surgery: < 2% in clean and < 10% in contaminated operations . Adequate surgical scrub, appropriate suture materials and antibiotic prophylaxis, perioperative correction of dehydration and poor nutrition are examples of effective therapy which can be conformed to by all surgeons . Other factors, such as the use of wound guards, drains and surgical dressings are less easy to estimate for effectiveness or be sure that they could be changed or left out of surgical ritual. Minerva Chir, 1995 Jun, 50(6), 553 - 6 {Pilonidal cysts and fistulas: radical excision "en bloc" and closure "per primam"}; Mecchia P et al.; For the radical surgical treatment of pilonidal cysts and fistulas, the authors suggest the excision "en bloc" of the complete pathological tissue and the primary closure, according to a procedure which considers not only a accurate surgical technique and a kind of dressing which avoids pressure and traction on the sutures, but also a s.t . antibiotic prophylaxis based on culture tests . This kind of approach in surgical treatment showed according to their experience, excellent immediate and long term results, causing slight inconvenience to patients, with a short recovery with regard to cases treated without primary closure. Med Clin North Am, 1995 May, 79(3), 509 - 22 Surgical antibiotic prophylaxis; Nichols RL; Improvements in antibiotic prophylaxis, including the timing of initial administration, appropriate choice of antibiotic agents, and the limiting of the duration of administration, have more clearly defined the value of this technique in many clinical surgical settings . Studies of antibiotic prophylaxis designed during the next decade should strongly consider individual patient risk factors when new antibiotic agents are tested or administration techniques are refined . A concentrated effort should be made in areas of clinical surgery in which the value of antibiotic prophylaxis has not been proven . When in doubt, it appears that a one-dose systemic regimen of an appropriately chosen cephalosporin given during the immediate preoperative period is safe and the indicated practice. Endoscopy, 1995 May, 27(4), 313 - 6 Percutaneous endoscopic gastrostomy (PEG): comparison of push and pull methods and evaluation of antibiotic prophylaxis; Akkersdijk WL et al.; BACKGROUND AND STUDY AIMS: Infection of the gastrostomy opening after placement of a percutaneous endoscopic gastrostomy (PEG) catheter has been reported to occur quite often, especially when the pull method is used . We therefore compared complications occurring with the pull and push methods, and evaluated the role of antibiotic prophylaxis . PATIENTS AND METHODS: In a prospective study, 100 consecutive patients were randomly assigned to group A (pull plus antibiotic prophylaxis: amoxycillin-clavulanic acid 3 x 1.2 g i.v . over 24 hours; 37 patients), group B (pull without antibiotic prophylaxis; 34 patients) and group C (push without antibiotic prophylaxis; 29 patients) . The indications for PEG placement were dysphagia due to oropharyngeal tumors (56%), neurological disease (32%), or other (12%) . Patients were evaluated twice weekly for one month after the PEG placement . RESULTS: PEG catheters were successfully placed in 96% of the patients . The total procedure-related complication rate was significantly lower in group A than in groups B and C (28%, 58%, and 70%, respectively; p < 0.01) . Major complications occurred in one patient in group A (seeding metastasis of a hypopharyngeal carcinoma in the gastrostomy tract), and in four patients in group B (three cases of peritonitis and one aspiration, resulting in two deaths), but in none of the group C patients . Group A patients experienced fewer peristomal infections than the other two groups (14%, 30%, and 41%, respectively: p = 0.05) . The risk of peristomal pain was similar (11%, 15%, and 11%, respectively; p = n.s.) . In three patients in group C, the PEG catheter had to be replaced by the pull method, due to repeated dislocation of the balloon catheter . CONCLUSIONS: The complication rate with PEG placement is high with both the push and pull methods . The complication rate with the pull method is significantly reduced when antibiotic prophylaxis is used. Ugeskr Laeger, 1995 Apr 24, 157(17), 2439 - 42 {Antibiotic prophylaxis in Danish orthopedic alloplastic surgery}; Aagaard H et al.; In order to assess the routine use of prophylactic antibiotics (AB) in arthroplastic surgery in Denmark, questionnaires were sent to all Danish orthopaedic departments and all general surgical departments that perform orthopaedic surgery . Fifty-six departments (93%) returned the questionnaires . All departments use prophylactic AB in primary knee and hip arthroplasty and in revision arthroplasty . In addition, all departments but one use prophylactic AB in arthroplasty secondary to osteosynthesis . The largest group of departments uses penicillinase-resistant penicillin (PRP) in their standard prophylaxis regimens . The second largest group uses second generation cephalosporins . With one exception, all use cefuroxime . A small group uses other types of AB . Fifteen percent of the departments combine systemic AB with gentamicin bone cement (GC) in primary hip arthroplasty, whereas 22% use this combination in primary knee arthroplasty . Significantly more departments use GC in revision arthroplasty (89%) and in arthroplasty secondary to osteosynthesis (63%) . Prolonged antibiotic prophylaxis (beyond 24 hours) is practised to a significantly higher degree in revision arthroplastic surgery than in the primary arthroplasties . In conclusion, one of two homogeneous groups of prophylactic AB is used in arthroplastic surgery in Denmark as prescribed in the literature. Br Dent J, 1995 Apr 22, 178(8), 289 - 95 Management of the orthodontic patient 'at risk' from infective endocarditis; Hobson RS et al.; There are no clear guidelines for the application of current antibiotic prophylactic regimes to orthodontic patients at risk from infective endocarditis . In order to ascertain current practice, a survey on various aspects of the management of orthodontic patients at risk from infective endocarditis was undertaken . Questionnaires were sent to all 1038 members of the British Society for the Study of Orthodontics and the British Association of Orthodontists . A total of 518 replies were received, 480 (46%) of which were completed in full and analysed . Eight cases of infective endocarditis associated with orthodontic treatment over a 44-year period were reported . The majority of respondents underestimated the number of at risk patients likely to be encountered over a 5-year period . Most orthodontists routinely contact the medical practitioner (62%) or hospital consultant (65%) for advice on the prescription of prophylactic antibiotics . Only 58 (12%) claimed to have refused orthodontic treatment for at risk patients . The majority of respondents advise the use of antibiotic prophylaxis for band placement and removal and manipulation of an unerupted tooth . A high standard of oral hygiene must be established prior to orthodontic treatment for at risk patients . Antibiotic prophylaxis in orthodontics should be used for procedures which cause gingival trauma eg band placement and removal . The daily use of a chlorhexidine mouthwash during treatment and prior to appliance adjustment is recommended. BMJ, 1995 Apr 8, 310(6984), 904 - 8 Differences in mortality after fracture of hip: the east Anglian audit; Todd CJ et al.; OBJECTIVE--To investigate differences between hospitals in clinical management of patients admitted with fractured hip and to relate these to mortality at 90 days . DESIGN--A prospective audit of process and outcome of care based on interviews with patients, abstraction from records with standard proforma, and follow up at three months . Data were analysed with chi 2 test and forward stepwise regression modelling of mortality . SETTING--All eight hospitals in East Anglia with trauma orthopaedic departments . PATIENTS--580 consecutive patients admitted for fracture of neck of femur . MAIN OUTCOME MEASURE--Mortality at 90 days . RESULTS--Patients admitted to each hospital were similar with respect to age, sex, pre-existing illnesses, and activities of daily living before fracture . In all, 560 (97%) were treated surgically, by a range of grades of surgeon . Two hundred and sixty one patients (45%; range between hospitals 10-91%) received pharmaceutical thromboembolic prophylaxis, 502 (93%; 81-99%) perioperative antibiotic prophylaxis . The incidence of fatal pulmonary emboli differed between patients who received and those who did not receive prophylaxis against deep vein thrombosis (P = 0.001) . Mortality at 90 days was 18%, differing significantly between hospitals (5-24%) . One hospital had significantly better survival than the others (odds ratio 0.14; 95% confidence interval 0.04-0.48; P = 0.0016) . CONCLUSIONS--No single factor or aspect of practice accounted for this protective effect . Lower mortality may be associated with the cumulative effects of several aspects of the organisation of treatment and the management of fracture of the hip, including thromboembolic pharmaceutical prophylaxis, antibiotic prophylaxis, and early mobilisation. Schweiz Rundsch Med Prax, 1995 Apr 4, 84(14), 415 - 20 {Indications for, diagnostic conclusions and therapeutic consequences of echocardiography . Studies in a medium-sized hospital}; Brunner-La Rocca HP et al.; Within a period of three months indications and diagnostic as well as therapeutic consequences of all echocardiographic studies were investigated in a middle-size hospital . 174 of a total of 188 examinations were usable . Most examinations were performed in order to detect or to verify left-ventricular failure or coronary heart disease . The diagnostic and therapeutic consequences were enormous; more than 90% of all pathological findings were listed as diagnoses in the final medical report . In terms of valvular heart disease, pericardial effusion and left-ventricular failure the echocardiographic study was most essential for diagnosis . In contrast most normal findings were seen with suspicion of coronary heart disease . Changes in medication or new prescription of oral anticoagulation, ACE inhibitors and beta-adrenergic antagonists were significantly related to the therapeutic recommendations of the echocardiographic studies . The recommendations concerning antibiotic prophylaxis of endocarditis or further diagnostic investigation were respected with few exceptions . Obviously little conclusion could be drawn from a normal echocardiographic study; a well-established indication is essential for the benefit of echocardiography. Laryngoscope, 1995 Apr, 105(4 Pt 1), 359 - 64 Cerebrospinal fluid fistula: the identification and management in pediatric temporal bone fractures; McGuirt WF Jr et al.; Cerebrospinal fluid (CSF) fistula represents a potentially lethal complication and requires a high index of suspicion to make the diagnosis . A 12-year retrospective study of pediatric basilar skull fractures identified 147 patients with temporal bone fractures, of which 37 patients exhibited evidence of CSF fistula . The diagnosis is made from a combination of clinical, radiographic, and chemical evaluation . The evolution of diagnostic techniques are reviewed, and the more recent and sensitive tests, such as beta-2 transferrin, are emphasized . Treatment of CSF fistula is nonsurgical in most cases . Surgical exploration and mastoid obliteration were required in two patients, and the indications for surgical treatment are explored . The use of antibiotic prophylaxis is controversial and not routinely indicated. Chest, 1995 Apr, 107(4), 1074 - 82 Systemic and hemodynamic effects of recombinant tumor necrosis factor alpha in isolation perfusion of the limbs; Eggimann P et al.; OBJECTIVE: To describe the systemic effects of high-dose recombinant tumor necrosis factor alpha (rTNF-alpha), recombinant interferon gamma (rIFN-gamma), and melphalan administered through hyperthermic isolation perfusion of the limbs (IPL) in patients with melanoma and malignant soft-tissue tumors . DESIGN: The clinical, hemodynamic, and biologic parameters were recorded after IPL during the postoperative period . SETTING: Surgical intensive care service of a 1,000-bed tertiary university medical center . PATIENTS: Nineteen patients referred to a pluridisciplinary Center for Oncology after relapse of regionally advanced melanoma or soft-tissues tumors, included in a phase 2 therapeutic study . RESULTS: Major systemic and hemodynamic changes were observed after IPL in all patients . Ninety-four percent (17/18) of the evaluable patients presented a shock unresponsive to fluid challenge, requiring the continuous perfusion of vasopressors, inotropic agents, or both . Analysis of hemodynamic data showed two distinctive patterns: a pure distributive shock in nine patients requiring norepinephrine, and a mixed distributive and cardiogenic shock in eight patients requiring vasopressor and inotropic agents . The oxygen parameters were characterized by an increase in both the delivery and the uptake of oxygen, with a prolonged reduced oxygen extraction ratio for most patients . The other observed effects were as follows: transient bilateral or mixed pulmonary infiltrates in all patients; some hematologic disturbances in 83% of patients; infection requiring a modification of the antibiotic prophylaxis in 61% of patients; and some liver toxic reactions in 50% of patients . Very high systemic TNF-alpha serum bioactivity was found in 12 patients for whom serum samples were available, indicating an early and important rTNF-alpha leakage from the IPL . No correlations could be found between the levels of TNF-alpha and the observed systemic effects . Despite the severity of the hemodynamic disturbance, no patient died . CONCLUSION: Major systemic effects, consisting mainly in cardiovascular, respiratory, and hematologic disturbances, were observed in patients after IPL with high-dose of rTNF-alpha . The likely explanation for these observations is an early rTNF-alpha leakage related to inadequate IPL technique . These data show that the iatrogenic administration of high circulating TNF levels lead to a "septic shock-like" syndrome without resulting in lethal organ dysfunction. Eur Heart J, 1995 Apr, 16 Suppl B, 126 - 31 Antibiotic prophylaxis for infective endocarditis from an international group of experts towards a European consensus . Group of Experts of the International Society for Chemotherapy; Leport C et al.; Antibiotic prophylaxis for infective endocarditis is recommended for cardiac patients at risk who undergo an at-risk procedure . Efforts should focus on patients with the highest risk, i.e., those with a prosthetic valve undergoing a dental procedure . Amoxicillin is the main recommendation in patients who are not allergic to penicillin . In patients allergic to penicillin clindamycin orally or vancomycin intravenously are proposed . Aminoglycosides are added for gastrointestinal or urological procedures. Eur Heart J, 1995 Apr, 16 Suppl B, 117 - 21 Prevention of endocarditis in the Nordic countries; Gutschik E; Bacterial endocarditis as the consequence of an iatrogenic bacteraemia has been recognized for a long time in the Nordic countries, and national recommendations were issued by groups of experts . It is generally agreed that antibiotic prophylaxis is needed in patients with high-risk conditions and that the maintenance of healthy gums and teeth is of major importance . Investigations, however, reported poor level of compliance, and pointed out that the procedural/practical aspect of interactions between patients, dentists and physicians have largely been neglected . In order to improve the level of compliance an 'endocarditis risk' card has been produced, and there has been a remarkable degree of harmonization of chemotherapeutic regimens recommended by the national organizations . Generally, a single dose of prophylaxis is recommended, because there is little evidence that antibiotic levels in humans must be maintained more than 6-7 h for effective prevention of endocarditis, and because compliance with a multiple dose regimen is highly questionable. Zhonghua Liu Xing Bing Xue Za Zhi, 1995 Apr, 16(3), 160 - 3 {A prospective study of perioperative antibiotic prophylaxis in reducing the rate of nosocomial infection among patients with intracranial tumors}; Zhang GH et al.; This paper analysed 525 intracranial neoplastic patients who were hospitalized from July, 1992 to June, 1993 . The patients were randomly divided into control and experiment groups . In the experiment group, patients who received one kind of antibiotic during perioperation had a nosocomial infection rate of 6.29% (11/175), while the patients in the control group where antibiotics were routinely used as usual had a rate of 17.43% (61/350) . There was a significant difference between the control (8.00%) and experiment group (2.29%) in terms of the intracranial infection incidence . Perioperative antibiotic prophylaxis showed great influence on the expenditure of antibiotics and duration of hospitalization in the patients with intracranial neoplastic tumors. Minerva Med, 1995 Apr, 86(4), 167 - 9 {Antibiotic prophylaxis with mezlocillin in elective biliary surgery}; Colombo A et al.; The authors report their experience of antibiotic prophylaxis in elective biliary surgery pertinent to 246 operated patients treated with short-term prophylaxis with mezlocillin . This method has turned out to be efficacious in reducing postoperative infections incidence, particularly in simple cholecystectomy . Therefore the authors advise using such a procedure in this frequent operation too. Laryngoscope, 1995 Mar, 105(3 Pt 1), 244 - 6 Prophylactic antibiotic use in clean, uncontaminated neck dissection; Slattery WH 3rd et al.; A recent report in the literature cites a 10% wound infection rate for clean, uncontaminated neck dissections in patients who did not receive antibiotic prophylaxis as compared with a 3.3% infection rate in patients who received prophylactic antibiotics . Although a trend favoring antibiotic prophylaxis was identified, the duration of therapy was not considered . The present analysis addresses this issue . The authors retrospectively reviewed the records of 120 patients who underwent clean, uncontaminated neck dissections over a 3-year period (July 1989 through May 1992) for variables related to wound infections . Radiation therapy had previously been used in 70% of these patients . Group 1 (31 patients) received 24 hours of perioperative antibiotic prophylaxis, and group 2 (89 patients) received antibiotic prophylaxis until the suction drains were removed (usually 4 or 5 days after surgery) . No perioperative wound infections occurred in either group . The authors concluded that perioperative antibiotic prophylaxis for 24 hours is sufficient to prevent wound infections in clean, uncontaminated neck dissections. Arch Otolaryngol Head Neck Surg, 1995 Mar, 121(3), 269 - 71 Cost analysis of antibiotic prophylaxis in clean head and neck surgery; Blair EA et al.; OBJECTIVE: This study was undertaken to assess the excess cost of hospitalization accrued to patients who develop postoperative wound infection following neck dissection in which the wound was not exposed to secretions from the upper aerodigestive tract . DESIGN: A retrospective cohort of patients who underwent "clean" neck dissection from 1976 to 1989 were evaluated . Antibiotic administration (yes or no), post-operative wound infection (yes or no), and duration and cost of hospitalization were assessed . SETTING: All surgeries were performed in a university medical center . PATIENTS: All patients underwent neck dissection in which the procedure was clean, ie, there was no exposure to secretions from the upper aerodigestive tract . MAIN OUTCOME MEASURES: Patients were assessed to determine administration of antibiotics (yes or no), development of postoperative wound infection (yes or no), and duration and cost of hospitalization . RESULTS: Wound infection developed in 10 (10%) of 99 patients who did not receive antibiotics . Of 93 patients who received perioperative antibiotics, three (3.3%) developed wound infection . This difference was not statistically significant . The type II (beta) error was greater than 0.2, suggesting that a significant difference may have been missed (false-negative) as a result of the small number of patients studied . The excess cost accrued to each patient who developed a postoperative wound infection was in excess of $36,000 (1992 dollars) . The cost of administration of antibiotic prophylaxis to 100 patients is less than this amount . CONCLUSION: The decision to withhold antibiotic prophylaxis should not be made in an effort to reduce hospital costs. Curr Opin Cardiol, 1995 Mar, 10(2), 107 - 16 Recent developments in the diagnosis and management of mitral valve prolapse; Devereux RB; Mitral valve prolapse (MVP), which occurs in about 3% of adults, is usually a primary, dominantly inherited condition . MVP may be diagnosed by auscultation of a mid-systolic click and late-systolic murmur that move dynamically with postural maneuvers . M-mode echocardiography confirms MVP by demonstrating late-systolic prolapse and two-dimensional echocardiography reveals leaflet billowing into the left atrium . Echocardiography identifies severe forms of MVP by documenting significant mitral regurgitation, enlargement and thickening of the mitral leaflets and annulus, and loss of leaflet apposition . In contrast to early reports, true "MVP syndrome" as revealed by controlled studies consists of low body weight and blood pressure, minor skeletal abnormalities, orthostatic hypotension, palpitations, and mitral regurgitation that is usually mild . Complications of MVP include progressive mitral regurgitation, infective endocarditis, orthostatic syncope, and possible risks of neurologic ischemia and arrhythmic sudden death . Risk factors we have identified for complications among patients with MVP include older age, male gender, the presence of mitral regurgitation, and possibly, higher weight and blood pressure . The cumulative risk of all complications of MVP by age 75 is from 5% to 10% for affected men and 2% to 5% for affected women . Patients with MVP who have neither a murmur nor Doppler evidence of mitral regurgitation may be reassured that their condition is benign . For other patients with MVP we have shown that oral antibiotic prophylaxis is cost-effective . The presence and severity of mitral regurgitation govern the frequency and intensiveness of follow-up. Ann Ital Chir, 1995 Mar-Apr, 66(2), 181 - 5 Conservative treatment in acute pancreatitis; Ihse I et al.; In the absence of causative therapy of acute pancreatitis the management of the disease focus on treatment and prevention of complications and symptoms . In mild acute pancreatitis intravenous fluid administration, analgetics and avoidance of oral fluid or food intake is sufficient in most cases . The treatment of severe pancreatitis involves identification of pancreatic and peripancreatic necroses, best demonstrated and evaluated by contrast-enhanced computerized tomography (CT) . Infection of such necroses is the most common cause of death from acute pancreatitis . Recent data suggest that antibiotic prophylaxis is worthwhile and it should therefore always be instituted in the severe form of the disease . Careful monitoring of vital functions is mandatory and early treatment with assisted ventilation and renal dialysis is advised . Adequate volume replacement and nutritional support is important . The role of the gut in the development of infected necroses is becoming increasingly obvious . Also, the absence of food in the intestine may increase the intestinal barrier damage . Therefore, enteral nutrition is discussed as a logical step in pancreatitis treatment . However, the food should be delivered below the ligament of Treitz (below the area of the cholecystokinin (CCK) cells) as CCK stimulation probably worsen the course of the disease. Rev Esp Anestesiol Reanim, 1995 Feb, 42(2), 51 - 7 {Selection and maintenance of lung donors}; Llau JV et al.; Lung transplantation is a relatively modern procedure that can afford improvement in quality of life to certain terminal patients with irreversible respiratory failure . Selection of the donor and the recipient must be both strict and flexible, as we apply criteria that are constantly being revised and extended . The care afforded the donor must include certain elements: exhaustive monitorization that serves to guide the intravenous replacement of fluids and maintenance of hemodynamic stability; assisted ventilation with PEEP, FiO2 under 0.4 and adequate flow volumes; prevention and treatment of neurogenic pulmonary edema; and prevention of infections through careful airways management involving appropriate antibiotic prophylaxis . The same protocol must be maintained while the organ is being extracted and the organ itself must be properly preserved until implanted . The anesthesiologist is fully involved in optimum management of the lung donor . We consider that such care is essential for achieving more and better quality lung donations. J Am Coll Surg, 1995 Feb, 180(2), 157 - 60 The role of cefoxitin prophylaxis in chronic pilonidal sinus treated with excision and primary suture; Sondenaa K et al.; BACKGROUND: Treatment of chronic pilonidal sinus with excision and primary suture is followed by a relatively high proportion of wound infections . The role of preoperative antibiotic prophylaxis in improving results is not clear . STUDY DESIGN: One hundred fifty-three patients with chronic pilonidal sinus were operated on with radical excision and primary suture and randomized to receive a single dose antibiotic prophylaxis of 2 g cefoxitin intravenously (n = 78) or no prophylaxis (n = 75) . RESULTS: The most common complications consisted of partial, slight separation of wound edges with slight discharge . In the group with cefoxitin, 34 patients (44 percent) had complications compared with 32 patients (43 percent) in the group without prophylaxis . Fifty-four patients (69 percent) healed within four weeks in the group with cefoxitin, whereas 48 (64 percent) healed within four weeks in the group without prophylaxis . After a follow-up period of six to 30 months, two patients in each group had not healed . Including these, two patients (3 percent) had recurrences in the group with cefoxitin and five patients (7 percent) in the group without prophylaxis (p = 0.41) . CONCLUSIONS: The immediate and short-term results after excision and primary suture for chronic pilonidal sinus are not influenced significantly by a single dose prophylaxis of 2 g cefoxitin. J Am Acad Dermatol, 1995 Feb, 32(2 Pt 1), 155 - 76; quiz 177-80 Antibiotic prophylaxis in dermatologic surgery; Haas AF et al.; Antibiotic prophylaxis is generally administered either to prevent wound infection or to hinder the development of endocarditis . Although the use of antibiotics in certain circumstances to prevent wound infection can be straightforward, there are other circumstances in which the decision to use antibiotics is much less clear . Endocarditis prophylaxis has traditionally been based on the American Heart Association's guidelines, which do not cover dermatologic surgery . This article discusses the rationale and controversies surrounding the use of antibiotic prophylaxis for prevention of both wound infection and endocarditis, reviews the few studies that pertain to dermatology, and provides recommendations for antibiotic prophylaxis on a case-by-case basis for those who perform dermatologic surgery. Rozhl Chir, 1995 Feb, 74(1), 8 - 10 {Personal experience with administration of Zinacef in the form of a "protected coagulum" in patients after heart surgery}; Rohn V; Antibiotic prophylaxis in the form of a so-called protected coagulum is an important part of prevention of postoperative infections in cardiosurgery . The selection of a suitable antibiotic depends on many factors--its effectiveness against the most frequent pathogens, the tissue penetration, undesirable effects . The authors compared two groups of patients operated on account of IHD using prophylaxis with cefalotine (491 patients) and cefuroxime (241 patients) . The groups are comparable as to baseline parameters . In the cefuroxime-treated group was a significantly lower incidence of infections of the surgical wound (12.6 % vs . 5.8 %) . The number of serious infectious complications (mediastinitis, osteomyelitis) and the incidence of other infections did not differ in the two groups. J R Coll Surg Edinb, 1995 Feb, 40(1), 28 - 30 Exploration of the common bile duct for stones: the influence of the flexible choledochoscope and perioperative antibiotic prophylaxis; Oshodi TO et al.; A retrospective study of 110 patients, out of a total of 743 open cholecystectomies, who have undergone common bile duct (CBD) exploration for stones between 1985 and 1990 . CBD exploration was performed in the presence of abnormal peroperative cholangiogram in 86 (78%) patients . The remaining 24 patients were known to have either an abnormal preoperative ERCP or palpable ductal stones at the time of surgery . Post exploratory choledochoscopy was performed as an additional completion procedure in 58 (53%) patients and it identified further stones in 28 (48.3%) of these patients . There were three patients in whom no stones were identified on exploration of the CBD . Documented evidence of peroperative antibiotic prophylaxis was obtained in 78 (71%) patients . A total of 27 (24.5%) patients developed complications including seven (6.4%) patients with retained stones . In four of these patients with retained stones, flexible choledochoscopy was undertaken as an additional completion procedure to ensure ductal clearance . Cardiorespiratory and septic complications were the next most common problems occurring in 6.5% and 5.4% respectively, of patients reviewed . In conclusion, the retained stone rate has fallen from 14% in 1987 to 6.4% in this study . The choledochoscope has influenced this as it identified further residual stones following conventional exploration . The sepsis rate has also fallen from 19.5% to 4.5% in this study . We believe this is due to the use of antibiotic prophylaxis. Eur J Pediatr, 1995 Feb, 154(2), 98 - 101 Mitral and aortic regurgitation in 84 patients with mucopolysaccharidoses; Wippermann CF et al.; In echocardiographic and necropsy studies nodular thickening of the mitral valve and, less frequently, of the aortic valve has been found in 60%-90% of patients with mucopolysaccharidoses (MPS) . Little is known about the haemodynamic consequences of these morphological changes . In this study 84 unselected patients with different enzymatically proven MPS and 84 age and sex matched, healthy persons were studied prospectively by colour Doppler flow mapping . The patients' age ranged from 1 to 47 years (median 8.1 years) . Mitral and aortic regurgitation were defined as a holosystolic or holodiastolic jet originating from the valve into the left atrium or the left ventricular outflow tract, respectively, with peak velocities exceeding 2.5 m/s . Of the 84 patients with satisfactory studies, mitral regurgitation was detected in 64.3% and aortic regurgitation in 40.5%, respectively . Regurgitation was severe in 4.8% of mitral valves and 8.3% of aortic valves . The frequency of aortic and/or mitral regurgitation was 75% in all patients, 89% in MPS I, 94% in MPS II, 66% in MPS III, 33% in MPS IV, and 100% in MPS VI . Combined mitral and aortic regurgitation was present in 29% of our patients . None of the control persons showed mitral or aortic regurgitation . CONCLUSION: Aortic and mitral regurgitation are more frequent in patients with MPS than previously thought and that therefore these patients should have regular colour Doppler flow mapping and antibiotic prophylaxis when required. Presse Med, 1995 Jan 14, 24(2), 81 - 7 {Lyme disease}; Belaich S; The history of Lyme disease, a contagious condition caused by Borrelia burgdorferi transmitted to man by ticks offers infectiologists a formidable lesson on how medicine progresses . Clinical description started in Europe at the turn of the century with Pick's description of what was then labelled chronic atrophic acrodermatitis . Fifty years later Hauser noted the affection was transmitted by ticks . Independently, Afzelius, then Lipschutz, described erythema chronicum migrans and its relationship with tick bites . Neurological involvement was also described with the skin signs . These early dermatological descriptions suddenly came into the limelight in 1975 when an epidemia of arthritis occurred in children in Lyme, Connecticut, USA . Many of the affected children had erythema chronicum migrans . Based on these observations and an epidemiological analysis of the epidemia, Steele and co-workers defined "Lyme disease" as a rheumatological disorder commonly associated with erythema chronicum migrans and sometimes with multiple organ involvement . In 1982 Borgdorfer suggested that tick bites transmitted a Spirochaeta which was later authentified as the causal agent: Borrelia burgdorferi . Immunofluorescence and ELISA tests were rapidly developed for the diagnosis of infection by this germ which is very difficult to culture . Antibiotic curative treatment was immediately available and in 1991 a consensus conference established recommendations for treatment of isolated and disseminated forms . Antibiotic prophylaxis is not necessary but rapid extraction of the tick after the bite can prevent the disease as transmission from tick to man takes several hours . And medical progress continues . Work is now being conducted on evaluating the extent of late neurological manifestations, on developing polymerase chain reaction methods to identify B . burgdorferi infection in specific organs and on developing a vaccine. Ann Chir Gynaecol, 1995, 84(4), 417 - 9 One dose cefuroxime prophylaxis in hip fracture surgery; Kaukonen JP et al.; One 3 g intravenous dose of cefuroxime during the induction of anaesthesia was administered randomly in a series of 162 consecutive hip fractures . The overall infection rate was 8.0%, and 2.4% for deep infections . The number of infections was seven in the prophylaxis group and six in the control group . The percentage of deep infections was 3.9 and 1.4, correspondingly . Antibiotic prophylaxis given did not seem to have an effect on the infection rate. Neurosurg Rev, 1995, 18(3), 169 - 72 Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 129 patients; Zentner J et al.; The efficacy of a single dose of cefotiam, a cephalosporin of the second generation, as prophylaxis for postoperative infection was analyzed in a prospective randomized study of 129 patients undergoing cerebrospinal fluid shunting . The main focus of interest was the rate of shunt infection requiring operative shunt removal . Data were evaluated in the total group and subgroups formed for normal and high risk patients, respectively . The overall rate of shunt infection was 7.5% in the cefotiam group and 12.9% in the control group . In the high risk subgroup infection rate was 14.3% with and 26.3% without cefotiam as opposed to 4.3% and 6.9%, respectively, in the normal risk subgroup . Although our results do not reach statistical significance, there is a noticeable difference of infection rate between those patients who receive the antibiotic and those who do not . Therefore, we favor single dose antibiotic prophylaxis in shunting procedures. Ann Chir, 1995, 49(6), 493 - 9 {Antibiotic prophylaxis in biliary surgery}; Gondret R et al.; Prophylactic antibiotics in gallbladder surgery is designed to reduce the incidence of postoperative wound infections . Bacteria isolated from the biliary tract are generally the same as those found in the pus of wounds . Prospective and placebo-controlled trials have shown the efficacy of prophylactic antibiotics in high-risk patients presenting one or more of the following criteria: age over 70 years, recent episode of acute chollecystitis, emergency cholecystectomy, presence of common duct stones, jaundice or diabetes mellitus in patients with no risk factors for gallbladder surgery, prophylactic antibiotics may not be essential . The efficacy of antibiotics in the prevention of wound infections has been demonstrated with first, second and third generation cephalosporins, ampicillin associated with clavulanate, ureido-penicillins, aminoglycosides, sulfonamides and quinolones . A single injection of antibiotic given one hour before incision is as effective as multiple-dose regimens . Currently, the choice of antibiotic should be mainly based on its cost . There is no evidence at the present time for systematic prophylactic antibiotics in laparoscopic surgery . Endoscopic procedures of the biliary tract do not require prophylactic antibiotics when obstruction has not been demonstrated. Head Neck, 1995 Jan-Feb, 17(1), 7 - 13 Risk factors for complications in clean-contaminated head and neck surgical procedures; Girod DA et al.; BACKGROUND . Contamination of a head and neck surgical wound with oropharyngeal secretions has been shown to dramatically increase the incidence of wound complications . Appropriate perioperative antibiotic prophylaxis has significantly reduced contaminated wound infection rates in several previous reports . The current study examined multiple patient parameters to determine risk factors for all perioperative complications following clean-contaminated head and neck surgical procedures . METHODS . Retrospective review of medical records from 159 patients who underwent clean-contaminated major head and neck surgical procedures at the University of Washington between 1985 and 1991 . More than 30 preoperative and operative parameters were evaluated, and all complications were recorded . The data were examined using a multivariate statistical analysis . RESULTS . An overall complication rate of 63% included 22% with wound infections (oro/pharyngocutaneous fistula or purulent drainage), 22% with other types of infections, and 51% with noninfectious complications . The overall perioperative mortality rate was 1.2% (two patients) . Prior radiotherapy, operative time, perioperative transfusion, and flap reconstruction were all associated with a significantly higher overall complication rate (p < or = 0.05) . Only prior radiotherapy therapy correlated with an increase in wound infection rate (p = 0.05) . CONCLUSIONS . Prior radiotherapy significantly increases the risk of perioperative complications and wound infections following clean-contaminated head and neck surgical procedures . Other factors reflecting the complexity of the procedure also influence the overall complication rate. Urologe A, 1995 Jan, 34(1), 59 - 61 {Erysipelas and elephantiasis of the scrotum . Surgical and drug therapy}; Geyer H et al.; Elephantiasis is the outcome of persistent lymphedema . It is refractory to different therapy modalities . The social approachability of patients with this disease is impaired by severe functional and cosmetic disturbances . The causal relationship between etiology and recurrent disease is demonstrated by two cases . Treatment options are discussed . Radical surgery is decisive for primary success since chronic inflammation and chronic edema support each other . Metabolic equilibrium, disinfecting skin areas and antibiotic prophylaxis are urgent steps in the successful treatment of Erysipelas disease. J Clin Epidemiol, 1995 Jan, 48(1), 45 - 57; discussion 59-60 Cumulative meta-analysis of clinical trials builds evidence for exemplary medical care; Lau J et al.; Cumulative meta-analysis of clinical trials (a Bayesian interpretation for accumulating evidence) will profoundly affect medical care by summarizing evidence in the assessment of technology innovations . Application of the technique to the randomized control trials (RCTs) of streptokinase treatment of acute myocardial infarction, reduction of peri-operative mortality by antibiotic prophylaxis, and prevention of death from bleeding peptic ulcers has revealed efficacy years before it was suspected by any other means . Arrangement of the trials according to event rate in the controls, effect sizes, quality of the trials or according to covariables of interest has supplied unique information . If carried out prospectively the technique supplies invaluable information regarding indications for another trial, the number of patients necessary to determine the validity of past trends, and the type of patients who might be benefitted . Careful examination in a cumulative manner of the prior trials can reduce the need for future large trials. Nord Med, 1995, 110(1), 9 - 11, 25 {Antibiotic prophylaxis in diagnostic and therapeutic urological interventions}; Hedelin H et al.; An enquiry into the use of antibiotic prophylaxis in conjunction with diagnostic or therapeutic urological procedures at hospitals in four Scandinavian countries showed manifest national differences to exist for most procedures . In transurethral resection, for instance, antibiotic cover was used at 79 percent of Finnish hospitals, but at only nine percent of Danish hospitals . Not only were dosage regimens characterized by wide national variation, but also the spectrum of antibiotics used, quinolones being most frequently used in Sweden, but ampicillin and pivampicillin in Denmark . For some procedures policy was more uniform in all countries, antibiotic cover rarely being used in connection with ureterocystoscopy (5 percent of hospitals), but often in conjunction with percutaneous stone surgery (72 per cent) . In certain procedures where there is strong evidence suggesting the necessity of antibiotic prophylaxis, it was not always used-e.g., in transrectal prostate biopsy where it was used at only 62 per cent of hospitals . The interpretation of published findings and clinical experience would appear to differ markedly, and local traditions would seem to be strong determinants of clinical routines . The wide variation suggests that all patients do not receive optimal treatment . To improve routines, our knowledge of antibiotic preparations needs to be expanded by well executed studies, followed by general implementation of the results at the various centres . A series of consensus conferences should be arranged and the recommendations published as a first step toward a more uniform and probably better use of antibiotic prophylaxis in conjunction with diagnostic and therapeutic urological procedures. J Bone Joint Surg Br, 1995 Jan, 77(1), 93 - 7 Local antibiotic therapy for severe open fractures . A review of 1085 consecutive cases; Ostermann PA et al.; We reviewed 1085 consecutive compound limb fractures treated in 914 patients at the University of Louisville over a nine-year period . Of these fractures, 240 (group 1) received only systemic antibiotic prophylaxis and 845 (group 2) were managed by the supplementary local use of aminoglycoside-polymethylmethacrylate (PMMA) beads . There were no significant differences in age, gender, fracture type, fracture location or follow-up between the two groups . All had copious wound irrigation, meticulous debridement and skeletal stabilisation, but wound management and the use of local antibiotic depended on the surgeon's individual preference and there was no randomisation . In group 1 there was an overall infection rate of 12% as against 3.7% in group 2 (p < 0.001) . Both acute infection and local osteomyelitis showed a decreased incidence in group 2, but this was statistically significant only in Gustilo type-IIIB and type-IIIC fractures for acute infection, and only in type-II and type-IIIB fractures for chronic osteomyelitis . Our review suggests that the adjuvant use of local antibiotic-laden PMMA beads may reduce the incidence of infection in severe compound fractures. Eur Heart J, 1995 Jan, 16(1), 120 - 5 High incidence of left atrial thrombus detected by transoesophageal echocardiography in heart transplant recipients; Derumeaux G et al.; The aim of the study was the detection of spontaneous echo contrast (SEC) and left atrial thrombus by transoesophageal echocardiography (TEE) in patients who had undergone orthotopic heart transplantation . TEE was prospectively performed in 64 heart transplant recipients (53 males, 11 females, mean age 51 years) . Since surgery (mean time: 31 months), all heart transplant recipients had received either aspirin (39), or dipyridamole (22), or both (3) . Despite the antiplatelet treatment, an acute arterial embolism (two strokes, one popliteal and one mesenteric ischaemia) occurred in four patients who subsequently received an oral anticoagulant therapy . TEE was performed with a biplane high-frequency transducer after lidocaine pharyngeal anaesthesia, midazolam intravenous injection and antibiotic prophylaxis . Mean ejection fraction was 63 +/- 10% . None had evidence of rejection at endomyocardial biopsy performed on the same day as TEE and analysed in a blinded fashion . All were in sinus rhythm . Left atrial SEC was found in 35 patients (55%) and was associated with left atrial thrombus in 18 patients (28%) . These thrombi were localized in the donor left atrial appendage in 10 cases, on the posterior wall of the left atrium in six cases, on the donor part of inter-atrial septum in one case and on the suture line in one case . They were not detected by transthoracic echocardiography (TTE) . When compared with patients without thrombus, no difference was found concerning left atrial size, left ventricular ejection fraction, pulmonary artery pressure and number of previous episodes of rejection . However, cardiac index was significantly lower in patients with left atrial thrombus.(ABSTRACT TRUNCATED AT 250 WORDS) Langenbecks Arch Chir, 1995, 380(1), 37 - 42 Perioperative management in thoracic surgery; Hallfeldt K et al.; The quality of perioperative treatment for patients undergoing thoracic surgery is of the utmost importance for postoperative morbidity and mortality . Hence, it was the purpose of this study to examine various aspects of our own procedure . The clinical course following 812 successive thoracotomies in 792 patients over a period of 3 years was documented and analysed . The overall complication rate was found to be 19.7%, with a mortality of 3.8% over a 30-day period . Secretostasis, atelectasis and pneumonia were the most common complications . Owing to the predeposition of autologous blood, the percentage of patients requiring allogeneic blood transfusion was reduced from 27% to 9% . There was no evidence suggesting an increase in the complication rate or a longer stay in hospital . Perioperative antibiotic prophylaxis has reduced postoperative wound infection significantly . Similar reductions in the FEV1 are recorded following thoracic surgery, irrespective of the amount of lung tissue resected . This observation indicates that the remaining lung tissue is severely compromised throughout the postoperative period and that the surgical trauma alone is a major factor influencing postoperative pulmonary function for at least 2 weeks. Lab Anim, 1995 Jan, 29(1), 16 - 36 Antibiotic therapeutics in laboratory animals; Morris TH; Information on antibiotic therapeutics in laboratory species, especially in rodents and rabbits, is reviewed . A number of areas are considered: interference by antibiotics with an experiment, antibiotic toxicity, routes of administration, effects of formulation on bioavailability, antibiotic prophylaxis, use of combinations of antibiotics, misuse of antibiotics, regulatory approval for antibiotic use in animals, sources of information on antibiotic indications and dose, and extrapolation of dose information from other species. Vojnosanit Pregl, 1995 Jan-Feb, 52(1), 9 - 11 {Personal experience in the care of thoracic war injuries 1992-1993}; Maric V et al.; The aim of this paper was to clear some dilemmas about the surgical treatment of chest injuries . In the period April 1992-December 1993 in the General Hospital of Foca 160 chest injuries were treated (71 penetrating and 89 unpenetrating injuries) that was 10.2% of the total number of injuries . The explosive injuries were 53.8% of cases and 46.2% sclopetary injuries . Those injuries dominated in 93 wounded and in 57 cases the injuries were associated . The isolated injuries were in 40% and combined ones in 60% of cases . Thirty five thoracotomies and 40 thorax drainages were done while on the rest of the wounded only surgical wound treatment was performed . The active immunization and antibiotic prophylaxis were performed on the wounded . The infection problem was present in one operated person and lethality rate was 4.4% . The treatment results were good due to the appropriate organization of the surgical service and timely primary specialist aid as well as sufficient quantity of blood and timely and adequate surgical procedure. Rev Hosp Clin Fac Med Sao Paulo, 1995 Jan-Feb, 50(1), 58 - 62 {Risk factors for surgical wound infection development in head and neck cancer surgery}; Velasco E et al.; Over a period of 24 months, patients undergoing surgical procedures for head and neck cancer at the Cancer Hospital in Rio de Janeiro, Brazil were followed-up prospectively for identification of surgical wound risk factors . A total of 273 patients fulfilling the National Nosocomial Infection Surveillance (NNIS) surgical criteria completed the analysis . The overall wound infection rate was 25.3% . Of the 11 potential risk factors for postoperative wound infections analysed by stepwise multiple logistic regression, the five variables that were independent of each other and highly predictive were patient undergoing an operation classified as either contaminated or infected, a surgery lasting longer than 5 hours, an American Society of Anesthesiologist (ASA) preoperative assessment score of 4 and 5, age over 50 years and prior radiotherapy . The preoperative stay, antibiotic prophylaxis, surgical drains, preoperative nutritional status, sex and the presence of prior infection did not have an independent significant contribution to the risk of infection . This study reports specific risk factors for head and neck cancer surgeries and contributes substantially to the effectiveness of infection control strategies to prevent their occurrence in this high-risk group of patients. Ann Emerg Med, 1994 Dec, 24(6), 1115 - 8 Orbital emphysema: how common, how significant? Birrer RB, Robinson T, Papachristos P. STUDY OBJECTIVE: To describe the natural history of orbital emphysema and its management in the emergency setting . DESIGN: Retrospective medical record review . SETTING: Inner-city integrated hospital system (four divisions) including one Level I trauma center . PARTICIPANTS: All cases of orbital floor fracture and orbital emphysema from January 1, 1988, to December 31, 1993 . RESULTS: The average patient was aged 33 years, and the male-to-female ratio was 7 to 1 . Trauma was the underlying etiology in all patients . Seventy-four percent of patients required hospitalization, and 43% developed significant complications . Eighty-three percent were managed with antibiotics . Orbital emphysema was identified on conventional radiographs in 65% of cases . CONCLUSION: Identification of orbital emphysema in the ED should prompt a careful search for associated injury . Consultation should be sought in the presence of orbital or ocular injury . Antibiotic prophylaxis is not necessary for clean wounds. Eur J Clin Microbiol Infect Dis, 1994 Dec, 13(12), 1033 - 7 Prospective randomised comparison of single-dose versus multiple-dose cefuroxime for prophylaxis in coronary artery bypass grafting; Nooyen SM et al.; To assess the efficacy of single-dose antibiotic prophylaxis in coronary artery bypass grafting, 1,016 consecutive patients were prospectively randomized to receive either a single dose or a three-day course of cefuroxime . Nine patients (0.9%) died within seven days; no death was caused by infection . For various reasons 163 other patients were not evaluable . Therefore, 844 patients were evaluated . Patients in group A (n = 419) received 20 mg/kg cefuroxime intravenously at induction of anaesthesia; group B (n = 425) received the same dose followed by 750 mg t.i.d . for three consecutive days . Both groups were comparable regarding all risk factors . The efficacy of the prophylactic regimens was evaluated by comparison of occurrence of wound infection in both groups . No significant differences in wound infection were observed between the two treatment groups: sternal site infection in the single-dose prophylaxis group was 14% versus 13% in the three-day course group; donor site infection occurred in 38% versus 39% . It is concluded that in coronary artery bypass grafting a single dose of cefuroxime is as effective as a three-day course in the prevention of wound infection. J Laparoendosc Surg, 1994 Dec, 4(6), 375 - 8 A reevaluation of antibiotic prophylaxis in laparoscopic cholecystectomy; Frantzides CT et al.; Antibiotic prophylaxis for cholecystectomy, although somewhat controversial, is nevertheless a routine component of surgical care . With the advent of laparoscopic cholecystectomy, this routine practice of antibiotic prophylaxis needs to be reevaluated . The present investigation was undertaken to determine the incidence of postsurgical infection in patients receiving antibiotic prophylaxis compared with patients receiving chlorhexidine gluconate scrub the evening before surgery . A total of 448 patients were enrolled in the study . Thirty-two of these patients were excluded because of the presence of intrinsic risk factors for infection . Two hundred twenty-eight patients received antibiotic prophylaxis, and 188 patients were enrolled in the non-antibiotic group . A total of 14 infections occurred in the antibiotic prophylaxis group, whereas no infections occurred in the chlorhexidine group . These results suggest that meticulous antiseptic skin cleansing is sufficient for prevention of postsurgical infection following laparoscopic cholecystectomy . Antibiotic prophylaxis should be used only in those patients exhibiting intrinsic risk factors, such as cholecystitis. Unfallchirurg, 1994 Dec, 97(12), 625 - 8 {Cost effectiveness of preventive antibiotic administration for lowering risk of infection by 0.25%}; Albers BA et al.; Antibiotic prophylaxis in closed fractures is cost-effective if the risk of a deep infection is reduced by 0.25% . This control study was undertaken to assess the cost-effectiveness of prophylaxis of postoperative infections after surgical treatment of closed fractures . The costs for 16 patients with infections (8 with deep infections, 8 with superficial infections) were investigated and compared with the costs for 16 similar but non-infected patients with special reference to length of hospital stay, antibiotics and surgery . The data were collected from the trauma department of the University Hospital of the Free University in Amsterdam . Costs in the group of 8 patients with superficial wound infection were not substantially higher than those for their non-infected controls . The occurrence of a deep infection meant costs an average of DFL 35,224 higher than an uneventful postoperative course . On the basis of these results, antibiotic prophylaxis of postoperative wound infections is cost-effective if it reduces the risk of deep wound infections by about 0.25%. Ceska Gynekol, 1994 Dec, 59(6), 314 - 8 {Antibiotic prophylaxis in cesarean section}; Martan A et al.; Childbirth by Caesarean section is associated with 7-10x more complications than spontaneous childbirth {28} whereby the second place is held by infection . One of the possible ways how to prevent these infectious complications is antibiotic prophylaxis . Views on the latter still differ as regards selection of the antibiotic, its effectiveness, onset of administration, dosage, period of administration etc . Prophylaxis should meet the following demands; it should be aimed, of short-term character, bactericide and non-toxic-these demands are met by cephalosporins of the second generation {11} . The objective of the present work was to evaluate the contribution of the prophylactic administration of antibiotics, i.e . a cephalosporin of the second generation-Zinacef (Cefuroxime) . The group was formed by 23 women to whom a dose of Zinacef was administered after childbirth by Caesarean section and subsequently twice after 8-hour intervals (1.5-0.75-0.75 i.m.) . The control group (23 women) did not have this prophylaxis . In both groups the authors compared the indication of s.c., time of loss of amniotic fluid before s.c., results of cultivations from the cervix, vagina, amniotic fluid, lochiae and sutures . The authors evaluated the postoperative course where they were interested in infectious complications, the temperature curve, period of hospitalization, the necessity to administer another antibiotic or to proceed with the antibiotic therapy after the prophylactic dose . The results are clearly in favour of the prophylactic administration of antibiotics to the risk group of patients delivering by Caesarean section. Asia Oceania J Obstet Gynaecol, 1994 Dec, 20(4), 383 - 8 Pregnancy outcome and mitral valve prolapse; Chia YT et al.; Mitral valve prolapse (MVP) comprises a large proportion of obstetric cardiac problems and has a general prevalence of 4% . We examined the obstetric outcome of patients with MVP delivered between 1988-1991 at the National University Hospital, Singapore . During this interval, deliveries totalled 16,755 of which 85 (0.51%) had maternal cardiac disease . Of these, 28 (32.9%) had echocardiographic evidence of non-myxomatous MVP . Ten patients (37.5%) had demonstrable mitral regurgitation and 4 (14.3%) had benign ventricular ectopics . All patients remained well throughout pregnancy . Gestation at delivery and use of analgesia did not differ significantly from non-cardiac patients . However, the labour induction rate was twice the department average at 17.9% . Twenty-four (85.7%) patients achieved vaginal delivery and 4 (14.3%) patients were delivered abdominally . All babies were liveborn . Eight patients (28.6%) did not receive antibiotic prophylaxis during labour and postpartum period and remained afebrile . The role of antibiotics in this category of patients is discussed . Patients with MVP without myxomatous valve changes may expect excellent pregnancy outcome. Br J Surg, 1994 Dec, 81(12), 1747 - 51 Effect of ranitidine on soluble interleukin 2 receptors and CD8 molecules in surgical patients; Nielsen HJ et al.; The effect of perioperative immunomodulation with the H2-receptor antagonist ranitidine on postoperative changes in soluble interleukin (IL) 2 receptor and soluble CD8 levels was assessed in 24 patients undergoing major elective abdominal surgery . Eleven patients were randomized to receive intravenous ranitidine 100 mg twice daily for 4 days from skin incision, followed by oral ranitidine 150 mg twice daily for a further 5 days; 13 control patients received no ranitidine . Routine blood analysis, clinical data, duration of surgery, anaesthesia, antibiotic prophylaxis and perioperative blood transfusion were similar in the two groups . Serum concentrations of soluble IL-2 receptor and CD8 were measured before operation (day 0) and in the morning of postoperative days 1, 3 and 9 using commercial enzyme-linked immunosorbent assay kits . In patients treated with ranitidine, the serum level of soluble IL-2 receptor increased from day 0 to day 9 (P < 0.01); in control patients it decreased from day 0 to day 1, did not change significantly by day 3 and increased by day 9 . The change from day 0 to day 1 was significantly different between the two groups (P < 0.01) . Five of the 13 control patients developed postoperative infectious complications . No significant differences were shown in soluble CD8 concentration during the postoperative period . The postoperative change in soluble IL-2 receptor level may reflect lymphocyte activation status; ranitidine appears to promote activation of mainly CD4-positive lymphocytes since serum levels of CD8 were unchanged . Ranitidine may, therefore, improve immune function during major surgery. Am J Cardiol, 1994 Nov 15, 74(10), 1024 - 9 Cost-effectiveness of infective endocarditis prophylaxis for mitral valve prolapse with or without a mitral regurgitant murmur; Devereux RB et al.; To assess the cost-effectiveness of prevention of infective endocarditis (IE) and to calculate cost-effectiveness of currently recommended regimens in patients with mitral valve prolapse (MVP), data on risk of death, complications, and health-care use, and cumulative incremental health-care costs due to the occurrence of IE were combined with data on the prevalence and manifestations of MVP, estimated years of life lost, and efficacy of antibiotic prophylaxis . Effectiveness and costs of standard endocarditis prophylaxis regimens were calculated per IE case prevented and years of life saved . Under the most likely scenario, oral amoxicillin prophylaxis for all MVP patients would prevent 32 cases of IE per million dental procedures at approximate costs of $119,000 per prevented case and $21,000 per year of life saved . Limiting prophylaxis to patients with mitral murmurs would prevent 80 cases of IE per million procedures at costs of about $19,000 per prevented case and $3,000 per year of life saved . Erythromycin prophylaxis was slightly less expensive than amoxicillin per benefit because of lower cost and lack of drug anaphylaxis, whereas intravenous ampicillin was 7 to 30 times more costly . Sensitivity analyses suggested that erythromycin prophylaxis might be cost-saving under some scenarios, whereas intravenous ampicillin use might cause net loss of life . Thus, prevention with oral antibiotics of the cumulative morbidity and incremental health care costs due to IE in MVP patients is reasonably cost-effective for MVP patients with mitral murmurs. Orv Hetil, 1994 Nov 13, 135(46), 2523 - 6 {Experience in the management of patients with artificial heart valves (analysis of the material of the Békés County Cardiology Clinic)}; Orosz I et al.; Authors report of 152 patients, 146 of whom underwent single mitral (n = 70), single aortic (n = 64), double aortimitral (n = 17) and aortic-mitral-tricuspid (n = 1) valve replacement with mechanical prostheses . 6 patients received bioprostheses . The mean age was 55 years . Follow-up ranged from 1 to 23 years (mean 5.1 years) . The methodology of follow-up consisted patients examination in our office (at least twice a year) and questionnaire . Valve related complications were defined as paravalvular leak (6 cases), valve thrombosis (3 cases), thromboembolism (13 cases), anticoagulant-related hemorrhage (21 cases), infectious endocarditis (6 cases) . During care 14 patients died . The most common causes of death were left-ventricle insufficiency (n = 6), infectious endocarditis (n = 3), prosthetic valve thrombosis (n = 1), cerebral hemorrhage (n = 2) and sudden death (n = 2) . 138 patients (56 percent) are retired or invalid . Authors emphasize the importance of regular control and the significance of anticoagulant policy (in the target international normalized ratio to 2.5-3.5 and the provision of the antibiotic prophylaxis to avoid the late complications. Ann Acad Med Singapore, 1994 Nov, 23(6), 832 - 7 Deep-seated infective mediastinitis in post-coronary artery bypass grafting patients; Khoo AK et al.; The median sternotomy is the preferred incision for coronary artery bypass grafting (CABG) but its usage was initially associated with wound infection rates of up to 5% . The advent of antibiotic prophylaxis and improved surgical technique has improved these rates to 1% to 2% in most series . During a 5-year period from January 1988 to December 1992, 2193 patients underwent CABG in the Singapore General Hospital . Of these, 22 (1%) suffered postoperative wound infection . Thirteen (0.59%) of these had deep-seated mediastinitis which involved the osteocartilagenous tissues and retrosternal space and 9 (0.41%) had superficial wound infections . The superficial infections were successfully treated with dressings and delayed closure in all cases . The deep-seated infections, however, required in addition, antibiotic therapy, povidone iodine irrigation, repeated debridement and flap closure . In total, 6 muscle and myocutaneous flaps were used with good result . This paper reviews the Plastic Surgery unit's experience in treating this difficult postoperative complication. Cardiologia, 1994 Nov, 39(11), 777 - 82 {Infectious endocarditis in dentistry practice: recent controversies and modes of the use of antibiotic prophylaxis}; Nave C et al.; A survey by questionnaire to assess the daily practice of the antibiotic prophylaxis of infective endocarditis by physicians attending post-graduate schools of the Institutes of Oral Surgery and Stomatology (Group A n = 83) and Cardiology (Group B n = 46) of the Second University of Naples has been conducted . They were asked about dental procedure and cardiopathies that require prophylaxis for infective endocarditis, the relationship between infective endocarditis and rheumatic disease and the provision of antibiotic . Extraction of tooth and dental and oral surgery have been reported as the most risky procedures . Moreover provision of antibiotic prophylaxis was suggested to patients not at risk (pacemaker or coronary artery bypass), and was not suggested in high risk conditions (mitral valve prolapse with regurgitation and hypertrophic cardiomyopathy) . Most of the 50-60% practitioners usually start the prophylaxis 24-48 hours before the procedure and prolong it for 48-72 hours . These results underline the need for improvement of the knowledge for the antibiotic prophylaxis of infective endocarditis. Tidsskr Nor Laegeforen, 1994 Oct 30, 114(26), 3071 - 4 {Antibiotic prevention and occurrence of wound infections in heart surgery and vascular surgery}; Andersen KS et al.; Post-operative wound infections are serious complications in cardiovascular surgery . In order to examine the routines for prophylactic antibiotics and frequency of wound infections, questionnaires were sent to heart and vascular surgery units in Norway . In heart surgery, the sternal wound infection rate registered during stay in hospital varied between 0-1.2% . Seven clinics used cephalothin prophylaxis and one cloxacillin and penicillin . One clinic added vancomycin in the case of valvular surgery . The duration of prophylaxis varied from six hours to four days . In vascular surgery, superficial wound infection rates of 1.5-4.0%, and deep infection rates of 0.8-2.0%, were reported . Seven clinics used cephalothin and three cefuroxime as prophylaxis . The duration of prophylaxis varied from one single dose to several days . In conclusion, the reported infection rates indicate that the antibiotic prophylaxis regimens used help to provide satisfactory protection against wound infections. Semin Arthroplasty, 1994 Oct, 5(4), 153 - 9 The incidence of sepsis after total hip replacement arthroplasty; Nasser S; The incidence of surgically acquired infection during the first 2 years after total hip arthroplasty has decreased more than 10-fold since the introduction of the procedure . Advances in surgical procedures, sterile technique, and antibiotic prophylaxis have contributed to the current incidence of less than 0.5% in most major centers . At the present time, the majority of cases are not related to intra-operative contamination, but to late seeding of the joint from bacterial sources elsewhere in the body . Unfortunately, the overall infection rate (when late sepsis is included) remains at over 1%, and will likely increase as the life expectancy of implants is increased and patients are followed up longer . Given that late sepsis is now the most common type of infection involving total hip replacements, attempts to reduce the infection rate must be directed toward this patient population . Methods must include patient education to prevent sepsis, as well as to identify potentially dangerous infections early so they can be treated expeditiously . The development of a sound basis for antibiotic prophylaxis in cooperation with our medical and dental colleagues in this regard will be welcome . The prompt treatment of infections before they can spread to the prosthetic joint is essential for the continued well-being of the total hip arthroplasty patient. Minerva Chir, 1994 Sep, 49(9), 747 - 50 {Is surgery duration really a complication factor?}; Liverani A et al.; Of the numerous factors which may cause postoperative complications, some authors sustain that the durations of surgery plays a fundamentally important role . On the basis of a retrospective survey and analysis of cases operated, the authors observe that this factor, if considered alone, does not appear to cause a significant increase in septic complications, anastomotic dehiscence or mean postoperative hospital stay . Four homogeneous groups of patients were examined . Two groups included 100 who had undergone abdominal surgery which had not contaminated the peritoneal cavity . The other two groups included 150 patients who had undergone partially polluting colorectal surgery . The general preparation of patients was similar, with the exception of antibiotic prophylaxis . The mean time was calculated by analysing anesthesiological records . From an analysis of the most recent data, which are characterized by the absence of anastomotic dehiscence and operative mortality, it can be seen that the incidence of sepsis has fallen to 4% even if mean operating time was long . Mean postoperative hospital stay was also reduced from 17.3 days to 13 days . The prolongation of operating times does not depend on the complexity of surgery, intraoperative complications or the surgeon's inexperience, but may be the result of the meticulous implementation of procedures and steps taken to prevent complications which, given that they require extreme care and attention, necessarily contribute to increasing the duration of surgery . With regard to antibiotic prophylaxis and the duration of surgery, it was observed that if antibiotic prophylaxis preceded the operation by more than one hour, the incidence of sepsis was about 20% . If treatment coincided with the induction of anesthesia or the start of surgery, then the incidence of sepsis fell to 13%.(ABSTRACT TRUNCATED AT 250 WORDS) Gastrointest Endosc, 1994 Sep-Oct, 40(5), 538 - 43 Antibiotic prophylaxis in patients with infectious risk factors undergoing gastrointestinal endoscopic procedures; Zuckerman GR et al.; Consecutive patients undergoing gastrointestinal endoscopic procedures were prospectively evaluated for the presence of risk factors for the development of infectious complications that indicated a need for prophylactic antibiotics . Criteria for the evaluation of risk factors were based on (a) former American Heart Association guidelines, (b) current American Heart Association guidelines, and (c) American Society for Gastrointestinal Endoscopy guidelines . Four hundred eighty-six patients underwent 507 procedures . Risk factors for the development of endocarditis or other infectious complications were found in 74 (15%) of all patients during the study period . Cardiac conditions in 51 patients were the most frequently encountered risk factor (69% of risk factors, 10% of all patients), with mitral valve prolapse in 25 patients accounting for 49% of patients with cardiac risk factors and 5% of all patients . Of the patients with mitral valve prolapse, 7 (28%, 1.4% of all study patients) had associated valvular regurgitation . None of the patients with mitral valve prolapse knew whether or not they had associated valvular regurgitation, and if they had had a previous echocardiogram, they were unaware of the results . Only 0.8% of patients had a prosthetic heart valve . The most common non-cardiac risk factor was the presence of a prosthetic joint (9 of 486, 1.8%) . Of the 486 patients, 14 required antibiotic prophylaxis according to the above-mentioned guidelines . Six of the 14 patients were given either a non-recommended antibiotic or the wrong dose of a recommended antibiotic . Conclusions: (1) A decision regarding whether to administer antibiotic prophylaxis had to be made in 15% of patients undergoing endoscopy.(ABSTRACT TRUNCATED AT 250 WORDS) Ophthalmic Surg, 1994 Sep-Oct, 25(9), 597 - 600 The effect of silicone intubation on failure and infection rates after dacryocystorhinostomy; Walland MJ et al.; Of 388 cases of dacryocystorhinostomy eligible for silicone intubation, intubation was used in 238 (61%) and not used in 150 (39%) . The indications for intubation were canalicular disease or sac characteristics predisposing to failure . No significant difference was found in the rate of failure (.5 < P < 1.0) or soft-tissue infection (.25 < P < .5) for either primary or repeated surgery . Antibiotic prophylaxis did not alter these risks in relation to silicone intubation. J Reprod Med, 1994 Sep, 39(9), 707 - 10 Post-cesarean section febrile morbidity . Antibiotic prophylaxis in low-risk patients; Jakobi P et al.; A study was conducted to assess whether antibiotic prophylaxis in low-risk patients for post-cesarean febrile morbidity was beneficial and cost effective . In a randomized, prospective study, 167 patients received a single, 1-g dose of cefazolin before clamping of the cord, and 140 did not . In the group given prophylaxis the febrile morbidity and postoperative therapeutic antibiotic usage were significantly lower than in the group not given prophylaxis (9% vs . 17.9%, P = .035, and 6.5% vs . 20%, P < .001, respectively) . We conclude that single-dose cefazolin prophylaxis is both beneficial and cost effective, even in patients considered to be at low risk of post-cesarean febrile morbidity . Since the value of antibiotic prophylaxis in high-risk patients is accepted, universal antibiotic prophylaxis in every cesarean section case is suggested. Transfus Sci, 1994 Sep, 15(3), 243 - 54 Graft-versus-host disease and the development of late complications; Deeg HJ; Graft-versus-host disease (GVHD) in both its acute and chronic forms is a severe complication after allogeneic marrow transplantation . GVHD is associated with structural and functional defects in many organs and tissues . Severe immunoincompetence may result in frequent, often severe and at times fatal infections caused by various organisms . Prolonged antibiotic prophylaxis, and possibly immunoglobulin administration are beneficial . Ocular complications, airway and pulmonary damage, and oral or dental problems may cause severe morbidity . Despite aggressive management, a proportion of patients will succumb to these complications . Severe skin disease and joint contractures are currently seen less frequently, mostly due to early treatment of the disease . Psychosocial rehabilitation of patients with chronic GVHD is a demanding and protracted challenge and should be approached by a multidisciplinary team. Am J Med, 1994 Aug, 97(2), 169 - 75 Spontaneous bacterial peritonitis: an update on evaluation, management, and prevention; Bhuva M et al.; Spontaneous bacterial peritonitis (SBP) is a serious complication in patients with cirrhotic ascites . Greater understanding of the pathogenesis and risk factors for the development of SBP recently has improved our ability to prevent and treat the infection . The decreased threshold for performing diagnostic paracentesis in cirrhotic patients coupled with the use of non-nephrotoxic antibiotics have resulted in decreasing mortality rates for patients with SBP . Despite these advances, recurrence is common and often fatal . Thus, the prevention of SBP by diuresis and oral antibiotic prophylaxis has recently been studied . This review summarizes the recent developments in SBP, with an emphasis on patient management and prevention of SBP. Clin Infect Dis, 1994 Aug, 19(2), 279 - 86 Role of antibiotics in the treatment and prevention of acute and recurrent cholangitis; van den Hazel SJ et al.; Cholangitis is usually the consequence of a combination of factors: impairment of the flow of bile and bacterial colonization of the biliary tract . Although reestablishing biliary drainage is the mainstay of treatment, antibiotics play an important role in the management of cholangitis . In this review, the use of antibiotics for treatment, prophylaxis, and maintenance therapy is discussed . Antibiotics for the treatment of acute cholangitis should be given for 7-10 days in therapeutic dosages and may allow a more selective timing of further interventions . Antibiotic prophylaxis for cholangitis ought to be given as a single (high) dose shortly before surgical or nonsurgical manipulations of the biliary system . Patients with a compromised biliary system (e.g., on account of an endoprosthesis in situ or hepaticojejunostomy) who are prone to develop recurrent bouts of cholangitis may benefit from antibiotic maintenance therapy, given daily in lower-than-therapeutic dosages. J Hosp Infect, 1994 Aug, 27(4), 257 - 62 Computer registration of infections used to measure the effect of prophylactic antibiotics on postoperative infections following osteosynthesis in hip fractures; Aagaard H et al.; Continuous registration of operations and wound infections was used to demonstrate the effect of prophylactic antibiotics in hip fracture osteosynthesis . In order to monitor wound infections and other postoperative complications in an orthopaedic department, 2 years' data on 688 patients with hip fractures, were entered into a personal computer program . During 1990, there was no formal policy for antibiotic prophylaxis; during 1991 prophylactic cefuroxime was recommended for osteosynthesis of hip fractures . In 1990 56% of patients were given prophylaxis and in 1991 this rose to 79% . Overall, 68% of patients had prophylaxis . The overall rate of deep wound infections (DWI) was significantly lower in patients treated with prophylactic antibiotics (0.6%), compared with those without prophylaxis (4.6%) . Patients with DWI were admitted to the hospital for an average of 43.7 days, compared with 14.6 days for patients without complications . We recommend the use of prophylactic cefuroxime in hip fracture osteosynthesis . Computer registration of complications is a useful method for clinical quality control in an orthopaedic department. Pract Periodontics Aesthet Dent, 1994 Aug, 6(6), 25 - 32; quiz 34 Clinical issues in the prevention of dental-induced endocarditis and prosthetic joint infection; Wahl MJ; No issue in medicine or dentistry is the subject of more misunderstanding than the prevention of infective endocarditis and late prosthetic joint infections . To resolve some of the confusion, national medical groups have published guidelines for the prevention of these infections, including the use of antibiotic prophylaxis for certain dental procedures and certain at-risk patients . While these guidelines are helpful, there still are clinicians who either do not recommend antibiotics when indicated or recommend antibiotics without indication . An understanding of these issues helps to prevent not only the infections but also the adverse antibiotic effects and associated legal problems . The learning objective of this article is to to educate clinicians on the prevention of dental-induced endocarditis and prosthetic joint infections. Med Clin (Barc), 1994 Jul 9, 103(6), 201 - 4 {A randomized prospective study of antibiotic prophylaxis compared to lavage of the surgical wound in nonperforating appendicitis}; Badia JM et al.; BACKGROUND: There are many doubts as to the efficacy of systemic antibiotic prophylaxis versus the methods of local treatment in the prevention of infection of the contaminated surgical wound . A controlled prospective study was designed to compare the effectiveness of a combination of parenteral antibiotics with lavage with physiologic serum of the surgical wound to prevent infection of the postappendectomy wound . METHODS: The patients in group A (antibiotic, n = 70) received a sole preoperative dose of methronidazol and gentamicin while in those in group I (irrigation, n = 71) the wounds were irrigated with physiologic serum prior to and following closure of aponeurosis . The patients were controlled at one week and one month after the intervention . RESULTS: The global rate of infection was 9.3% . Six patients of group A and five of group I developed wound infection (p = 0.06), The age and length of the intervention were significantly higher in the infected patients (41 vs 23 years, p = 0.0001 and 53 vs 41 minutes, p = 0.03, respectively) . Intraperitoneal culture was positive in 70% of the patients who posteriorly developed wound infection, being positive in only 9.4% of the uninfected patients (p = 0.0001) . Eight of the infections (73%) were detected following discharge from hospital . The cost of prophylaxis in group A was seven-fold higher than that of group I . CONCLUSIONS: Lavage of the surgical wound with physiologic serum may be an effective, safe and inexpensive method to prevent infection of the wound following appendicectomy for unperforated appendicitis. Head Neck, 1994 Jul-Aug, 16(4), 307 - 12 Complications of craniofacial resection for tumors involving the anterior skull base; Kraus DH et al.; BACKGROUND . A consecutive series of 85 patients undergoing craniofacial resection for malignant tumors involving the anterior cranial base between 1974 and 1992 was reviewed . RESULTS . There were two (2%) postoperative deaths . Postoperative complications occurred in 33 (39%) patients . Local major complications occurred in 26 (31%) patients, local minor in 7 (8%), and systemic in 5 (6%) . More than one complication occurred in a number of patients . Bacterial contamination led to a significant proportion of local, septic complications . Repair of the skull base defect with a pedicled pericranial flap was unsatisfactory and was associated with an increased incidence of local major complications . A local major complication was associated with a dramatic lengthening of hospitalization . CONCLUSION . Future endeavors for prevention of complications should focus on antibiotic prophylaxis and reconstruction of the cranial base defect with better vascularized flaps. Injury, 1994 Jul, 25(5), 297 - 300 Factors affecting the outcome after proximal femoral fractures; Fox HJ et al.; One hundred and forty-two consecutive patients with proximal femoral fractures were audited prospectively over a 1-year period . Mobility, age and sex were recorded along with timing of surgery, complications, 'will to live', length of admission, mortality, mobility and housing requirements on discharge . Operative procedures were performed mostly by intermediate surgical staff, on night-time emergency lists shared with other specialties . Patients were treated on a ward with nursing staff levels less than the minimum recommended by professional bodies . Mean hospital stay was 31 days . In-patient mortality was 37 per cent in males and 5 per cent in females . It was possible to predict protracted hospital stay in 84 per cent, mortality in 84 per cent, mobility on discharge in 92 per cent and need for rehousing in 83 per cent of patients . Of the 10 principal variables that affected outcome, four could be influenced by hospital practice . These variables were associated with 1284 hospital bed days, which constituted 30 per cent of total bed occupancy . Fifty-five per cent of these were associated with non-medical delay to surgery, 25 per cent with wound infection or re-operation and 20 per cent with broken pressure areas . There would appear to be the potential to improve outcome in proximal femoral fractures by stabilizing fractures within 24 h, adopting measures additional to antibiotic prophylaxis to reduce infection and ensuring that patients do not develop pressure sores. Br J Surg, 1994 Jul, 81(7), 987 - 8 Administration of heparin and antibiotic prophylaxis; Avery CM et al.; An audit was performed to examine the time of administration of heparin and antibiotic prophylaxis to patients at risk of deep vein thrombosis, pulmonary embolism and post-operative wound infection . The records of 648 consecutive patients undergoing major surgery within a 12-month period were reviewed retrospectively . Heparin prophylaxis was given before surgery to only 30.9 per cent of patients undergoing elective procedures and in only 22.7 per cent of emergencies . Antibiotic prophylaxis was given before operation or at induction of anaesthesia to 82.1 per cent of patients undergoing elective procedures and in only 72.1 per cent of emergencies . It is concluded that administration of heparin and antibiotic prophylaxis is inadequate despite the provision of a written protocol. Am J Surg, 1994 Jun, 167(6), 601 - 3 Electrocautery used to create incisions does not increase wound infection rates; Groot G et al.; A prospective, randomized, blinded clinical trial was conducted to determine whether electrocautery as a means of creating abdominal or thoracic wounds would result in increased wound infection rates . Over a 15-month period, 492 consecutively studied patients were randomly placed into 1 of 2 groups: scalpel or electrocautery . There were no differences in age grouping, use of steroids, incidence of diabetes, number of days preoperative, operative time, use of preoperative antibiotic prophylaxis, use of drains, number of obese patients, or gender ratio . Wound infections developed in 38 of the 250 scalpel patients (15%) and in 30 of the 242 cautery patients (12%) . The use of electrocautery to create surgical wounds does not increase wound infection rates. Am J Gastroenterol, 1994 Jun, 89(6), 832 - 4 Pre-endoscopic antibiotics for the prevention of bacterial endocarditis: do we use them appropriately? Mogadam M, Malhotra SK, Jackson RA. OBJECTIVE: Because native valve bacterial endocarditis following endoscopic procedures is extremely rare, recent guidelines have discouraged indiscriminate use of pre-endoscopic antibiotics . The purpose of this study was to determine whether these guidelines have had an impact in prescribing antibiotic prophylaxis prior to endoscopic procedures . METHODS: All ambulatory endoscopic procedures carried out from January 1, 1992, through December 31, 1992, in a 412-bed community hospital in Northern Virginia were reviewed to identify cases receiving antibiotic prophylaxis . Inpatients, percutaneous gastrostomies, and ERCPs were not included, since many had received antibiotics for reasons other than endocarditis prophylaxis . We also surveyed a random sample of board certified gastroenterologists practicing at teaching hospitals in Northern Virginia and Washington, DC, to determine their practice patterns . We used the recent recommendations of the American Heart Association with minor modification as the "appropriate" guideline . RESULTS: Only 10% of physicians use antibiotic prophylaxis appropriately . Most physicians over-utilize antibiotics in a variety of settings that do not require such measures . Conversely, many physicians do not prescribe antibiotics for disorders which do require prophylaxis . CONCLUSION: Although "appropriate" guidelines for prophylactic antibiotics are available, and we have estimated the risk of acquiring native valve bacterial endocarditis following endoscopic procedures to be only 1 in 5-10 million procedures, the majority of physicians do not use prophylactic antibiotics appropriately. Surg Clin North Am, 1994 Jun, 74(3), 519 - 36 Wound infections; Sawyer RG et al.; Wound infections continue to be an important entity in terms of use of time and medical resources . Currently, the following risk factors are known to strongly predispose to wound infection: pre-existing medical illness, prolonged operative time, wound contamination, and contaminated or dirty wounds . Tissue level factors, including the local microenvironment, white cells, and cellular products that mediate inflammation, are important, and their manipulation holds promise for future therapies . For now, the judicious use of antibiotic prophylaxis and organized systems of wound surveillance are the most effective means to reduce the wound infection rate to its pathophysiologically attainable minimum. Pol Arch Med Wewn, 1994 Jun, 91(6), 483 - 90 Therapy of opportunistic infections; Drinovec J; Opportunistic infections are becoming really or apparently more frequent because of improved diagnostic techniques, increased age of the people in the developed world, better medical therapy, and higher number of patients living with transplanted organs and on immunosuppressive and glucocorticoid therapy, and also because of AIDS pandemic . Prevention of bacterial, fungal and viral infections includes classical preventive measures, surveillance, and education of patients and medical personnel . Vaccination is important especially to prevent viral diseases and also some bacterial ones . Routine antibiotic prophylaxis decreases some surgical infections . Meticulous follow-up of immunocompromised patients and specific anti-infective therapy saves the patients' lives in non-fatal diseases and prolongs the life in AIDS patients. J Am Dent Assoc, 1994 May, 125(5), 602 - 4, 606 Radiographic protocol for patients needing antibiotic prophylaxis: dental schools report no consensus; Jones GA et al.; A survey of current U.S . and Canadian dental school policies shows different opinions about whether intraoral radiographs are invasive procedures and would require antibiotic prophylaxis before treatment. Ann R Coll Surg Engl, 1994 May, 76(3), 147 - 9 Anticonvulsant and antibiotic prophylaxis in head injury; Dunn LT et al.; The evidence for and against the prophylactic use of anticonvulsants and antibiotics in head injury is reviewed . There is a lack of blinded placebo-controlled trials in this area . On balance there is no compelling evidence to support the use of either anticonvulsant or antibiotic prophylaxis in head injury, with the possible exception of antibiotic prophylaxis in compound depressed skull fractures and penetrating brain injuries. Acta Otorhinolaryngol Ital, 1994 May-Jun, 14(3), 235 - 44; discussion 301-5 {Basic elements of antibiotic prophylaxis: the rationale}; Marcucci L; In brief, the following study shows the necessity of chemoantibioticprophylaxis . This is to be carried out in operations where the risk of contamination is probable . The antibiotic is to be administered before the operation . Active drugs are used to confront foreseen pathogenics and ensure sufficient M.I.C . for the duration of the operation itself . Moreover, the results obtained from a polycentric research are underlined . The results show post-operative infections, with particular importance being placed on the antibiotics to be used as far as isolated germs are concerned. Presse Med, 1994 Apr 23, 23(16), 755 - 62 {Interventional neuroradiology . Drug treatment, monitoring and function tests}; Laurent A et al.; Specialized monitoring as well as function tests and drug therapy play an ever growing role in neuroradiological procedures . The particular route of administration and the territories involved in neuroradiology require special precautions . Anaesthesia must enable the operators to monitor the central nervous system since the patients must remain totally immobilized for several hours . Catheterization is made safe by careful asepsia and antibiotic prophylaxis and by preventing embolic events, particularly in neuro-cervico-facial interventions where an anticoagulant protocol is important . Arterial spasms can be prevented or cured with calcium inhibitors . The safety of the procedure itself is guaranteed by various function tests including sensitivity to ischaemia using anaesthetic barbiturates, controlled clampings or the lidocaine test . Undesirable effects of both emboli (e.g . toxicity of cyanoacrylate glue) and embolization (e.g . subsequent venous thrombosis) can be prevented by adapted anti-inflammatory drugs . Herein, we describe the routine monitoring conditions, drugs prescribed and function tests performed at the Therapeutic Angiography Department of the Lariboisiere Hospital, Paris. J Am Dent Assoc, 1994 Apr, 125(4), 429 - 36 Dental care and the prosthetic joint patient: a survey of orthopedic surgeons and general dentists; Shrout MK et al.; Orthopedic surgery and general dentistry residency program directors were surveyed about treatment considerations for dental patients with prosthetic joints . The majority believed dental diseases can affect joint prostheses and thought orthopedic surgeons should be consulted before dental treatment . Both groups recommended antibiotic prophylaxis for these patients. Oral Surg Oral Med Oral Pathol, 1994 Apr, 77(4), 341 - 3 Extraction of impacted third molars . A longitudinal prospective study on factors that affect postoperative recovery; Capuzzi P et al.; A longitudinal prospective trial was carried out on 146 patients to evaluate which factors can have an effect on postoperative recovery after extraction of impacted third molars or wisdom teeth . The following factors were considered: (1) age, (2) sex, (3) smoking habits, (4) use of the birth control pill, (5) previous history of pericoronitis, (6) degree of difficulty of the extraction, (7) expertise of the surgeon, (8) length of surgery, and (9) antibiotic prophylaxis . The following results were obtained and statistically significant differences were noted with respect to the pain in the context of (1) sex-males noted more pain on the 1st and 3rd days (p < 0.05) compared with females; (2) expertise of the surgeon--patients treated by surgeons with considerable or average expertise reported less pain on the first and third days (p < 0.05) compared with patients treated by surgeons with little expertise; and (3) age--a direct correlation was noted between age and pain (p < 0.05). J Chemother, 1994 Apr, 6 Suppl 2, 29 - 33 Cost-effectiveness of antibiotic prophylaxis of wound infection; Davey PG; The estimated cost of a wound infection can vary substantially between countries and is dependent not only on the type of surgery performed, but also on varying medical practices and differing accounting methods . We therefore devised a flexible method to compare the cost-effectiveness of different antibiotic prophylactic regimens . Taking into account drug cost and the difference in infection rate between regimens, for any given wound infection cost, the analysis can indicate which regimen is most appropriate. Semin Dermatol, 1994 Mar, 13(1), 27 - 34 Antibiotic prophylaxis; Haas AF; The appropriate use of antibiotic prophylaxis is confusing for all surgeons and it is certainly not straight-forward for dermatologists . There are no set guidelines which encompass skin surgery . This article reviews antibiotic prophylaxis both to prevent wound infections and to prevent endocarditis . Some of the issues and controversies surrounding the use of antibiotic prophylaxis are discussed, and guidelines are provided which should be of assistance to those who perform dermatologic surgery. Ophthalmology, 1994 Mar, 101(3), 608 - 11 Soft tissue infections after open lacrimal surgery; Walland MJ et al.; BACKGROUND: Soft tissue infection after open lacrimal surgery is said to be uncommon . This study was designed to determine the rate of infection and the effect of early antibiotic prophylaxis after open lacrimal surgery . METHODS: Two consecutive patient groups undergoing open lacrimal surgery were studied by review of case notes: the first group (152 patients) did not receive antibiotic prophylaxis after surgery, and the second group (128 patients) did . RESULTS: Infection occurred in 2 of the 128 patients who were given prophylactic antibiotics (1.6%) and in 12 of the 152 patients who were not (7.9%; P < 0.02) . Silicone intubation did not affect the infection rate, but patients who had sustained previous facial trauma did have a significantly increased rate of infection (P < 0.01) . CONCLUSIONS: Soft tissue infection occurs in approximately 8% of patients after open lacrimal surgery . A 5-fold reduction in this rate can be achieved with routine administration of antibiotics after surgery . The use of silicone tubing does not increase the risk of infection. J Thorac Cardiovasc Surg, 1994 Mar, 107(3), 896 - 900 Antibiotic prophylaxis in pulmonary surgery . A prospective randomized double-blind trial of flash cefuroxime versus forty-eight-hour cefuroxime; Bernard A et al.; The aim of this study was to determine whether a 48-hour antibiotic prophylaxis regimen with a second-generation cephalosporin was more efficient than a flash antibiotic prophylaxis regimen in pulmonary operations . All the included patients underwent lung resection . Patients with preoperative infection were excluded . All the patients were given cefuroxime (1.5 gm intravenously) at the time of the anesthetic induction and again 2 hours later . The randomization was done postoperatively: group 1 was given placebo intravenously (n = 102) and group 2 was given cefuroxime intravenously (n = 101), each every 6 hours for 48 hours . The overall rate of infections was 46% in the 48-hour cefuroxime group versus 65% in the flash group (p = 0.005) . The difference remained significant even after an adjustment with prognosis variables (p = 0.01) . Six empyemas (6%) in the flash group were noted versus one (1%) in the 48-hour group (p = 0.03) . From day 3 to day 8 after the operation, chest x-rays films were more often assessed as being normal in the flash group than in the 48-hour group (p = 0.005) . On day 3 after operation, white blood cell counts were 13,020 +/- 1,220 elements/mm3 in the flash group versus 11,620 +/- 1,220 elements/mm3 in the 48-hour group (p = 0.03) . A 48-hour antibiotic prophylaxis regimen decreases the rate of deep infections and particularly the rate of empyemas. Fertil Steril, 1994 Feb, 61(2), 243 - 7 Transcervical fallopian tube catheterization and recanalization for proximal tubal obstruction; Thompson KA et al.; OBJECTIVE: To evaluate further the safety and efficacy of selective ostial salpingography combined with transcervical wire recanalization for the diagnosis and treatment of proximal tubal obstruction . DESIGN: Prospective study . SETTING: Division of Reproductive Endocrinology and Department of Radiology at Harbor-University of California Los Angeles (UCLA) Medical Center, a tertiary care academic institution . PATIENTS: Twenty-eight infertile patients diagnosed with proximal tubal obstruction by hysterosalpingogram (HSG) or by chromopertubation at laparoscopy (total of 46 obstructed tubes) . INTERVENTIONS: After antibiotic prophylaxis and IV analgesia a conventional HSG was performed . If proximal tubal obstruction was confirmed, selective salpingography was done under fluoroscopic guidance . If proximal tubal obstruction was still present, wire recanalization using a new prototype cannula was then performed . If recanalization was successful, contrast media was injected to confirm tubal patency . MAIN OUTCOME MEASURES: Proximal tubal patency, complete tubal patency, pregnancies . RESULTS: Eleven of 46 tubes (23.9%) were patent by HSG . Ostial salpingography of the remaining 35 tubes revealed 6 patent tubes (13%) . Nine of the 29 obstructed tubes (31%) had successful wire recanalization, and 8 of these were patent distally . There were 4 intrauterine pregnancies (IUPs) and 1 ectopic pregnancy after recanalization and 2 IUPs after ostial salpingography . CONCLUSION: Selective salpingography should be considered at the time of an HSG showing proximal tubal obstruction . If indicated, wire recanalization can also be attempted . Selective ostial salpingography combined with wire recanalization is a safe and effective procedure for the diagnosis and treatment of PTO. Br J Surg, 1994 Feb, 81(2), 205 - 8 Impact of thymopentin on the incidence and severity of postoperative infection: a randomized controlled trial; Braga M et al.; The effectiveness of perioperative administration of thymopentin in preventing postoperative infection was evaluated in 206 patients with cancer (54 gastric, 152 colorectal) who underwent elective major surgery . Comparable subsets of patients were obtained with respect to age (proportion over 65 years) and nutritional status (patients with serum albumin level less than 30 milligrams or weight loss of 10 per cent or more of usual body-weight were considered to be malnourished) . Patients were then randomly assigned to a control group or to a group receiving thymopentin . All patients received perioperative short-term antibiotic prophylaxis and postoperative parenteral nutrition . Levels of CD3-, CD4- and CD8-positive T cell subsets were evaluated before and after surgery in 20 (ten elderly) patients from each group . The severity of postoperative infection was evaluated using a sepsis score . In elderly patients thymopentin prevented the postoperative drop in CD3- and CD4-positive T cell subpopulations that was observed in controls (P < 0.05d) . The postoperative infection rate was 17.5 per cent in the group given thymopentin and 24.3 per cent in controls (P not significant) . The mean (s.d.) sepsis score was 6.7 (3.1) in the group receiving thymopentin and 9.4 (5.8) in controls (P not significant) . Considering only elderly patients, the mean (s.d.) sepsis score was significantly lower in those treated with thymopentin than in control patients (6.9(2.1) versus 11.3(4.7)) . In conclusion, administration of thymopentin did not significantly reduce the postoperative infection rate . However, it prevented the drop in number of CD3- and CD4-positive T cells after operation and reduced the severity of postoperative infection in elderly patients. J Hosp Infect, 1994 Feb, 26(2), 133 - 6 A randomized prospective study of cefoxitin versus piperacillin in appendicectomy; Salam IM et al.; A randomized prospective study of antibiotic prophylaxis using a single dose of either cefoxitin or piperacillin is presented . The trial was carried out in Al Ain Hospital in the period 1989-1992 on 250 adult patients with non-perforated appendicitis . One group (124 patients) received 2 g cefoxitin, the other group (126 patients) 2 g piperacillin . Antibiotics were administered intravenously in the operating theatre immediately before surgery . Wound infection occurred in three patients, 2.4% of the cefoxitin group and in five patients (4%) of the second group (with no significant difference) . The commonest infecting organisms were Escherichia coli (5 out of 8) . Mean hospital stay for patients with wound infection was 15 days (range 12-21) compared with 6 days, (range 4-8) for non-infected cases . Prophylactic cefoxitin or piperacillin were each therefore similarly effective in minimizing the rate of wound infections in patients with non-perforated appendicitis. Arch Intern Med, 1994 Jan 24, 154(2), 137 - 44 Myths of dental-induced endocarditis; Wahl MJ; Although the latest (1990) American Heart Association recommendations for the prevention of bacterial endocarditis are by far the simplest yet, many physicians and dentists still do not comply with them . One of the reasons for this low compliance is that many clinicians rely on "myths" of dental-induced endocarditis prevention . To educate clinicians on endocarditis and its prevention, the myths of dental-induced endocarditis prevention are analyzed . Myth 1: For the most part, physicians and dentists are aware of and comply with American Heart Association guidelines on antibiotic prophylaxis for prevention of infective endocarditis . Myth 2: Most cases of bacterial endocarditis of oral origin are caused by dental procedures . Myth 3: American Heart Association antibiotic regimens give almost total protection against endocarditis after dental procedures . Myth 4: Antibiotics should be administered for any dental procedure that causes bleeding . Myth 5: If a patient was receiving recent antibiotic therapy before the dental procedure, there is no need to change the dose or the antibiotic before the dental procedure . Myth 6: The risk of endocarditis is almost always greater than the risk of antibiotic toxic effects . Myth 7: Parenteral antibiotics before dental procedures are preferable for most patients with high-risk conditions (eg, prosthetic heart valves and previous history of endocarditis) . Myth 8: All patients with mitral valve prolapse should routinely receive antibiotic prophylaxis for dental procedures . Myth 9: Clinicians should err on the positive side of antibiotic prophylaxis to prevent lawsuits. Knee Surg Sports Traumatol Arthrosc, 1994, 2(4), 250 - 4 Late follow-up results of operative ankle arthroscopy in patients under local anaesthesia; Valentin A et al.; The purpose of this study was to evaluate our long-term results of operative ankle arthroscopy in local anaesthesia, without tourniquet and antibiotic prophylaxis, and to see whether we could produce the same results other investigators had published using general anaesthesia . Between 1987 and 1992, 51 operative ankle arthroscopies were performed--all as out-patient procedures . Thirty-six patients had local anaesthesia, 7 had general anaesthesia, one had spinal anaesthesia and one had epidural anaesthesia . No prophylactic antibiotics were given . Indications for surgery were the same for patients who had local anaesthesia as for those who had the other types of anaesthesia . Nineteen patients had partial synovectomies, 8 had removals of osteophytes, 7 had debridements of osteochondral fractures, 6 had debridements of mild degenerative osteoarthritis, 3 had loose bodies and 2 had septic arthritis . After a mean of 3 years (range 1-8) the patients were sent a questionnaire . They were asked to rate activity level, pain, swelling, and limb stiffness on a four-grade scale pre- and postoperatively and to rate their total subjective improvement . They were also asked if they would undergo the same procedure again knowing the outcome of the procedure . Forty-five patients (88%) were available for follow-up . Thirty-four patients (76%) were improved, 10 remained unchanged, and one became worse after surgery . No correlation existed between preoperative symptom duration, sex, trauma, type of anaesthesia, postoperative diagnosis or type of surgical procedure . Minor complications occurred in 11% of patients . Eighty-four percent of the patients said they would undergo the same procedure again . The type of anaesthesia used did not influence this decision.(ABSTRACT TRUNCATED AT 250 WORDS) Minerva Chir, 1994 Jan-Feb, 49(1-2), 55 - 8 {Antibiotic prophylaxis with cefoxitin in acute nonperforated appendicitis}; Mecchia P et al.; The purpose of this investigation was to examine the safety and efficacy of cefoxitin in preoperative prophylaxis of acute nonperforated, appendicitis . During twelve consecutive months, a single i.v . dose of cefoxitin was administered to 151 patients suffering from nonperforated appendicitis . The study confirms the preoperative prophylaxis with cefoxitin used regularly with patients who are undergoing an appendicectomy. Eur J Gynaecol Oncol, 1994, 15(1), 14 - 8 Antibiotic prophylaxis in Wertheim-Meigs surgery . A single dose vs three doses; Cartana J et al.; A prospective, randomized study to compare the prophylactic efficacy of a single dose of piperacillin with that of a three doses, was carried out with patients undergoing Wertheim-Meigs surgery . The results demonstrate that in this case three doses of piperacillin have a higher efficacy than one dose in the prevention of febrile complications and post-operative infections. J Orthop Trauma, 1994, 8(1), 64 - 6 Double-blind randomized prospective study of the efficacy of antibiotic prophylaxis for open reduction and internal fixation of closed ankle fractures; Paiement GD et al.; Antibioprophylaxis has been proven to be efficient for some orthopaedic procedures . However, its efficacy for clean limited procedures with metallic implants is not clear . One hundred twenty-two closed ankle fracture patients undergoing open reduction and internal fixation were randomized, double-blindly, to receive either cephalothin (1 g i.v . every 6 h x four doses) or a placebo starting before tourniquet application . Mean trauma-surgery delay was 30.2 h, and average tourniquet duration was 65.4 min . Four patients (three of 62 on placebo and one