J Urol, 1991 Dec, 146(6), 1594 - 5 Nonsurgical management of primary vesicoureteral reflux in complete ureteral duplication: is it justified? Peppas DS, Skoog SJ, Canning DA, Belman AB. We reviewed the treatment of 56 children with vesicoureteral reflux and complete duplication of the collecting system, including 14 who had complete bilateral duplication . A total of 70 refluxing duplicated systems was analyzed . Of the patients 18% demonstrated spontaneous resolution of reflux within 42 months, 23% are currently stable on prophylactic antibiotics and 57.1% underwent surgical correction . Spontaneous resolution of reflux occurred in 58% of the children with grades I to III/V reflux . In comparing the group with reflux and duplication to a group with reflux into single systems, we conclude that the patients with duplication and lower grades of reflux can be managed nonoperatively, while infection is prevented with antibiotic prophylaxis. J Cardiothorac Vasc Anesth, 1991 Dec, 5(6), 574 - 6 Adverse reactions to vancomycin prophylaxis in cardiac surgery; Valero R et al.; Several adverse effects of vancomycin have been reported . The aim of this study was to assess the incidence of adverse responses to antibiotic prophylaxis with vancomycin in cardiac surgical patients . Prospectively, 116 consecutive patients (106 adults and 10 children) undergoing cardiac surgical procedures in this institution from January to June 1990 were studied . After the anesthetic induction, vancomycin, 1 g in adults and 10 mg/kg in children, was intravenously administered over 30 minutes . The infusion rate was slowed if any adverse effect was observed . As a control group, 10 similar patients were evaluated during the same period of 30 minutes after anesthetic induction but prior to vancomycin administration and surgical stimulation . Thirty-one patients (26.72%) developed an adverse effect, mainly hypotension (29 patients, 25%), which was considered severe in 15 patients (12.93%) . Seven patients (6.03%) developed a maculopapular erythema that was associated with hypotension (Red-Man's syndrome) in 5 patients and with bronchospasm in 1 patient . The incidence of adverse reactions in children (20%) was similar to the overall incidence . Only 1 patient in the control group (10%) developed hypotension during the period studied . The incidence of adverse reactions was not related to age, body weight, vancomycin dose administered per kilogram body weight, type of surgical procedure, or associated disease . Mean duration of the infusion was similar in patients with and without adverse responses (34.60 +/- 12.41 minutes and 37.38 +/- 14.55 minutes, respectively) . It is concluded that perioperative prophylaxis with vancomycin in cardiac surgery produces a high and unpredictable risk of significant hypotension. Fam Pract Res J, 1991 Dec, 11(4), 371 - 8 Recurrent otitis media: a cost-utility analysis of simulated treatment using tympanostomy tubes vs antibiotic prophylaxis; Bisonni RS et al.; Using a cost-utility analysis, the effectiveness of tympanostomy tubes was compared to that of antibiotic chemoprophylaxis in young patients with recurrent otitis media . The tympanostomy approach (T-tubes) consisted of placement of a polyethylene grommet in the tympanic membrane, with systemic and local antibiotics administered for one week . The chemoprophylaxis approach consisted of antibiotics in full doses for seven to ten days, followed by continuous antibiotic chemoprophylaxis for six months . Because the T-tube strategy under the model assumptions was more expensive ($396.44 vs $281.30) and yielded slightly less benefit (net utility of .9325 vs . .9476 for initial antibiotic therapy), the chemoprophylaxis option was preferred . We conclude that the initial treatment for recurrent otitis media should consist of acute antibiotics followed by chemoprophylaxis, with T-tubes reserved for treatment failure . Extreme changes in the baseline probabilities of cure or recurrence with antibiotic therapy or in the cost of antibiotic therapy or tympanostomy surgery were required to alter this conclusion . Varying therapy preference (utility) values did not materially alter the conclusions. Neurosurgery, 1991 Dec, 29(6), 822 - 6 Cerebrospinal fluid shunting for hydrocephalus in the adult: factors related to shunt revision; Puca A et al.; Cerebrospinal fluid shunting procedures are widely employed in the treatment of hydrocephalus and other disturbances of the dynamics of cerebrospinal fluid . In spite of its popularity, this operation frequently requires surgical revision . A retrospective analysis of a series of 356 adults who underwent the insertion of a cerebrospinal fluid shunt between January 1970 and December 1988 was performed . The incidence of revision was analyzed, and an attempt was made to identify possible causal factors . The overall incidence of surgical revisions was 28.65%; the number of revisions in the same patient ranged between one and eight . The most frequent causes of revision were distal malposition, obstruction, and infection . A statistically significant difference (P less than 0.05) was found in both the risk of revision in patients who had undergone previous operations and those who had not and in the incidence of revision before and after January 1985 . Meticulous surgical technique as well as perioperative antibiotic prophylaxis appear responsible for the latter . The differences in the incidence of revision among patients treated with different types of shunts and valves, though remarkable, is not statistically significant. Klin Wochenschr, 1991 Nov 26, 69(19), 863 - 6 Prophylaxis of traveler's diarrhea in Egypt: results of a double blind controlled study; Raedsch R et al.; Diarrhea represents the most frequent health problem of Western tourists visiting subtropical and tropical areas . Antibiotic prophylaxis has been suggested by some authors but may not be generally advisable because of adverse drug effects . In the present study we investigated the prophylaxis of traveler's diarrhea using a combination of tannalbuminate and ethacridin-lactate . During a 16-day cruise in Egypt, 77 tourists were assigned to either placebo or prophylactic doses of tannalbuminate (500 mg) and ethacridin-lactate (50 mg), 1 tbl . b.i.d., in a randomized double-blind fashion . The number of bowel movements, consistency of stools, and clinical symptoms like nausea, abdominal cramps, vomiting, and fever were monitored daily . In the placebo group (n = 43) 35 tourists developed diarrhea (81.4%), whereas in the verum group (n = 34) only 18 tourists (52.9%) had diarrhea (p less than 0.0125) . In the travelers receiving verum and developing diarrhea the clinical symptoms were less pronounced than in the placebo group . These results demonstrate that the events of traveler's diarrhea may be reduced; moreover, symptoms are attenuated by medical prophylaxis with tannalbuminate and ethacridin-lactate. Am J Surg, 1991 Nov, 162(5), 438 - 41 Local gentamicin application for perineal wound healing following abdominoperineal rectum excision; Rosen HR et al.; A major complication of abdominoperineal rectum excision for rectal or anal carcinoma is local wound infection . The main reason for this infection is that systemically administered antibiotic prophylaxis does not reach sufficiently high concentrations of antibiotic in the tissue of the sacroperineal wound . Since gentamicin-polymethylmethacrylate (PMMA) in the form of chains of beads has been confirmed as a useful tool in the treatment of local infection in bone and soft tissue surgery, we have evaluated its effect on the abdominoperineal rectum excision in a prospective, randomized trial . Forty-four patients with rectal or anal carcinoma entered the study . Only patients with stage Dukes D were excluded from the trial . Following randomized selection, the patients were treated either with local gentamicin and drainage (Group A) or drainage alone (Group B), using the Lloyd-Davies procedure . The two groups were comparable regarding age, sex, tumor stage and level, and risk factors predisposing for an infectious complication (anemia, nutritional status, blood transfusion) . The postoperative mortality rate was 0% in both series . Analysis of local perineal wound healing revealed a statistically significant higher percentage of primary wound healing in Group A than in Group B (87% versus 46%; p less than 0.01) . This led to a significantly shorter hospitalization period for patients in Group A (p less than 0.01) . Gentamicin-PMMA chains have been demonstrated to exert a favorable effect on local wound healing and the postoperative outcome of patients with abdominoperineal rectum excision. J Laryngol Otol, 1991 Nov, 105(11), 916 - 7 Mastoidectomy packs: Xeroform or BIPP? Chevretton EB, McRae RD, Booth JB. A retrospective study comparing adverse events using bismuth iodoform paraffin paste (BIPP) and Xeroform as dressings for newly fashioned mastoid cavities after mastoidectomy was undertaken . There were 20 patients in each group . Adverse events were defined as offensive packs, mastoid cavity infections and systemic signs of infection . There were no adverse events using BIPP packs whether or not prophylactic antibiotics were used . Xeroform packs were associated with a significantly higher incidence of adverse events compared to BIPP when using no antibiotic prophylaxis (P less than 0.005) or amoxycillin (P less than 0.005) . Adverse events with Xeroform packs were abolished using ciprofloxacin and metronidazole prophylaxis . We conclude that BIPP is the mastoid dressing of choice. Infection, 1991 Nov-Dec, 19(6), 456 - 8 Antibiotic prophylaxis in biliary surgery; Mascarenhas AF; Early studies in which a higher incidence of wound infection and septic complications in biliary surgery was found demonstrated the need for antibiotic prophylaxis . In two studies, one retrospective and one prospective, the role of prophylactic antibiotics in biliary surgery was studied in "at risk" and "no risk" groups of patients . Twenty-eight percent of "no risk" patients had a positive bile culture . It was concluded that a single dose of 1 g cefotaxime, administered upon induction of anaesthesia, is a safe and effective prophylactic regimen in biliary surgery. Infection, 1991 Nov-Dec, 19(6), 391 - 4 Use of perioperative antibiotic prophylaxis in selected surgical procedures--results of a survey in 889 surgical departments in German hospitals; Kappstein I et al.; In 1989, a survey on perioperative antibiotic prophylaxis was conducted in 2,739 surgical (general surgical, orthopedic, traumatologic, and cardiothoracic) departments of German hospitals . In all, 889 (32.5%) questionnaries were returned . Regarding the choice of antibiotic and the duration of prophylaxis the respective rates of correct statements were as follows: 32.6% and 55.0% in gastric surgery, 29.5% and 42.9% in colorectal surgery, 38.3% and 50.5% in biliary tract surgery, 81.0% and 41.0% in total hip replacement, 91.3% and 0% in heart valve replacement, and 95.7% and 0% in coronary artery bypass graft . Altogether, the choice of antibiotic and the duration of prophylaxis were correct in only 49.1% and 43.3%, respectively. Geburtshilfe Frauenheilkd, 1991 Nov, 51(11), 905 - 14 {Effect of surgical procedure and adjuvant therapy on cosmetic results after breast conserving therapy in breast cancer}; Engel K et al.; A total of 207 patients undergoing breast conserving therapy (BCT, excision of tumour with clear margins, radiotherapy, sequential chemotherapy for node-positive patients) were clinically evaluated after a median follow-up of 11 months (min 2/max 22) . The aim of the study was to analyse the impact of various individual factors, surgical techniques and adjuvant therapies on the cosmetic result . In 85.7% of all cases the objective outcome was satisfactory (very good: 48.8%, good: 36.9%) and in 14.3% unsatisfactory (fair: 13%, poor: 1.3%) . Objective cosmetic results were rated significantly better by the patients (p = 0.01), in cases with biopsy weights of greater than 100 grms . (large/hyperplastic breast, p = 0.01), non-reconstructed mammary glands (simply closure of subcutis and skin, p = 0.01), non suction drainage of the breast (p - 0.04) and normal healing of the wound (p = 0.01) . There was a trend towards better cosmetic results in the premenopause in patients with a tumour localised in the upper outer quadrant, in cases of a curvilinear as compared to a radial incision (upper/outer quadrant) and in small or average-sized breasts with biopsy weights of less than 50 grms . Cosmetic results were unaffected by a "two-step" procedure, standardised postoperative radiotherapy (45-55 Gy) and by sequential chemotherapy (3x CHT/radiotherapy/3x CHT) . Unsatisfactory cosmetic short-term results should primarily be regarded as a surgical complication of BCT . Results can be improved by taking into consideration the importance of the relation of breast/biopsy-weight as well as standardising the operative procedure (curvilinear incision, closure of subcutis and skin, drainage without suction, perioperative antibiotic prophylaxis). JPEN J Parenter Enteral Nutr, 1991 Nov-Dec, 15(6), 619 - 24 Evaluation of the predictive performance of nutritional indicators by receiver-operating characteristic curve analysis; Braga M et al.; Four hundred twenty-two cancer patients who underwent major surgery were studied . At admission, nutritional status was evaluated in all patients by assessing serum albumin (SA), total iron-binding capacity (TIBC), total lymphocyte count (TLC), serum cholinesterase activity (CHE), and weight loss (WL) . All patients received perioperative short-term antibiotic prophylaxis and postoperative total parenteral nutrition . Prognostic ability of nutritional indicators was assessed by receiver-operating characteristic (ROC) curve analysis . The area beneath the ROC curve (Az) is an index of predictor performance when its value ranges from 0.5 (chance performance) to 1 (perfect prediction) . Specificity, sensitivity, Youden index, and predictive values were determined for each nutritional parameter within a wide range of potential threshold values . Postoperative septic complications were observed in 85 (20.14%) patients . The Az values for the considered nutritional parameters ranged from 0.52 to 0.57 and that showed the low predictive ability of the parameters . When sensitivity and specificity for each nutritional parameter were examined at different thresholds, a clearly more predictive cutpoint was not observed, but ranges of values with a similar predictivity were observed . Significant ranges of predictivity were found for SA (33 to 35 g/L), for TIBC (2200 to 2300 micrograms/L), for TLC (2100 to 2200 million/L), for CHE (1700 to 1900 U/L), and for WL (7% to 12%) . The higher values of Youden index were as follows: 1.183 for WL (cutoff 11%), 1.150 for TLC (cutoff 2100 million/L), and 1.145 for SA (cutoff 35 g/L) . In conclusion, ROC curve analysis showed that the nutritional parameters had a low predictive ability.(ABSTRACT TRUNCATED AT 250 WORDS) Ann R Coll Surg Engl, 1991 Nov, 73(6), 348 - 51 Antibiotic prophylaxis in penetrating injuries of the chest; Demetriades D et al.; Most prospective studies recommend antibiotic prophylaxis whilst a thoracostomy tube is in place or even longer . We conducted a randomised study of 188 patients with penetrating chest injuries requiring a chest drain . Of these patients, 95 received a single dose of ampicillin before insertion of the chest tube, the remaining 93 patients received additional antibiotic prophylaxis for as long as the drain was in place . The incidence of intrathoracic sepsis (pneumonia or empyema) was 3.1% and 3.2%, respectively . It is concluded that single-dose prophylaxis in penetrating chest trauma is as effective as prolonged prophylaxis . The importance of chest physiotherapy immediately after the drain insertion and of early removal of the drain is stressed . The role of various possible risk factors in the development of sepsis is discussed. Br J Oral Maxillofac Surg, 1991 Oct, 29(5), 341 - 6 Prophylactic antibiotics for patients with artificial joints undergoing oral and dental surgery: necessary or not? Field EA, Martin MV. Prophylactic antibiotic cover for certain oral and dental procedures for patients with artificial joints is a controversial issue . This paper examines the evidence supporting the use of antibiotic cover and concludes that routinely, for the majority of patients with artificial joints, it is not justified . Certain medically compromised patients with artificial joints have a slightly increased risk of infection and, under these circumstances, antibiotic prophylaxis may be justified . The antibiotic recommended for this group is cephradine or in the case of penicillin allergy, clindamycin . Preoperative dental fitness is mandatory for all patients who are to receive artificial joints . This information will be of interest to the oral and maxillofacial surgeon in his own clinical practice, and when giving advice to local general dental practitioners. Minerva Ginecol, 1991 Sep, 43(9), 409 - 11 {Antibiotic prophylaxis in obstetric surgery . Experience with a sulbactam-ampicillin combination}; Alba E et al.; Antibiotic prophylaxis reduces the incidence of infections after some types of surgical interventions; in Obstetrics it can prevent infections in high risk situations . Infections can occur in particular situations, even in cesarean sections (CS) at low risk . The incidence of puerperal endometritis is variable in literature, while the incidence of pelvic or surgical wound infections is 3.8% in elective CS with respect to 7.5% in emergency CS . This study verifies the efficacy of the sulbactam-ampicillin association (Unasyn, Pfizer) in the prophylaxis of all cesarean sections, complicated or not . Unasyn was administrated one hour prior to CS and 8 and 16 hours after CS in 162 patients . Therapy was continued in 8 cases because of high risk for infection . The evaluation of the efficacy of the drug was based on clinical criteria . There were no complications or fever recorded and no toxic or allergic reactions occurred . Antibiotic prophylaxis is recommended for all patients undergoing CS. Arch Dermatol, 1991 Sep, 127(9), 1357 - 60 Antibiotic prophylaxis of wound infections in skin surgery; Bencini PL et al.; A controlled prospective study of 2165 outpatients undergoing skin surgery was performed to evaluate the utility and the effects of several antibiotic schedules for prophylaxis of wound infections . The patients were divided into four groups . Twenty-three of the 541 group A patients, given no antibiotics, had wound infections . Eight of the 542 group B patients, given systemic antibiotics from immediately after surgery until the third day, had wound infections . Four of the 540 group C patients, treated only with local sterile antibiotic powder sprinkled into the wound during surgery, had wound infections develop, and only one infection occurred in the 542 group D patients given systemic antibiotics from 2 days before surgery until the second day after surgery . This last schedule was the best for prophylaxis of wound infections in contamination-prone regions . Local antibiotic administration is a simple method for prevention of infections in routine skin surgery. Postgrad Med, 1991 Sep 1, 90(3), 99 - 106 Staving off acute otitis media . When is prophylaxis with antibiotics desirable? Bergus GR. Acute otitis media affects most young children and is the condition for which children are most frequently treated with antibiotics . A pattern of recurrent acute ear infections develops in some children and is a source of frustration for parents and physicians . Recurrent episodes can exacerbate asthma or other underlying medical problems, and long-term effects can include chronic otitis media with permanent middle-ear injury and, possibly, delay in psychomotor and language development . Antibiotic prophylaxis can reduce the number of episodes of acute otitis media in children at high risk for recurrent infection . There is no perfect antibiotic to prevent acute otitis media . However, the risks associated with the drugs described in this article are low . Prophylaxis with antibiotics does not prevent all episodes of acute otitis media but can reduce the number of episodes by 50%. Am J Emerg Med, 1991 Sep, 9(5), 413 - 5 Fishhook injuries: a prospective evaluation; Doser C et al.; A prospective study was conducted involving 100 nonrandomized, consecutive patients who suffered fishhook injury during the summer of 1990 in Alaska . Time of injury prior to admission to the emergency department, location of fishhook, method of removal, wound care, systemic antibiotic prophylaxis, anesthetic, tetanus immunization status, fishhook size, and complication rate were evaluated . Results of this study suggest that most fishhook injuries involve the hands or head and that postremoval wound care including oral antibiotic therapy may not be critical . Local anesthetics and simple removal techniques are adequate for nearly all fishhook injuries . Routine systemic antibiotic prophylaxis is not necessary for uncomplicated soft tissue injury due to fishhooks not involving cartilage or tendons. Rev Hosp Clin Fac Med Sao Paulo, 1991 Sep-Oct, 46(5), 215 - 8 {Risk factors for infection after heart surgery}; Pasternak J et al.; A consecutive series of 84 patients operated by the same surgical team was studied in order to identify risk factors for post operative infection . Female sex and longer antibiotic prophylaxis were significantly associated with higher infection risk; the risk of dying of infection was more pronounced with infected men than with infected women . Diabetes, undernutrition, low albumin serum level in the first or in the fifth day post-operatively, asthma or pneumonia in the past did not correlate with infectious risk, as well as use of antibiotic before surgery or longer hospitalization before surgery. Rev Infect Dis, 1991 Sep-Oct, 13 Suppl 10, S810 - 4 Methodologic aspects of clinical studies of perioperative antibiotic prophylaxis; Platt R; Many issues affect the design, conduct, and analysis of clinical evaluations of perioperative antibiotic prophylaxis . The most important of these are the selection of appropriate procedures for evaluation, the choice of meaningful outcomes, the comparison of outcomes among groups of patients who are really comparable to one another, the unbiased assessment of outcomes, the assessment of a number of patients sufficient to provide adequate statistical power for the detection of meaningful differences, and the generalizing of results . In evaluating perioperative prophylaxis, investigators often strive to identify small absolute differences among the risks of infections with different prophylactic regimens . For many specific procedures and drug regimens, such evaluations are limited by the difficulty of studying a sufficient number of individuals . Although randomized clinical trials are the standard for clinical evaluation, observational data may also prove useful under some circumstances. J Hosp Infect, 1991 Sep, 19 Suppl C, 59 - 64 The value of oral antibiotic prophylaxis in biliary tract surgery; McArdle CS et al.; In this study the relationship between the presence or absence of organisms in bile or on closing wound swabs and the subsequent development of wound sepsis was confirmed . There was no significant difference in the incidence of septic complications among three treatment groups in which cefuroxime (iv) and ciprofloxacin (iv or oral) were administered . Consideration of costs attributable to the choice of antibiotic prophylaxis suggests that oral ciprofloxacin in biliary tract surgery may offer significant advantages. Obstet Gynecol, 1991 Aug, 78(2), 209 - 12 Morbidity and vaginal tubal cautery: a report and review; Smith RP et al.; Vaginal tubal sterilization was once the procedure of choice for interval sterilization . This technique fell out of favor in part because of a perceived increase in morbidity over the evolving laparoscopic techniques . Complications should be minimized by the advent of routine antibiotic prophylaxis and improved operating techniques that allow shorter procedure times . We retrospectively reviewed 240 vaginal tubal sterilization procedures performed by a single physician . Long-term follow-up (more than 5 years) was available in over half the study group (52%) . Half of all operations were completed in 12 minutes or less, with an average time of 14.5 minutes . The planned vaginal procedure was completed in all but two cases, both of which required laparotomy secondary to dense adhesions . Median estimated blood loss was 20 mL . No postoperative infection was encountered . These data suggest that vaginal tubal sterilization may still be a safe alternative for interval sterilization. G Chir, 1991 Aug-Sep, 12(8-9), 462 - 6 {Infections in surgery}; Tremiterra S et al.; In this paper the authors review current concepts on surgical infections . Topics covered are: hospital-acquired surgical infections, prognostic indexes, antibiotic prophylaxis, surveillance and control measures. Eur J Clin Microbiol Infect Dis, 1991 Aug, 10(8), 625 - 9 Analysis of Escherichia coli isolates from subjects with travellers' diarrhoea using DNA probes and serotyping; Rademaker CM et al.; Escherichia coli isolated from faeces of 54 healthy volunteers who visited Tunisia for eight days were examined . These volunteers participated in a randomized double-blind placebo-controlled study to establish whether ciprofloxacin could prevent travellers' diarrhoea . Escherichia coli strains isolated before travel, during episodes of travellers' diarrhoea, immediately after return and five weeks after return were serotyped and tested for the presence of virulence genes indicating diarrheogenic properties by hybridization with a set of four non-radioactively labelled DNA probes . Subjects receiving ciprofloxacin prophylactically to prevent travellers' diarrhoea were asymptomatic and no Escherichia coli could be cultured shortly after return home . Sixty-four percent of subjects (18/28) who did not receive antibiotic prophylaxis suffered from travellers' diarrhoea . Hybridization tests detected 8 enterotoxigenic Escherichia coli strains producing heat stable toxin, 13 enterotoxigenic strains producing heat labile toxin and 10 strains which produced both heat labile and stable toxin . Of the 31 probe positive strains, 29 (94%) were cultured from 11 volunteers with travellers' diarrhoea . A bacterial cause was thus determined in 61% of the volunteers who experienced travellers' diarrhoea. Ophthalmic Surg, 1991 Jul, 22(7), 409 - 11 Isolated fractures of the orbital floor: risk of infection and the role of antibiotic prophylaxis; Westfall CT et al.; The application of antibiotic prophylaxis to fractures of the orbital floor is controversial . The incidence of infection following this injury remains undefined . We report a case of orbital cellulitis following orbital floor fracture, and attempt to define guidelines for the appropriate use of antibiotics in the setting of an isolated blowout fracture. Surg Gynecol Obstet, 1991 Jul, 173(1), 25 - 8 Selective antibiotic prophylaxis in biliary tract operations; Kasholm-Tengve B; A prospective study of 397 patients with primary biliary operations performed for benign disease included a perioperative culture of the bile . Two main groups of patients in whom bacteria in the bile and, thus, probably increased risk postoperative infection was common, are patients undergoing emergency operation (60 per cent bacteria in the bile, as compared with 22 per cent in those with elective operations) and patients with a history of acute cholecystitis or pancreatitis, or both, or jaundice (49 per cent bacteria in the bile with a positive history as compared with 11 per cent without) . The rate of infection was 2.8 per cent in high-risk groups, as compared with 0.6 per cent in patients undergoing elective operative procedures with no history of acute cholecystitis, pancreatitis or jaundice . Thus, antibiotics can probably be reserved for those patients who had emergency surgical treatment and for those with elective operations and a history of acute cholecystitis, pancreatitis or jaundice . In addition, antibiotic prophylaxis might be indicated for all patients who are 75 years of age or older, as bacteria in the bile seems to be common in this age group even without a history of the aforementioned complications. Radiology, 1991 Jun, 179(3), 843 - 7 Percutaneous nephrostomy tube placement: an outpatient procedure? Cochran ST, Barbaric ZL, Lee JJ, Kashfian P. The authors report their experience with 56 percutaneous nephrostomies (PCNs) performed on an outpatient basis on 55 patients . Complications included pain that required use of parenteral medication in four patients, bleeding in three that resolved spontaneously, and shaking chills or fever in 12 . This last complication, considered to be a sign of sepsis and treated with antibiotics, occurred more frequently than the 1.4%-4.5% infectious complication rate reported in the literature . Antibiotic use during and after PCN significantly decreased the likelihood of sepsis . In the high-risk group, antibiotic administration during and after PCN decreased the risk of developing signs of sepsis from 50% to 9% . On the basis of the authors' results and the findings in the literature about antibiotic prophylaxis, guidelines are recommended to improve the safety of PCN as an outpatient procedure . In the majority of instances PCN should still be considered to be more safely performed as an inpatient procedure at this time. West Indian Med J, 1991 Jun, 40(2), 55 - 9 Clinical and cost effectiveness of prophylactic parenteral penicillin in the care of simple wounds undergoing suture repair; Taylor DD et al.; Physicians working in casualty and outpatient departments where adverse conditions prevail often prescribe antibiotic prophylaxis routinely at the time of suture repair of simple wounds . To evaluate this practice, we performed a randomized, controlled study of parenteral chemoprophylaxis of simple wounds undergoing suture repair . Uncomplicated wounds were randomized to either treatment with a combination of benzathine penicillin (2.4 million units) and procaine penicillin (2.0 million units) intramuscularly, or a control group . At the time of suture removal, seven days later, all wounds were reviewed for signs of infection . Of 320 patients enrolled in the study, 173 (54.1%) returned for review . Among treated wounds, 75 of 81 (92.6%) were healing, compared to 79 of 92 (85.9%) controls (p = 0.24) . A significantly higher rate of healing was observed when wounds repaired nine or more hours after injury and involving the arms, legs, or trunk were treated (22 of 23, 95.7%) compared to those in whom prophylaxis was omitted (20 of 30, 66.7%) (p = 0.03) . Wounds involving the head, and wounds repaired within nine hours after injury had a high rate of healing (greater than 90%), whether prophylaxed or not . Based on a 30% higher healing rate for the patients who benefited from treatment (arm, leg, trunk wounds repaired after nine or more hours), the drug cost of implementing prophylaxis for this group alone was more than five times that of an expectant, non-prophylactic strategy . These results serve to remind practitioners of the possibility that a clinically effective mode of therapy may not necessarily be cost-effective in the delivery of health care. Todays FDA . 1991 Jun;3(6):3C, 7C. Antibiotic prophylaxis for infective endocarditis; Cassatly MG; Dentists routinely treat patients who require antibiotic prophylaxis for infective endocarditis . In this article, the signs and symptoms of infective endocarditis as well as the hemodynamic events involved are discussed . Furthermore the rationale for the choice of antibiotic, the type of patient requiring prophylaxis, and the different regimes as recommended by the American Heart Association are presented. Eur J Surg, 1991 Jun-Jul, 157(6-7), 403 - 5 Antibiotic prophylaxis in high risk biliary surgery: one dose of ceftriaxone compared with two doses of cefuroxime; Hjortrup A et al.; In a controlled trial 219 high risk patients undergoing biliary surgery were allocated at random by sealed envelopes to one of two treatment groups . Group I (n = 112) received a single dose ceftriaxone 1 g intravenously at the time of skin incision, and group II (n = 107) was given cefuroxime 1.5 g intravenously at the time of skin incision, followed by a second dose eight hours later . There were no significant differences between groups in age, sex, diagnosis, or operations carried out . There were three wound infections in group I (3%) and four in group II (4%) (p = 0.65) . One patient in group I and two patients in group II developed intra-abdominal abscess and septicaemia (0.9% and 1.9%, respectively) . Five patients developed pneumonia postoperatively in group I (5%) and six in group II (6%) (p = 0.65) . There was no significant difference of the total number of postoperative infectious complications (wound infection, intraabdominal abscess, septicaemia, and pneumonia) between the groups (p = 0.42) . A single dose of ceftriaxone given intravenously at skin incision was as effective as two doses of cefuroxime for the prophylaxis of wound infection in this high risk group of patients. An Esp Pediatr, 1991 Apr, 34(4), 273 - 5 {Conservative treatment of post-appendectomy abscesses}; Gutierrez San-Roman C et al.; The standard form of treatment for an abscess in the abdominal cavity is surgical drainage . We present a prospective study of 626 patients under the age of ten who underwent appendectomy . The antibiotic prophylaxis consists of cefoxitin and ampicillin . Postoperative intra-abdominal abscess were found in 1.4% of the patients who were then treated with antibiotics (metronidazole plus amicacin) . Following this course of treatment, of the nine abscess, 4 required no surgical drainage, and progressed favourably as shown by the clinical controls and ultrasonography (US) . In 3 patients, percutaneous drainage was performed and controlled by US . This paper shows that antibiotic therapy is a useful alternative in the treatment of postappendectomy intraabdominal abscess. J Pediatr, 1991 Apr, 118(4 ( Pt 1)), 546 - 54 Neonatal screening for sickle cell disease: a cost-effectiveness analysis; Tsevat J et al.; PURPOSE: To determine the cost-effectiveness of screening newborn infants for sickle cell disease . DESIGN: We developed a decision model that examined two strategies: (1) screening neonates and administering penicillin to infants found to have sickle cell disease in the hope of preventing pneumococcal sepsis, and (2) not screening but administering penicillin to infants after symptoms of sickle cell disease develop . The model calculates the cost-effectiveness of these strategies during the first 3 years of life . We applied the model to three prototypic populations of neonates--black, nonblack with a relatively high prevalence of hemoglobin S genes, and nonblack with a low prevalence of hemoglobin S genes . DATA IDENTIFICATION: We obtained from the published literature the effectiveness and risk of penicillin prophylaxis, the risk of pneumococcal sepsis, and the probability that in infants not screened the development of symptoms would lead to the discovery of sickle cell disease within the first 3 years of life; we used the published literature and the Hardy-Weinberg law to determine the prevalence of sickle cell disease . We used actual variable costs of screening, antibiotic prophylaxis, and hospitalization for pneumococcal sepsis or anaphylaxis . RESULTS: Screening and then treating affected black infants costs only $3100 more per life saved than not screening . Screening nonblack populations with a high prevalence of hemoglobin S genes would cost $1.4 million per life saved, and screening low prevalence populations would cost $450 billion per life saved . CONCLUSIONS: Screening black infants is very worthwhile, but screening populations in which the hemoglobin S gene is rare is unjustified. Int Surg, 1991 Apr-Jun, 76(2), 127 - 30 Prophylactic use of a single dose of tobramycin in elective colorectal surgery; Vanderveken M et al.; The aim of this prospective study is to acquire clinical experience with a single high dose of tobramycin in prophylactic use . Sixty three patients undergoing elective colorectal surgery, were assigned to receive antibiotic prophylaxis (24 hours perioperatively) in the form of a single high dose of tobramycin and a classically recommended thrice-a-day (TID) administration of clindamycin . The planned dose for tobramycin was 3.3 mg/kg/day . Adjustment was made in case of impaired renal function . Serum levels of the drug were monitored . The results showed well predictable levels . Six out of fifty five evaluable patients (10.9%) presented postoperative infectious complications within the follow up period . No renal nor otovestibular toxicity was recorded. J Can Dent Assoc, 1991 Apr, 57(4), 321 - 5 Mitral valve prolapse: a review of the syndrome with emphasis on current antibiotic prophylaxis; Sandor GK et al.; Mitral valve prolapse syndrome (MVPS) is the name given to the heart valve abnormality described by Barlow over two decades ago . This condition is of particular importance to the dentist as these patients are thought to be at risk of developing infective endocarditis with routine dental procedures which may cause gingival bleeding . This paper is an updated version of an article that originally appeared in the University of Toronto Dental Journal in 1990 . In 1984, guidelines for antibiotic prophylaxis were provided by the American Heart Association (AHA) . More current prophylactic regimens are also presented, with emphasis on the current recommendations of the AHA, recently published in December of 1990. J Oral Maxillofac Surg, 1991 Apr, 49(4), 340 - 2 Survey of antibiotic prophylaxis for intraoral orthognathic surgery; Heit JM et al.; A survey was sent to 114 oral and maxillofacial surgery residency programs to determine the prophylactic use of antibiotics with intraoral orthognathic procedures . Seventy-four percent of the programs responded . Review of the data showed that all programs used antibiotic prophylaxis for intraoral orthognathic procedures, and that penicillin or a cephalosporin were the drugs most often used . However, there was no consistent protocol for the method or duration of drug administration . A discussion of rationale for antibiotic usage, concentration, and duration is presented. Clin Ter, 1991 Mar 31, 136(6), 393 - 8 {Antibiotic prophylaxis with ceftazidime in pediatric surgery}; Inserra A et al.; The authors report their experience with Ceftazidime in surgical prophylaxis in childhood . 50 patients have been treated, suffering from surgical diseases, with 100 mg/kg of Ceftazidime in 3 doses (1 before, 1 after 6 hrs and 1 after 12 hrs from surgery) . No side effects were observed and in no case was it necessary to discontinue treatment . Both bacterial and clinical results indicate good tolerability and very rapid effectiveness of the drug . Complications were present in 3 cases (6%) (in 2 cases wound infiltration and in 1 case a Douglas abscess) but no modification in treatment was necessary . All complications were present in so-called "dirty surgery" with a relative percentage of 18.7, that is far below values reported in the literature for this kind of surgery. N Z Med J, 1991 Mar 13, 104(907), 85 - 8 An audit of anticoagulation and endocarditis prophylaxis after heart valve surgery; Fitzpatrick MA et al.; OBJECTIVE: to audit anticoagulant control and endocarditis prophylaxis following heart valve surgery . DESIGN: retrospective review of all 190 patients living in Canterbury who had heart valve surgery between January 1981 and December 1986 to determine the incidence of endocarditis and complications of anticoagulation . RESULTS: there were 35 late deaths, of which nine were attributed to thromboembolism (3), major bleeding (2), or endocarditis (4) . The rate of thromboembolic events, and major bleeding was 4.6 and 3.3/100 patient years of warfarin therapy respectively, while the incidence of late endocarditis was 0.96/100 patient years . Two episodes of endocarditis occurred after minor dental procedures performed without antibiotic prophylaxis . Many dentists indicated that they would not have recommended prophylactic therapy for these procedures . Some patients had inadequate recall of important details of anticoagulant control or endocarditis prophylaxis . Only 24% knew their latest prothrombin ratio, yet a survey of general practitioners revealed that, in their view, the majority of patients may be capable of monitoring their own anticoagulant therapy . CONCLUSION: the incidence of potentially preventable long term complications of heart valve surgery is comparable to other series . Nevertheless, these complications could be reduced by better patient education possibly enhanced by greater involvement of the patient in their anticoagulant control . The indications for antibiotic prophylaxis for dental procedures should be broadened for this group of patients. Zentralbl Hyg Umweltmed, 1991 Mar, 191(2-3), 171 - 81 {Hygiene barriers in the hospital--instrumentation aspects}; Sonntag HG; There is a contrary course between the development of high sophisticated instruments which are used in all medical fields on the one hand and the establishment of relevant hygienic measurements for the processing of such instruments on the other hand . For this situation the following reasons can be mentioned: 1 . Along the technical development of these instruments the hygienist is not consulted 2 . The processing of such instruments is delegated to assistant personal and their critical comments are not realised by those clinicians who are responsible for the use of these instruments and 3 . nosocomial infections triggered by still contaminated instruments will be concealed by perioperative antibiotic prophylaxis . There are many examples for instruments which cannot be processed in the right way and which are specially used in surgery in endoscopy and in intensive care units . The constructive cooperation between the technician the clinician using the instruments and the hygienist alone will provide the elimination of technical and psychological barriers in this field and allow the construction and use of those instruments which can be processed in a hygienic relevant way. Injury, 1991 Mar, 22(2), 111 - 3 Is antibiotic prophylaxis necessary for internal fixation of low-energy fractures? Hughes SP, Miles RS, Littlejohn M, Brown E. A series of 54 patients who had low-energy, closed fractures requiring internal fixation were entered into a randomized prospective study comparing prophylactic antibiotics with no treatment . In five patients who did not have antibiotics a superficial wound infection or fever was recorded . In those who received antibiotics, no infection or fever was detected . However, there was no statistical difference between the two groups, and it is concluded that there is no need for prophylactic antibiotics when internally fixing low-energy fractures. N J Med, 1991 Mar, 88(3), 201 - 4 Complications of caustic ingestion; Arif A et al.; The use of steroid and antibiotic prophylaxis no longer is tenable on the basis of recent studies showing their inability to favorably influence the outcome of caustic injuries . The need for early endoscopic and radiologic assessment if not gastroesophagectomy for severe injuries now is the management of choice . Further efforts to identify high-risk populations and efforts to educate them of the dangers must continue. J Periodontol, 1991 Mar, 62(3), 227 - 31 Antibiotic prophylaxis for medical-risk patients; Pallasch TJ et al.; The three current regimens for the prevention of infective endocarditis are discussed and compared along, with at-risk patients and dentally-induced bacteremias . The principles of antibiotic prophylaxis, and other medical conditions where antibiotic prophylaxis is controversial or inadequately documented is critically analyzed. Isr J Med Sci, 1991 Mar, 27(3), 134 - 6 Reduction of hospital cost and administration of prophylactic antibiotherapy in gynecological surgery; Matkaris M et al.; The present study attempts to evaluate the efficacy and safety of three of the most popular third-generation cephalosporins, and demonstrates the reduction in cost resulting from their use . Our study included 223 women admitted for abdominal hysterectomy (mean age 54), 200 of whom were assigned randomly to one of four groups . The first group did not use an antibiotic prophylaxis . The second group used ceftriaxone, the third cefotaxime and the fourth ceftazidime . In the three treatment groups one 2-g dose of the antibiotic was provided 60 min before the operation . Additional doses were given only if post-operative infection was established . Our results indicated that one dose of antibiotic prophylaxis with third-generation cephalosporins reduces the morbidity in gynecological surgery . Cefotaxime proved to be the most cost-effective of these three cephalosporins, with low morbidity and a low rate of hospitalization. Rev Fr Gynecol Obstet, 1991 Mar, 86(3), 233 - 42 {Anti-infective prophylactic measures in cesareans}; Chauvet-Jauseau MF et al.; Septic complications remain important in obstetrical surgery due to the serious threat they pose to life and the sequelae which they may leave . The authors have therefore attempted to identify which of the anti-infectious prophylactic treatments used in cesareans were the most effective . This analysis was based on cases in their unit seen from 1984 to 1988 and on a review of the literature . Of the patients who underwent a cesarean (9.4 percent out of 7,855 deliveries), 2 percent were infected, with and incidence of 0.65 percent serious infections (0.4 percent septicemia) . On the basis of the literature, the following risk factors were identified: 1st cesarean, cesarean during labor, rupture of the membranes, surgical problem, anemia, obesity and low socio-economic level . The local fundamental and systemic prophylactic measures taken were special antibiotic prophylaxis in the patients with a risk of infection only . The short protocol, with a single injection of penicillin A or a first generation cephalosporin, after clamping the umbilical was preferable and, according to all the studies, had the advantage of avoiding the selection of resistance. J Natl Cancer Inst, 1991 Feb 6, 83(3), 190 - 4 Brief intensive chemotherapy for metastatic non-small-cell lung cancer: a phase II study of the weekly CODE regimen; Murray N et al.; Fifty-three patients, 17 with stage IIIB and 36 with stage IV non-small-cell lung cancer, were given CODE (cisplatin, vincristine, doxorubicin, and etoposide) plus antibiotic prophylaxis and an antiemetic regimen in an intensive chemotherapy program emphasizing weekly treatment and a planned brief duration (9-12 weeks); for 45 of these patients, the CODE program also included antifungal prophylaxis and supportive corticosteroids . Of the total study population, 33 patients (62%) responded to treatment, including five (9%) with complete response . The median survival for the entire group was 42 weeks (55 weeks for those with stage IIIB and 39 weeks for those with stage IV) . More than 40% were alive at 1 year . Comparison of granulocyte counts of patients receiving prednisone with those of the subgroup to whom no corticosteroids were given showed less granulocytopenia for those receiving prednisone . Use of prednisone thus allowed improved delivery of myelosuppressive drugs . CODE was halted in nine patients because of disease progression . Although more constitutional side effects are associated with weekly chemotherapy than with standard chemotherapy, only 12 of the remaining 44 patients (27%) failed to receive at least 9 weeks of treatment . Serious toxicity was uncommon: There were no treatment-related deaths and only three episodes of neutropenia with fever . CODE is a novel treatment for non-small-cell lung cancer that this pilot study provided entirely in an outpatient setting over a 9-12 week period with an acceptable incidence of toxicity and a promising level of efficacy . Additional testing and comparison with other regimens or supportive care alone are warranted. Scand J Thorac Cardiovasc Surg, 1991, 25(1), 73 - 6 Antibiotic prophylaxis in non-cardiac thoracic surgery . A double-blind study of penicillin vs . cefuroxime; Krasnik M et al.; Patients referred for elective pulmonary surgery were enrolled in a prospective, randomized, double-blind study comparing the prophylactic efficacy of four-dose regimens of penicillin-G 5 million IU and cefuroxime 1.5 g . the first dose given immediately preoperatively . The treatment groups were comparable preoperatively with regard to all tested demographic factors . No significant intergroup difference was found concerning postoperative empyema, wound infection, septicaemia, pneumonia or fever of unknown origin, or any other complication or parameter tested in connection with pulmonary surgery . No side effects were observed, and no effects on the patients normal bacterial flora . Penicillin is recommended as prophylaxis in this type of surgery. An Otorrinolaringol Ibero Am, 1991, 18(1), 5 - 13 {Perioperative prophylaxis in patients with head and neck tumors}; Bernal Sprekelsen M et al.; Sixty-one cancerous patients of the larynx, hipopharynx and tongue underwent surgery under perioperative prophylaxis with Cefuroxim and Metronidazole during 3 days . Alterations of the healing process could not be observed and the parameters both clinic and chemical were normal . The seric level of antibiotics was effective against most of the bacteria cultured from tracheal secretions and from the posterior wall of the oral cavity . Perioperative antibiotic prophylaxis is compulsory when major surgery is performed in head and neck. Injury, 1991 Jan, 22(1), 20 - 4 Short-course antibiotic prophylaxis in penetrating abdominal injuries: ceftriaxone versus cefoxitin; Demetriades D et al.; This was a prospective, randomized study of 123 patients with penetrating abdominal injuries . The patients received ceftriaxone or cefoxitin for 24 h (in the presence of colonic injury, 48 h) . The overall incidence of abdominal sepsis was 7.3 per cent (ceftriaxone 5 per cent, cefoxitin 9.5 per cent, P greater than 0.05) . Colonic injury was the most important risk factor for the development of septic complications . Other factors, such as the weapon used, a prehospital time longer than 4 h, shock on admission, multiple organ injuries, and small bowel perforation, did not influence the incidence of sepsis. Chirurg, 1991 Jan, 62(1), 32 - 5 {Anal condylomata acuminata . A prospective comparison of HIV positive and negative patients}; Buchmann P et al.; Between July 1986 and May 1987 23 patients suffering from anal condylomata acuminata were treated at the University Hospital of Zurich . The influence of HIV-infection on the disease is described . An almost equal frequency of recurrencies between positives and negatives was observed in a three year follow-up time . However, in positive patients recurrence was earlier and much more extensive . A two-stage procedure which sometimes is advocated in very extensive lesions gave very bad results in HIV positives . We use a radical excision by electrocoagulation on the mucosa and perianally and avoid circular necrosis in the lower anal canal only . Infectious complications are not to be feared except in patients with symptomatic HIV-infection resulting in the recommendation for a antibiotic prophylaxis in such cases. J Orthop Trauma, 1991, 5(1), 66 - 70 Management of penetrating pneumatic nailgun injuries of the knee; Levy AS et al.; Of 36 patients who presented over a 3-year period with nailgun injuries, nine of these injuries were found to have penetrated into the knee joint . Six of these injuries were treated by operative nail removal, curettage of the nail tract, and examination of the joint . The remaining three patients had nail removal, followed by irrigation of the joint in the emergency room . All nine injuries had antibiotic prophylaxis before and after nail removal . In three of six patients treated by operative irrigation and debridement, a piece of clothing or nailgun resin was discovered in the nail tract or floating within the knee joint . None of the patients in the group treated by operative nail removal, joint visualization, irrigation, and nail tract curettage experienced any complications, whereas one patient treated nonoperatively developed a septic knee . Due to the unique nature of these nailgun puncture wounds, we strongly advocate operative nail removal, curettage of the nail tract, visualization of the joint, and use of prophylactic antibiotics in the treatment of nailgun arthrotomies. Chemotherapy, 1991, 37(1), 66 - 9 Short-term antibiotic prophylaxis in elective colorectal surgery; Tsimoyiannis EC et al.; In the last 2 years, 50 patients who underwent elective colorectal surgery were prospectively studied about antibiotic prophylaxis . Two groups of 25 patients each were randomly selected . Both received: (a) a colic preparation: hypactic drugs and two enemas during the day before surgery and (b) metronidazole 0.5 g plus neomycin 1 g per 8 h orally for 1 day before surgery . Every group also received: group A, metronidazole 0.5 g plus amikacin 500 mg i.v . 2 h before surgery and the same doses per 8 or 12 h, respectively, for 2 days postoperatively; group B, ornidazole 1 g by intravenous infusion plus ceftriaxone 2 g i.v . 2 h before surgery and the same doses of the drugs per 24 h for 2 days postoperatively . Wound infection occurred in 1 case of group A versus 2 cases of group B (p greater than 0.25) . Ornidazole plus ceftriaxone prophylactic antibiotic therapy is therefore as effective as a classic therapy (metronidazole plus amikacin) and constitutes an alternative choice for patients undergoing elective colorectal surgery, because the simple manner of its administration (once per 24 h) is resulting in cost saving due to gained nursing time. Pediatr Infect Dis J, 1991 Jan, 10(1), 2 - 11 Evaluation of ventilating tubes and myringotomy in the treatment of recurrent or persistent otitis media; Le CT et al.; In a prospective controlled study of the efficacy and sequelae of ventilating tubes, 44 children with bilateral recurrent acute otitis media (greater than 6 episodes/year) and 13 children with bilateral persistent middle ear effusion (greater than 3 months) received unilateral ventilating tube insertion in a randomly selected ear . The contralateral ears were randomized to receive either myringotomy alone or no surgery . Clinical, otoscopic, tympanometric and audiologic examinations were performed before the study and 2 to 4 weeks later, then at 3-month intervals for up to 2 years and at 36 months after surgical randomization . Medical therapy and antibiotic prophylaxis were used whenever indicated . While the ventilating tubes remained functional (mean duration, 10 months) the ears with a tube had significantly fewer episodes of otitis media than their contralateral ear (P less than 0.001; 95% confidence intervals -0.7, -1.7) and had more hearing improvement (P = 0.005; 95% confidence intervals, -5.9, -1.2) . After tube extrusion there was a tendency for surgically treated ears to have more otitis and worse hearing, but not at a significant level . Tympanosclerosis, retraction and atrophy were more common in ears that received tubes . The majority of ears treated medically also improved . There is need for a more cautious and selective use of ventilating tubes. Zentralbl Chir, 1991, 116(13), 795 - 800 {General or individually calculated preventive antibiotic administration . Summary of the Magdeburg appendicitis study}; Birkigt HG et al.; A prospective randomized clinical trial was performed to determine the efficiency of single-dose antibiotic prophylaxis in preventing septic complications after appendectomy . The infection rate increased significantly in the control group without antibiotic prophylaxis (9.3% to 20.3%) . Older patients with severe appendicitis had more advantages from the prophylaxis than younger one . We have suggested to perform antibiotic prophylaxis individually only in those patients with high risk of septic complications after appendectomy. Ann Dent, 1991 Summer, 50(1), 5 - 8 Failures of endocarditis prophylaxis: selective review of the literature and a case report; van der Bijl P et al.; Patients at risk for developing infective endocarditis require antibiotic prophylaxis before bloody dental procedures . However, despite prophylactic measures, some patients still develop the infection . A selective review of the literature is given and a case report of prophylactic failure in a high risk patient is presented. Langenbecks Arch Chir, 1991, 376(3), 172 - 5 {Etiology and consequences of postoperative wound infection}; Rogy M et al.; The incidence of postoperative wound infection ranges between 4.6% and 36% after gastrointestinal operations respectively . To evaluate the factors which influence the postoperative wound infection we prospectively analyzed our patients between 1/1989 and 1/1990 . 444 patients from three general surgical units of our clinic entered this study . The overall wound infection rate was 6.3% . We classified the patients into 3 operative groups: Group I: subcutaneous operations; Group II: intraabdominal operations without opening the GI-tract; Group III: gastrointestinal operations . Wound infection rate in group I was 1.8%, in group II 7.3% and in group III 13.7% . The differences were highly significant . Both univariate (chi 2-test) as well as a multivariate (Cox-Model) analysis were done . We figured out that classification of patients (p = 0.000), operation time (p = 0.009), operating room (p = 0.000), intensive care unit (p = 0.026), long-term antibiotic prophylaxis (p = 0.001), subcutaneous haematoma (p = 0.000) and length of closed drainage time (p = 0.001) are of significant value . In the Cox model the classification of patients into 3 groups surpassed all the other factors . Postoperative hospital stay was lengthened in patients with wound infection significantly (p = 0.0025). G Chir, 1991 Jan-Feb, 12(1-2), 34 - 6 {The correlation of bacteriobilia/wound infections in elective biliary surgery}; Guglielminetti D et al.; The authors report their experience concerning the cultural study of bile samples taken during elective biliary surgery . All the operations were carried out after a randomized preoperative antibiotic prophylaxis . Among the 138 cases examined the presence of surgical infections (wound infection) was taken into account . A lack of correlation between the germs present in the bile and those isolated from samples of complicated cases, was registered . However, the Authors emphasize that, although antibiotic prophylaxis gives a reduced percentage of postoperative infections, it is unable to sterilize the bile. Agressologie, 1991, 32(10 Spec No), 467 - 70 {Prevention of postoperative infections with cefotiam (Pansporine) in orthopedic surgery}; Frajman JM et al.; This prospective, randomized study was carried out in the Orthopaedic Traumatology service, Hopital Bichat, from March 1987 to June 1989 in order to compare the efficacy of an antibiotic prophylaxis either with cefotiam in "flash" administration or with cefazolin in continued administration (48 hours) . This study included 207 patients undergoing a total hip or knee-joint replacement . The both groups (89 patients with cefotiam, 118 patients with cefazolin) were comparable with regard to all criteria . The general and local evolution did not show statistical significant difference in the occurrence of complications in the both groups . No infectious complication occurred after the operation for the two groups . Then, cefotiam, in "flash" administration (2 g with the anesthetic induction) proves to be as effective as a conventional antibiotic prophylaxis with cefazolin in the prevention of infectious complications in orthopaedic surgery. Soc Sci Med, 1991, 32(11), 1263 - 8 Relationships among and demographic predictors of dentists' self-reported adherence to national guidelines; Dorsey M et al.; How dentists learn about and integrate new procedures and techniques into dental practice are major concerns in innovation research in dentistry . The purposes of this study were to: (1) develop reliable measures of self-reported adherence to different national guidelines; (2) to examine the relationships among the different measures; and (3) to determine if predictors of these adherence behaviours exist . One thousand U.S . general dentists were asked to complete a survey of adherence behaviours to established guidelines in infection control, radiation protection, and antibiotic prophylaxis . Thirty-five percent responded to the mailed survey . Reliable scales were developed in infection control and antibiotic prophylaxis behaviors . Step-wise multiple regression analysis produced several weak predictors of adherence to guidelines in these two areas . Characteristics of early adopters such as office complexity, membership in professional associations, and year of graduation, were consistent with other dental innovation literature . Significant correlations were found between adherence behaviors in infection control and antibiotic prophylaxis . These correlations do support the findings that practitioners who are early adopters of innovation are likely to do so in more than one area. Klin Wochenschr, 1991, 69 Suppl 26, 43 - 6 {Perioperative use of antibiotics for preventive indications}; Vestweber KH et al.; The prevention of infections in surgical patients undergoing an operation is a major challenge . One of the several possibilities is the administration of appropriate antibiotics during the perioperative period . For this type of prophylactic use the agent selected should be given before contamination--a single dose is very often sufficient . Common indications for antibiotic prophylaxis are: operations involving a high chance of contamination and those that have hither to be clean but in which the implications of infections would be highly threatening. Zentralbl Chir, 1991, 116(24), 1391 - 8 {Postoperative wound infections and perioperative preventive antibiotic administration}; Roding H; Nearly 200 clinical studies concerning perioperative antibiotic prophylaxis are compiled and evaluated by biometric methods, however without fulfilling the criteria of meta-analysis . Derived from its results it can be concluded, that this prophylaxis is indicated for the wound categories "clean" and "clean-contaminated" . An effective level of antibiotics is necessary only for the period of operation . No benefits could be demonstrated by prolongation of the prophylaxis or by combination of two or more antibiotics . Regarding the limited power of this compilation a reduction of postoperative wound infections is to be expected in "clean-contaminated" procedures to a quart, in "clean" procedures to a half in comparison with procedures without prophylaxis. Acta Neurochir (Wien), 1991, 113(3-4), 103 - 9 Intra-operative antibiotic prophylaxis in neurosurgery . A prospective, randomized, controlled study on cefotiam; Gaillard T et al.; In this prospective, randomized and controlled study the effect of cefotiam for the prevention of wound infections following trepanations was investigated . The main interest was centered on the rate of post-operative bone flap infections requiring operative revision . Administration of cefotiam was randomized for patients undergoing major craniotomies . The antibiotic was administered intravenously in a single dose of 2 g with induction of anaesthesia . Only clean or clean contaminated cases were included . Excluded were contaminated cases, operations with a transnasal-transsphenoidal approach, shunt-operations and patients with any other preoperative infection or antibiotic therapy . Outpatients were excluded due to difficulties in obtaining sufficient clinical information . From originally 918 consecutive patients operated on 711 fulfilled the entry criteria . With regard to age, sex, diagnosis and the site of te trepanation, control patients (n = 355) and cefotiam treated patients (n = 356) were shown to be comparable . In the various subgroups formed for different primary diagnoses, concomitant steroidal therapy and concomitant severe internal medical diseases cefotiam treated patients and controls were comparable as well . A highly significant difference for bone flap infection could be shown with 0.3% in the cefotiam group versus 5.1% in the control group (p less than 0.001) . The overall rate of post-operative deep wound infections including meningitis and abscesses was also significantly (p less than 0.005) different with 3.1% in the cefotiam versus 9.0% in the control group . Thus it was concluded that a single dose of cefotiam significantly reduces post-operative deep wound infection. Langenbecks Arch Chir Suppl Kongressbd . 1991;:333-9. {Mortality and morbidity conference . Perioperative fatalities}; Pichlmaier H et al.; Postoperative complications in 4675 patients were investigated . There were specific patterns of complications with significant differences between vascular and general surgery and transplantation . On the basis of test operations (inguinal hernia, cholecystectomy, resection of colon and rectum) it could be shown that differences were ward-specific . Over a period of 12 years, a certain decrease of complication rates could be demonstrated (wound infection, from 9% to 1.25%; pneumonia, from 8% to 2.5%; mortality, from 6.3% to 1.8%) . Changes in clinical practice (antibiotic prophylaxis, bowel cleansing, introduction of new techniques, etc.) may be responsible for these improvements . We are convinced that a regular complication conference essentially influences the actions of physicians and nurses. Akush Ginekol (Sofiia), 1991, 30(1), 13 - 7 {Short-term antibiotic prophylaxis in cesarean section and hysterectomy}; Punevska M; The usage of antibiotics for prevention of infection in surgical practice is taken into consideration with the most frequent pathogenic agents, which are isolated from the genital tract and their sensitivity to antibiotics, pharmacokinetic properties of the antibiotic-tissue penetration, duration of action, concentration (without any risk) and established clinical efficiency . The potential benefit from prophylactic antibiotic should always be balanced against the possible damage . The duration of prophylaxis should be as short as it could be, in order to avoid the danger for occurrence of resistant strains . A single antibiotic dose is ideal . Cephalosporins are the most suitable for current prophylaxis. J Arthroplasty, 1991, 6 Suppl, S17 - 22 Total hip arthroplasty after McMurray's osteotomy; Nagi ON et al.; Total hip arthroplasty (THA) was done as a secondary procedure after McMurray's osteotomy in 15 cases, with a time lapse of 14-132 months between the two operations . Marked improvement in pain and function was achieved in 14 cases, although hip stiffness was greater than that in primary THA cases . It was noted that delay in THA enhanced the operative difficulties and decreased the overall improvement obtained . No special femoral component was employed, and extensive soft-tissue dissection was carried out to obtain near-normal hip biomechanics to decrease the chances of long-term loosening . Marked medullary canal distortion was encountered in eight cases . In spite of this, there were no cases with femoral shaft fractures . Trochanteric osteotomy should be employed in cases in which the canal is severely distorted . In these cases, routine antibiotic prophylaxis and adequate preoperative planning should be done. Akush Ginekol (Sofiia), 1991, 30(2), 26 - 30 {Antibiotic prophylaxis in operations performed by a microsurgical technic}; Nalbanski N et al.; The authors studied the effect of a single prophylactic dose of Cephalozoline in a dose of 2 g . used in 50 women, operated by microsurgical technique for tubal sterility . In comparison with 100 women with continuous prophylaxis with Ampicillin and gentamycin there was a reduction in infectious postoperative complications of the same 50 women without any disturbance in general state, pulse or laboratory parameters . Side effects due to Cephazoline were not established. Pharm Weekbl Sci, 1990 Dec 14, 12(6A), 296 - 8; discussion 299 Meta-analysis of randomized controlled trials of antibiotic prophylaxis in abdominal hysterectomy; Wttewaall-Evelaar EW; The value of antibiotic prophylaxis in abdominal hysterectomy was reviewed by meta-analysis . Two independent literature searches (1986-1988) yielded 150 relevant papers, however, only 17 (11.3%) papers met our inclusion criteria . The selected papers described prospective, randomized, blinded, placebo-controlled studies of patients undergoing elective abdominal hysterectomy . In 14 of 17 (82%) trials, first- or second-generation cephalosporins were used . Results pooled confirm that antibiotic prophylaxis will reduce infectious morbidity following elective abdominal hysterectomy . Hospital stay is little affected and significant levels of infectious morbidity remain. Pharm Weekbl Sci, 1990 Dec 14, 12(6A), 292 - 4; discussion 294-5 Antibiotic prophylaxis in vaginal hysterectomy . Three doses of cefuroxime plus metronidazole versus one dose of ciprofloxacin; Brouwer WK et al.; The prophylactic efficacy of three intravenous doses of cefuroxime 1,500 mg plus metronidazole 500 mg in vaginal hysterectomy was compared with placebo in a prospective double-blind randomized study . Febrile morbidity occurred in 13 of 26 patients in the placebo group and 0 of 27 patients in the study group . In a second prospective randomized study, the efficacy of intravenous ciprofloxacin (200 mg single dose) was compared with the cefuroxime plus metronidazole regimen . Febrile morbidity was found in 3 of 54 patients in the ciprofloxacin group, but in none of the 58 patients in the cefuroxime plus metronidazole group. Clin Mater, 1991, 7(1), 51 - 81 Cellular events in the mechanisms of prosthesis loosening; Pizzoferrato A et al.; The functional restoration of a joint damaged by trauma or disease is obtained by prosthetic surgery . In particular the implantation of hip prostheses is regarded as routine in orthopedic surgery and thorough research has been developed in this field . The prosthetic replacement of the knee and even more so the ankle and elbow occurs less frequently in clinical practice and has been studied less intensively . The results of artifical hip replacement are generally good, both in terms of pain relief and the restoration of satisfactory joint function . Nevertheless, as time passes, a high rate of failures have been recorded due to prosthesis infections, fracture and wearing of the prosthetic components and prosthesis loosening by various causes . The use of ultra-filtered air and laminar flow in operating theatres and antibiotic prophylaxis have dramatically reduced the incidence of infections in total hip arthroplasty . Thanks to the setting up of new stem configurations and the use of superalloys that are highly resistant to fatigue failure, the fracture of the femoral component has been virtually eliminated as a complication of total hip arthroplasty replacements . Loosening is thus the most frequent complication in total hip replacement. Aust N Z J Med, 1990 Dec, 20(6), 759 - 64 The clinical role of transoesophageal echocardiography; Black IW et al.; The role of transoesophageal echocardiography (TEE) was evaluated in a consecutive series of 100 procedures performed in 86 patients (age 17-81, mean 56 years) . All patients had prior transthoracic echocardiography (TTE) . TEE was performed with a 5 MHz phased array transoesophageal transducer with pulsed wave Doppler and colour flow mapping capability . Forty-four per cent of patients received intravenous sedation and 36% received antibiotic prophylaxis . There were no complications of TEE . The TTE and TEE findings were compared . In patients referred for possible cardiac source of embolism, left atrial thrombi were detected in 8/27 TEE studies but in none of 27 TTE studies . In 12 patients with prosthetic valve dysfunction TEE distinguished prosthetic from periprosthetic regurgitation in 9/12 studies compared to 3/12 with TTE . In 11 patients with suspected aortic dissection TEE correctly detected dissection in all seven cases in which the diagnosis was subsequently confirmed, whereas TTE showed only equivocal findings in two cases . Vegetations were detected by TEE in 4/5 studies in patients with proven native valve endocarditis and by TTE in 2/5 . No vegetations were detected by TTE or TEE in five studies in patients with proven prosthetic valve endocarditis . Compared with other investigations there were no false positive TEE studies and one possible false negative study . We conclude that TEE is a safe procedure which often provides additional clinical information to transthoracic echocardiography. Br J Anaesth, 1990 Dec, 65(6), 826 - 8 Unconsciousness associated with midazolam and erythromycin; Hiller A et al.; An 8-yr-old boy suffering from an asymptomatic ventricular septal defect was given erythromycin for antibiotic prophylaxis before adenoidectomy . Sixty minutes after premedication with oral midazolam 0.5 mg kg-1 and oral atropine 0.03 mg kg-1, an infusion of erythromycin 400 mg was started . When 200 mg of erythromycin had been infused, the patient lost consciousness, but other vital functions remained normal . After 45 min, he awakened spontaneously . At the time the plasma concentration of midazolam was 134 ng ml-1 . In order to investigate possible interactions between midazolam and erythromycin, we studied the pharmacokinetics of midazolam in six children of the same age undergoing minor otolaryngological surgery . The plasma concentration of midazolam in the patient who lost consciousness was significantly greater than in six other children without concomitant administration of erythromycin . The altered pharmacokinetics of midazolam may result from reduced hepatic clearance of midazolam caused by an enzyme inhibiting drug, erythromycin. Asia Oceania J Obstet Gynaecol, 1990 Dec, 16(4), 347 - 51 Efficacy of cefoxitin for the prevention of postoperative infection in abdominal hysterectomy; Sutthijumroon S et al.; Prophylactic effect of cefoxitin against postoperative infection at a dose of 2 g intravenous (single dose 30 minutes before the operation) was investigated using fever index in patients who underwent the elective, nonradical abdominal hysterectomy . The results obtained are summarized as follows . Total fever index values were 12.9 +/- 10.0 degree-hours in the control group (n = 39), 11.3 +/- 9.7 degree-hours in the study group (n = 39) . There were no statistical significance between both groups . Data from this investigation does not suggest the concept that prophylactic antibiotics are beneficial in the reduction of postoperative infection . The results of this prospective study reflected in unnecessity of antibiotic prophylaxis in abdominal hysterectomy. Otolaryngol Head Neck Surg, 1990 Dec, 103(6), 1009 - 11 Metronidazole in head and neck surgery--the effect of lengthened prophylaxis; Sawyer R et al.; Previous studies of antibiotic prophylaxis have shown that treatment for 24 hours has been beneficial for head and neck surgery and that longer periods of antibiotic therapy have not improved results . Metronidazole (Flagyl), unlike other antibiotics tested, has been shown to be effective in an experimental abscess, even if treatment is begun up to 120 hours after administration of inoculum . This article presents a prospective, randomized, multifactorial study comparing a brief vs . a prolonged duration of metronidazole and cefazolin prophylaxis in 50 consecutive patients with a head and neck cancer undergoing operation . Patients receiving 2 days vs . 7 or more days of antibiotic prophylaxis were compared . Statistical analysis of data demonstrated a striking reduction in severity of wound complications and a reduced incidence of wound infections in the group treated with 7 or more days of antibiotic prophylaxis. Hepatogastroenterology, 1990 Dec, 37 Suppl 2, 90 - 4 To assess the efficacy of prophylaxis in digestive tract surgery using a predictive model of complication risk; Mozzillo N et al.; One hundred and ninety-one patients, all candidates for major clean-contaminated surgery, were classified according to the risk of developing postoperative wound infection, using clinical and nutritional factors . A widely validated nutritional assessment model, the Prognostic Nutritional Index (PNI), was used preoperatively to evaluate the risk and probability of post-operative septic complications . Based on the predicted outcome, patients were assigned to either a poor or a good risk group for statistical comparison . A prospective, double-blind, randomized trial was performed to compare the effectiveness of the monocyclic beta-lactam, aztreonam, with gentamicin for short-term perioperative prophylaxis . In the poor risk group (PNI greater than 40), aztreonam prophylaxis significantly reduced postoperative septic complications (p less than 0.05) . The use of an objective scoring system to assess the risk of postoperative sepsis is recommended for future studies on antibiotic prophylaxis as it offers a realistic assessment basis. J Antimicrob Chemother, 1990 Dec, 26(6), 823 - 9 Determination of bone and fat concentrations following systemic cefamandole and regional cefuroxime administration in patients undergoing knee arthroplasty; Hoddinott C et al.; Five patients undergoing routine total knee replacement received standard antibiotic prophylaxis of 1000 mg of iv cefamandole and also regional administration of 750 mg of cefuroxime . Regional dosing was carried out at the start of the operation, following the application of a mid-thigh tourniquet, by administration into a foot vein . Samples of bone and fat were collected during the operation and assayed for cefuroxime and cefamandole by HPLC analysis . The mean cefuroxime bone (133.1 mg/l) and fat (88.4 mg/l) levels following regional administration were significantly higher (P less than 0.001) than the mean cefamandole bone (9.1 mg/l) and fat (9.8 mg/l) levels following systemic dosing . The possibility of administration of prophylaxis by the regional route is suggested. Presse Med, 1990 Nov 17, 19(38), 1755 - 8 {Antibiotic prophylaxis in cesarean sections without high risk of infection . Therapeutic trial of cefotetan versus placebo}; Racinet C et al.; Caesarean sections are performed with an ever increasing frequency, and their morbidity rate due to infection varies between 35 and 40 per cent . The effectiveness of antibiotic prophylaxis has been demonstrated in caesarean sections with a high risk of infection, but few studies have been devoted to caesarean sections without this high risk . The purpose of our study was to evaluate the effectiveness of antibiotic therapy in this second type of caesarean section since its postoperative infection rate is not negligible (about 25 per cent) . We therefore set up a two-centre randomized trial comparing two groups of 133 women without any particular risk of infection . At the moment of umbilical cord clamping, one group received cefotetan 1 g intravenously, while the other group received an intravenous injection of a placebo solution . The postoperative infection rate was 12.5 per cent in the treatment group and 26.9 per cent in the control group (P less than 0.05) . The relative risk in the placebo-treated women was 2.15 (95 per cent confidence limits, 1.41 to 3.28) . Antibiotic prophylaxis prevented 53.5 per cent of postoperative infections (95 per cent confidence limits, 29 to 69.5 per cent) . Moreover, in the treatment group infections were less severe, resulting in a significant decrease in hospital stay and a lower overall cost . We conclude that antibiotic prophylaxis with cefotetan is effective in caesarean sections without a high risk of infection, as it significantly reduces the postoperative morbidity due to infection. G Chir, 1990 Nov-Dec, 11(11-12), 643 - 6 {Aztreonam and clindamycin in short-term antibiotic prophylaxis in colorectal surgery: results of a multicenter studies}; Gardini G et al.; The Authors studied the effects of a short-term prophylaxis (Aztreonam + Clindamycin) administered to 259 patients operated on for colo-rectal diseases . Thirteen wound sepsis (5.15%) and 49 different infections (19.44%) occurred in this group of patients . The study confirms the link between P.N.I . greater than 50 and the incidence of wound infections . The incidence of urogenital sepsis was correlated with the catheterization period (greater than 6 days), operative time (greater than 200 min.), hospitalization (greater than 12 days) and age (greater than 70 years) . General tolerance to the antibiotics was good. Clin Orthop, 1990 Nov, (260), 232 - 41 Trochanteric fractures . Mobility, complications, and mortality in 607 cases treated with the sliding-screw technique; Larsson S et al.; Six hundred seven trochanteric fractures (563 patients) were treated with a sliding-screw technique and followed clinically and roentgenographically for at least one year . Of 351 patients admitted from their homes, 209 (60%) were discharged to their homes after an average of 18 days in the hospital . During the first year another 61 (17%) patients returned home after rehabilitation in a geriatric ward . Of 446 patients walking without support or with one cane before surgery, 360 (80%) had regained the same mobility after one year . The one-year mortality rate was 18%, while the ten-year rate was 74% . Compared with a control cohort, the mortality rate was increased during the first two years after fracture . The increase in mortality was influenced by advanced age, admission from long-term care institutions, male gender, and ambulatory or nonambulatory status before surgery . Forty-five (7.4%) were reoperated, 17 because of technical complications, three because of infection, and three because of nonunion . No further nonunions occurred . The deep infection rate was nine of 339 (2.7%) before and two of 268 (0.8%) after the introduction of antibiotic prophylaxis . Thromboembolic complications decreased from 4.1% to 1.2% after the introduction of dextran 70 as thromboembolic prophylaxis. BMJ, 1990 Oct 20, 301(6757), 911 - 2 Audit of major colorectal and biliary surgery to reduce rates of wound infection; Hancock BD; OBJECTIVE--To reduce the rates of wound infection for major colorectal and biliary surgery . DESIGN--Prospective audit of antibiotic prophylaxis by keeping copies of typed notes of operations and annotating them at discharge and at first follow up visit and annual review of prophylactic regimen according to yearly rate of wound infection and modification if necessary . SETTING--The work of one consultant surgeon working in a district general hospital . PATIENTS--All patients having major colorectal resection during 1976-89 (400) and cholecystectomy during 1981-9 (500) . MAIN OUTCOME MEASURES--Wound infection, defined as any discharge from the wound as detected by observation during inpatient stay and by specific questioning at the first follow up visit six weeks later . RESULTS--Serial changes in prophylaxis for colorectal surgery resulted in a progressive reduction in the rate of wound infection from 43% in 1976, with no prophylaxis, to 1% during 1986-9 with single intravenous doses of metronidazole and cefuroxime intraoperatively and with lavage of the peritoneal cavity and wound with 0.1% tetracycline . During 1981-7, with no prophylaxis, the rate of infection in biliary surgery was 12% whereas in 1988-9, after the introduction of lavage with tetracycline alone, the rate was reduced to 2% . IMPLICATIONS AND ACTION--Simple prospective audit identified the need for changes in antibiotic prophylaxis; successive rounds of audit resulted in improved rates of wound infection, and lavage with 0.1% tetracycline seemed to be a major factor in achieving this. Acta Chir Scand, 1990 Oct, 156(10), 707 - 10 Intraabdominal abscess formation after major liver resection; Andersson R et al.; A series of 138 major liver resections undertaken between 1971 and 1987 were reviewed . Intrabdominal abscesses developed in 11 (8%) patients, a mean of 23 days (range 10-42) after operation and two died (mortality 18%) . Eight developed after 63 right hepatectomies, two after 24 right lobectomies, one after 34 left hepatectomies and none after left lobectomies (17) . Patients who developed intra-abdominal abscesses underwent significantly longer operations (mean (SEM) 400 (48) compared with 275 (21) min) (p less than 0.05) and had significantly more bleeding during the operation (7,600 (1,750) compared with 3,200 (430), p less than 0.01) than those who did not . The amounts recovered from the abdominal drains, both before and after the diagnosis, were comparatively greater in patients with abdominal abscesses . Antibiotic prophylaxis was given to 10 of 11 patients who did and 89 of 127 patients who did not, form abscesses . We conclude that the risk of intra-abdominal abscess formation after major liver resection is increased: when a large amount of liver tissue is removed (right hepatectomy or lobectomy); when there is a lot of intraoperative bleeding; and when the operation takes a long time . Antibiotic prophylaxis did not affect the risk of abscess formation this series. Eur J Vasc Surg, 1990 Oct, 4(5), 547 - 8 Pseudomembranous colitis after abdominal aortic aneurysm repair; Rayter Z et al.; We report three patients who developed pseudomembranous colitis following aortic aneurysm resection . Colonic ischaemia can occur after such surgery and ischaemic colonic mucosa is known to be more susceptible to damage by bacteria and their toxins . This colonic ischaemia together with the antibiotic prophylaxis used may render aortic aneurysm patients susceptible to pseudomembranous colitis . It is important to distinguish pseudomembranous from ischaemic colitis in these patients as specific and effective drug therapy can be given to those with the pseudomembranous type. Can J Surg, 1990 Oct, 33(5), 385 - 8 Antibiotic handbook and pre-printed perioperative order forms for surgical antibiotic prophylaxis: do they work? Girotti MJ, Fodoruk S, Irvine-Meek J, Rotstein OD. The authors attempted to compare the value of two strategies--an educational (antibiotic handbook) and a control (perioperative pre-printed physician order form, which contained antibiotic orders)--in modifying physicians' patterns of antibiotic prophylaxis for preventing infection in patients who undergo elective surgery . They reviewed the charts of 240 such patients on five different surgical services in one teaching hospital . Use of the antibiotic handbook (educational strategy) increased overall compliance with the recommended regimens from 11% to 18% (p = 0.06) . The control strategy (perioperative pre-printed physician order form) increased compliance from 17% to 78% (p less than 0.01). J Trauma, 1990 Oct, 30(10), 1231 - 8 The prophylactic use of antibiotic impregnated beads in open fractures; Henry SL et al.; Four hundred four compound fractures were reviewed in 339 patients treated between August 1983 and November 1987 . The 252 males and 87 females had a mean age of 33 years (range, 14-86) . One hundred twenty-seven (31.4%) fractures were classified as Grade I, 153 (38.9%) as Grade II, and 124 (30.7%) as Grade III by Gustilo's classification . The mean Injury Severity Score was 15 (range, 9-57) . Three hundred thirty-four of the open fractures (82.7%) were managed with antibiotic-impregnated bead chains (tobramycin) and systemic antibiotic prophylaxis (cefazolin, tobramycin, and penicillin) . Seventy open fractures (17.3%) received systemic antibiotic prophylaxis (cefazolin, tobramycin, and penicillin) without supplemental use of the antibiotic beads . All open fractures underwent acute irrigation and debridement . In the 404 fractures 46.5% of wounds were closed primarily, 12.9% underwent delayed primary closure, 7.9% were left open, and 32.7% were temporized by the antibiotic bead pouch technique until definitive flap coverage and skin grafting were performed . Of the 404 fractures evaluated, 17 (4.2%) developed an acute wound infection . Of these wound infections, eight (11.4%) were in the group managed with systemic antibiotics alone . By comparison, nine (2.7%) of open fractures treated with combined systemic antibiotics and antibiotic-impregnated beads developed an infection . Chronic osteomyelitis developed in 18 of 404 open fractures (4.5%) . Ten (14.3%) open fractures which developed osteomyelitis were managed with systemic antibiotics whereas eight (2.4%) fractures managed with systemic antibiotics and antibiotic-impregnated beads developed a chronic infection.(ABSTRACT TRUNCATED AT 250 WORDS) Thorac Cardiovasc Surg, 1990 Oct, 38(5), 280 - 4 Heart transplantation: intraoperative management, postoperative therapy and complications; Haverich A et al.; Currently, heart transplantation (HTX) is performed as an orthotopic cardiac replacement according to the technique of Lower and Shumway in over 95% of the cases with good results . Survival after heterotopic HTX, by contrast, remain poor (one year survival: 50%) . Postoperative therapy compiles primarily prophylactic measures to prevent complications, especially organ rejection and infections . Immunosuppressive prophylaxis generally includes a triple drug therapy consisting of cyclosporin, prednisolone, and azathioprine for maintenance therapy . Initially there is often an additional application of poly- or monoclonal antibodies . The prime measure to prevent infection during the initial hospital stay will be reversed isolation of the recipient . Initial antibiotic prophylaxis resembles that of conservative cardiac surgery, but in addition antiviral and antifungal prophylaxis is applied . The most common postoperative complication following HTX is cardiac rejection, which is detected by routine endomyocardial biopsies . At our institution the incidence of rejection decreases from 3.07 episodes per patient in the first 3 months to 1.97 episodes during the last 6 months of the first year after HTX . In general, acute rejection is treated by methylprednisolone (3 x 500 mg/day) or anti-T-cell-antibodies . Infections often occur following intervals of increased immunosuppression, usually early postoperatively and following therapy of acute rejections . Often, invasive diagnostic measures have to be taken rapidly in order to allow for specific therapy (antibiotics, antimycotic treatment, virostatic agents) . Close follow-up of the heart transplant recipient and rapid therapy of possible postoperative complications enable the current one-year survival rates of 80% or more. J Chemother, 1990 Oct, 2(5), 306 - 9 Antibiotic prophylaxis in gynecological surgery; Oliva GC et al.; A randomized prospective study was undertaken at the Obstetrics and Gynecology Clinic of the Catholic University of Rome in order to evaluate the effectiveness of two wide spectrum antibiotics: mezlocillin and cefotetan . Both drugs were administered 2 g i.v . 15 to 20 minutes preoperatively to allow optimal serum and tissue levels of antibiotic at the moment of bacterial innoculation . 184 patients undergoing elective gynecological surgery for nonmalignant disease were considered eligible for the study (124 pts abdominal hysterectomy, 58 pts vaginal hysterectomy) . We found no statistically significant differences between the results obtained with the two drugs. N Z Med J, 1990 Sep 12, 103(897), 428 - 9 Single dose prophylaxis in colorectal surgery; Bissett IP et al.; Moxalactam disodium (Latamoxef), was evaluated as a single dose prophylactic antibiotic against wound infection in open colorectal surgery . One hundred and five consecutive patients admitted to the university department of surgery, Wellington Hospital, were studied . Twelve patients were excluded because either the antibiotic was not given or antibiotics were given for other reasons . Eleven patients developed early wound infections and one further patient developed a late infection, an overall wound infection rate of 13% (95% CI 7-19) . Whilst this infection rate is higher than that previously reported from this unit using more prolonged (3 dose) antibiotic prophylaxis (9.8%, 95% CI 9.6-10) the difference is not likely to be significant because the patient groups were not matched, and the comparisons were sequential . On the basis of the present study it is concluded that 1 g of moxalactam disodium administered at the induction of anaesthesia in open colorectal surgery is inexpensive, is associated with a low incidence of side effects and its further use in colorectal surgery would seem to be justified. DICP, 1990 Sep, 24(9), 841 - 6 Antibiotic prophylaxis in cesarean section; Glick M et al.; Several controversies exist regarding the use of antibiotic prophylaxis in cesarean section . Studies have investigated effectiveness, choice of drug, timing, duration, and appropriate route of administration . Efficacy of antibiotic prophylaxis in preventing postoperative endometritis in certain high-risk patients has been well documented . Factors identifying patients at high risk for endometritis include: indigent socioeconomic status, labor prior to cesarean section, rupture of chorioamniotic membranes, and number of vaginal examinations . Although many different antibiotics have been tested, no particular regimen has been found to be superior . Administration of antibiotics after cord clamping reduces the risk of fetal exposure without compromising maternal risk of endometritis . A single dose of ampicillin or a first-generation cephalosporin (e.g., cefazolin or cephalothin sodium) given intravenously provides adequate prophylaxis . No additional benefit has been demonstrated with the use of multiple-dose regimens. Minerva Med, 1990 Sep, 81(9), 649 - 51 {Hereditary spherocytosis and splenectomy}; Bertolini A et al.; The case of a sixteen year old girl with hereditary spherocytosis, submitted to splenectomy, is presented . After operation the patient had four serious infections; for this reason she is now treated by antibiotic prophylaxis. J Heart Transplant, 1990 Sep-Oct, 9(5), 502 - 8; discussion 508-9 Influence of the donor lung on development of early infections in lung transplant recipients; Zenati M et al.; Infection of the lung allograft is the greatest cause of morbidity and mortality after heart-lung transplantation . To better understand the pathogenesis of these infections, we compared the results from cultures of the donor tracheas with the type and prevalence of early intrathoracic infections in the recipients . In the last 37 recipients, intrathoracic infections occurred within 2 weeks of operation in 16 (43%) . Organisms isolated from the donor tracheal cultures were different from those associated with early infections, except for three of four recipients with heavy growth of Candida in donor tracheal cultures, in whom fatal invasive candidiasis developed caused by the same species of Candida isolated from the donor culture . Comparisons were made between recipients with (n = 16) and without early infection (n = 21) for age of donors and recipients, ischemic time, length of donor stay in an intensive care unit, donor arterial oxygen pressure, duration of recipient intubation, sterile donor tracheal culture or culture with presence of mouth flora, bacterial pathogens, or Candida, method of lung preservation, and antibiotic prophylaxis of donor . The only factor significantly associated with the onset of early infection was the presence of mouth flora in the donor tracheal culture (p = 0.004, Fisher's exact test, two sided) . Multiple logistic regression was performed to test the additional contribution of other covariates after adjusting for the presence of mouth flora . None of the other covariates contributed to the occurrence of early infection . Recipients with early infection had a significantly lower survival compared with those without early infection (p = 0.04) by the Kaplan-Meier survival analysis.(ABSTRACT TRUNCATED AT 400 WORDS) Endoscopy, 1990 Sep, 22(5), 229 - 33 Complications of diagnostic gastrointestinal endoscopy; Hart R et al.; Undesired side effects and complications of gastrointestinal endoscopy and premedication are rare events . However, this is true only of endoscopic units with experienced investigators, modern equipment and monitoring . The complication rate of upper gastrointestinal endoscopy is about 0.1% with cardiopulmonary events predominating . The typical complication of colonoscopy is perforation, seen in 0.2% . The relevant ERCP specific complication is acute pancreatitis in about 1%, followed by acute cholangitis . The most serious complications of laparoscopy are hemorrhage from the liver biopsy site, bleeding from abdominal wall varices, and perforation of the colon . The cardiopulmonary mortality is low for upper gastrointestinal endoscopy as well as for colonoscopy (1 death/20,000 procedures) . Premedication, chronic obstructive pulmonary disease, coronary heart disease, valvular heart disease and, last but not least, advanced age, must be considered risk factors for the development of complications of gastrointestinal endoscopy . Balanced indication, particularly in the elderly patient, should be the consequence . If possible, endoscopy should be performed without sedatives . If premedication is necessary, it should be used sparingly . Not only patients at high risk for the development of cardiopulmonary complications, but all patients undergoing endoscopy must be carefully monitored after premedication, during and after endoscopy . The non-invasive procedure of pulse-oximetry is appropriate for continuous monitoring of arterial oxygen saturation in patients with cardiopulmonary diseases, irrespective of their premedication status . Antibiotic prophylaxis is recommended in patients with valvular heart disease or prosthetic valves . Standardized cleaning and disinfection of the instruments is of great importance to avoid hepatitis B or HIV transfer.(ABSTRACT TRUNCATED AT 250 WORDS) J Neurosurg, 1990 Sep, 73(3), 383 - 6 Antibiotic prophylaxis during prolonged clean neurosurgery . Results of a randomized double-blind study using oxacillin; Djindjian M et al.; The efficacy of oxacillin as a prophylaxis for infection was analyzed in a 27-month randomized double-blind study of 400 patients who had undergone clean neurosurgical interventions lasting longer than 2 hours . Four neurosurgeons took part in the study and 356 patients were eligible for final analysis . Among the 171 patients treated with oxacillin, there was one case of infection (0.6%), compared to nine (4.9%) of the 185 patients given a placebo . The difference between the two groups was statistically significant (p = 0.0398) . This study, together with others (randomized or not), clearly demonstrates the efficacy of antibiotic prophylaxis in prolonged clean neurosurgery. Neth J Surg, 1990 Aug, 42(4), 96 - 100 Antibiotic prophylaxis in biliary tract surgery--current practice in The Netherlands; Meijer WS; A questionnaire about the current practice of antibiotic prophylaxis in biliary tract surgery was sent to the chairmen of the departments of surgery of 175 hospitals in The Netherlands . The Dutch hospitals are classified into three categories depending on the type of residency in general surgery . Overall, 80 per cent replied . Antibiotic prophylaxis in elective cholecystectomy is given in 76 per cent of the clinics (100/132), and single-dose prophylaxis is employed in 28 per cent of the clinics (28/100) . In patients with acute cholecystitis, emergency surgery is the treatment of choice in 108 hospitals (82%) . Differences in antibiotic prophylaxis between the three categories of hospitals include the omission of prophylaxis in elective cholecystectomy in 31 per cent of the C-clinics (vs . 10% in A-clinics and 16% in B-clinics), and the use of single-dose prophylaxis in 13 per cent of the B-clinics (vs . 30% of the A-clinics and 31% of the C-clinics) . Since prophylaxis for more than 24 hours has no additional effect and peri-operative prophylaxis in acute cholecystitis is mandatory, antibiotic prophylaxis in biliary tract surgery is inappropriate in at least 31 hospitals in The Netherlands (23%). Pediatr Clin North Am, 1990 Aug, 37(4), 839 - 62 The medical evaluation of the sexually abused child; Paradise JE; The diagnosis of suspected sexual abuse is nearly always based on a description of abuse provided by the child . The physician should invite a child to describe his or her sexual victimization in detail if such a "disclosure" interview has not already occurred, if the child seems ready to describe the abuse, and if a child protective services worker has not yet been notified of the suspected abuse . If an allegedly abused child has already been carefully interviewed, however, the physician should instead obtain information from the child's parents or other appropriate adults to determine how best to address the questions being raised . Nonspecific behavioral or somatic complaints unaccompanied by a specific description of sexual abuse should generate a differential diagnosis for further investigation . The goals of the physical examination of the sexually abused child are to identify abnormalities that warrant further diagnostic efforts or treatment, to obtain specimens to screen the patient for sexually transmitted infections, and to make observations and take specimens that may corroborate the patient's history of victimization . These goals should be met in the context of a standard, complete physical examination . The advisability of postcoital contraception should be discussed with every postmenarcheal victim seen within 72 hours after a rape . Because gonorrhea and chlamydial infections are the most prevalent STDs seen after sexual abuse and are often asymptomatic, universal screening for these infections is recommended . Parents of all abused children should be given an opportunity to make an informed choice about HIV screening . Because the risk of acquiring STDs is low, routine antibiotic prophylaxis is not recommended for sexually abused children . Physicians must report all cases of suspected sexual abuse to states' child protective services agencies . Failure to do so can incur legal penalties . Reporting sexual assaults of children to local law enforcement officials is strongly advised . The long-term impact of sexual abuse on children's psychological adjustment is unpredictable . In the short term, children's circumstances vary widely . Some show no evidence of psychological distress . Others have severe, pervasive difficulty . Office counseling by the empathetic and knowledgeable primary care physician, short-term crisis counseling, a more formal psychological evaluation, and longer-term psychotherapy may be recommended for individual children, depending on the nature and severity of each child's symptoms, his or her parents' preference, and the availability of services in the child's community. Plast Reconstr Surg, 1990 Aug, 86(2), 260 - 7; discussion 268-9 Preoperative antibiotics and capsular contracture in augmentation mammaplasty; Gylbert L et al.; The main drawback with augmentation mammaplasty using implants is capsular contracture . The cause of this complication is still unknown . Silicone particles, hematoma, and bacterial contamination are some of the etiologic factors discussed . In this randomized, double-blind study on 76 breast-augmented women, 50 percent of the patients had preoperative prophylaxis with benzylpenicillin and dicloxacillin . Bacteria samples were taken intraoperatively . The number of negative cultures increased significantly with antibiotic prophylaxis . In four follow-ups during the first postoperative year, the rate of contractures was evaluated by subjective and objective methods . The results showed no statistically significant difference between the placebo and the antibiotic group with respect to the incidence of capsular contracture. J Urol, 1990 Aug, 144(2 Pt 2), 541 - 4; discussion 545 Renal scarring and vesicoureteral reflux in children with myelodysplasia; Cohen RA et al.; The records of 180 myelodysplasia patients followed from 3 to 18 years were reviewed . Studies included cystography to evaluate vesicoureteral reflux and dimercapto-succinic acid renal scintigraphy to identify acute inflammation and renal scarring . Scarring was noted in 28 of 180 patients (15.5%), of whom 68% were girls . Of the patients with renal scarring 75% had associated reflux and 40% over-all were identified as having reflux . Management of patients with vesicoureteral reflux included clean intermittent catheterization, antibiotic prophylaxis and anticholinergics when indicated . Only 17 of 72 patients (24%) had ureteral reimplantation . Surgical indications included persistent high grade reflux and/or progressive upper tract damage . Reflux resolved in 62% of those on medical management . Resolution was not dependent on grade of reflux (as compared to primary reflux) . Twenty-one patients are stable and being followed with persistent reflux . In 7 patients new renal scars developed during aggressive medical management, 5 of whom underwent subsequent surgical correction. Cesk Otolaryngol, 1990 Aug, 39(4), 185 - 90 {Antibiotic prophylaxis of early infection in otorhinolaryngology surgery}; Skerik P et al.; The authors draw attention to the urgency of antibiotic prophylaxis of early infection in surgical disciplines and emphasize the main principles of its expedient implementation . In otorhinolaryngology antibiotic prophylaxis proves useful in a number of surgical procedures; the authors submit, however, also examples when they do not consider antibiotic prophylaxis expedient . Among antibiotics used for prophylactic administration they consider at present for the majority of ENT operations cephalosporins of the first generation most useful . Their spectrum is roughly equal to the action of penicillin, oxacillin and ampicillin combined . When selecting an antibiotic, however, always ain individual approach must be used and its selection must be adjusted to the epidemiological situation in different areas and health institutions . The prophylactic use of different types of antibiotics cannot have permanent validity, we have to foresee rotation of antibiotics and the introduction of further new preparations. Clin Orthop, 1990 Jul, (256), 215 - 23 Medial external fixation with lateral plate internal fixation in metaphyseal tibia fractures . A report of eight cases associated with severe soft-tissue injury; Ries MD et al.; Eight patients with unstable fractures involving the articular surface and metaphyseal-diaphyseal bone of the proximal or distal tibia associated with severe soft-tissue injury or compounding wound were treated with irrigation, debridement, tetanus inoculation, antibiotic prophylaxis, and combined internal fixation with one-half frame external skeletal fixation for neutralization . All patients were followed to complete healing and functional restoration of the extremity . All fractures healed, but one superficial and one deep infection occurred . All patients achieved at least 110 degrees of knee motion . This method should be considered in unstable metaphyseal and articular tibia fractures not adequately stabilized with a lateral plate in which use of an additional medial plate is required for stability, but contraindicated because of the status of the soft tissues or extensive comminution of the bone. Ther Umsch, 1990 Jul, 47(7), 612 - 7 {Infected vascular prostheses}; Ammann J; Szilagyi's statement: 'The management of cases with infected arterial implants proves to be a task of grave and sometimes insurmountable difficulty' has kept its validity until today . In spite of restrictive patient selection, perfect surgical skill and perioperative antibiotic prophylaxis, infection of vascular grafts still do occur . Diagnosis has to be established without delay, and treatment of such often fatal infections is an aggressive surgical one. Minerva Chir, 1990 Jun 30, 45(12), 887 - 9 {Short-term antibiotic prophylaxis in cholecystectomy}; D'Amico G et al.; After describing the stages of surgical infection and the efficacy of short-term antibiotic prophylaxis in surgery, the paper reports a trial in which a single dose of Ceftriaxone was administered in 50 cases of cholecystectomy, with excellent results in terms of efficacy and tolerability. Pathol Biol (Paris), 1990 Jun, 38(5 ( Pt 2)), 564 - 7 {Comparative study of two protocols of antibiotic prophylaxis in endoscopic urologic surgery}; Lepage JY et al.; We report an open, prospective, randomized and double-blind study which compared two groups of patients without preoperative bacteriuria, undergoing transurethral urologic surgery . A first group received cefazoline 3 g perioperatively and a second group a single preoperative dose of cefotiam 1 g . A hundred patients were included in each group which were well matched on all essential characteristics, risk factors, surgery, anesthesia and postoperative temperature . The incidence of postoperative infection (bacteriemia and bacteriuria) was the same in both groups (16%) . It is concluded that in transurethral urologic surgery performed in patients without preoperative bacteriuria, 1 preoperative dose cefotiam is as efficacious as 3 perioperative doses cefazoline. HNO, 1990 Jun, 38(6), 197 - 201 {Perioperative preventive use of antibiotics in head and neck surgery}; Mann W et al.; The results of five consecutive prospective trials define the role of perioperative antibiotic prophylaxis in head and neck surgery . For contaminated head and neck cases and for endonasal sinus surgery, a single-dose prophylaxis seems to be sufficient . Most clean cases do not need antibiotic prophylaxis . Risk factors for wound infection include nicotine or alcohol abuse, poor oral hygiene and increasing age . Previous radiotherapy seems to be of minor importance. Surg Clin North Am, 1990 Jun, 70(3), 689 - 701 Pre-, intra-, and postoperative antibiotics; Feliciano DV et al.; Endogenous contamination from perforation or rupture of the gastrointestinal tract; exogenous contamination from missiles, knives, or invasive lines