Is Antibiotic Prophylaxis Necessary before Dental Implant Procedures in Patients with Orthopaedic Prostheses? A Systematic Review

As the population ages, more and more patients with orthopaedic prostheses (OPs) require dental implant treatment. Surveys of dentists and orthopaedic surgeons show that prophylactic antibiotics (PAs) are routinely prescribed with a very high frequency in patients with OPs who are about to undergo dental procedures. The present study aims to determine the need to prescribe prophylactic antibiotic therapy in patients with OPs treated with dental implants to promote their responsible use and reduce the risk of antimicrobial resistance. An electronic search of the MEDLINE database (via PubMed), Web of Science, LILACS, Google Scholar, and OpenGrey was carried out. The criteria used were those described by the PRISMA® Statement. No study investigated the need to prescribe PAs in patients with OPs, so four studies were included on the risk of infections of OPs after dental treatments with varying degrees of invasiveness. There is no evidence to suggest a relationship between dental implant surgeries and an increased risk of OP infection; therefore, PAs in these patients are not justified. However, the recommended doses of PAs in dental implant procedures in healthy patients are the same as those recommended to avoid infections of OPs.

Review of Perioperative Prophylactic Antibiotic Use during Laparoscopic Cholecystectomy and Subsequent Surgical Site Infection Development at a Single Children's Hospital

Objectives With the rise of antibiotic resistance, the use of prophylactic preoperative antibiotics (PPA) has been questioned in cases with low rates of surgical site infection (SSI). We report PPA usage and SSI rates after elective laparoscopic cholecystectomy at our institution. Materials and Methods A retrospective review of children younger than 18 years who underwent elective outpatient laparoscopic cholecystectomy between July 2010 and August 2020 was performed. Demographic, preoperative work-up, antibiotic use, intraoperative characteristics, and SSI data were collected via chart review. SSI was defined as clinical signs of infection that required antibiotics within 30 days of surgery. Results A total of 502 patients met the inclusion criteria; 50% were preoperatively diagnosed with symptomatic cholelithiasis, 47% with biliary dyskinesia, 2% with hyperkinetic gallbladder, and 1% with gallbladder polyp(s). The majority were female (78%) and Caucasian (80%). In total, 60% (n = 301) of patients received PPA, while 40% (n = 201) did not; 1.3% (n = 4) of those who received PPA developed SSI, compared with 5.5% (n = 11) of those who did not receive PPA (p = 0.01). Though PPA use was associated with a 77% reduction in the risk of SSI in multivariate analysis (p = 0.01), all SSIs were superficial. One child required readmission for intravenous antibiotics, while the remainder were treated with outpatient antibiotics. Gender, age, body mass index, ethnicity, and preoperative diagnosis did not influence the likelihood of receiving PPA. Conclusion Given the relatively low morbidity of the superficial SSI, conservative use of PPA is advised to avoid contributing to antibiotic resistance.

The Risk-Benefit Ratio of Leech Therapy: A Single-Center Retrospective Study

Background: Venous congestion in transplanted or replanted tissues remains a common and challenging complication of plastic and reconstructive surgery. The local application of medicinal leeches is effective in reducing postoperative venous congestion in skin flaps and restoring normal blood flow. However, leech therapy is associated with a number of risks, including infections; in order to digest blood, leeches have a symbiotic relationship with Aeromonas species in their gut. Aeromonas infections are associated with a dramatic decrease in flap salvage rates. This is why prophylactic antibiotic treatment and external decontamination of the leeches are widely recommended. Methods: We performed a single retrospective study of patients having undergone leech therapy between January 1st, 2010, and December 31st, 2018, at Amiens-Picardie University Hospital, France. Each patient’s medical history, clinical data, laboratory results, prophylactic antibiotic use, and complications were recorded.Results: A total of 37 patients (mean age: 47) had undergone leech therapy after reconstructive surgery. Antimicrobial prophylaxis was documented in 32 (84.6%) patients. However, there are no guidelines on the choice of prophylactic antibiotic treatment. Twenty-four of the 37 (64.8 %) patients had anemia (mean hemoglobin level: 8.5 (6-11.1) g/dL), and 13 of the 24 (54%) required a transfusion. Thirteen of the 37 patients (35.1%) had a post-operative infection mainly due to Aeromonas spp. (76.9%). Leech therapy was effective in 23 of the 37 patients (62%) overall and in 2 of the 10 patients (20%) with an Aeromonas infection. The association between Aeromonas infection and flap salvage failure was highly significant (p = 0.005).Conclusions: The results of the study emphasized that clinical bacteriologists and surgeons should be aware that leeches are potential sources of infection.

Complications Associated With Totally Implanted Venous Access Devices in the Arm Versus the Chest: A Short-Term Retrospective Study

Purpose: To retrospectively compare complications for totally implanted venous access devices (TIVADs or ports) in the arm vs. the chest. One participating institution implanted all TIVADs in the arm, whereas the other institution implanted them in the chest. Methods: Subjects were consecutive patients > 18 years with a device inserted between July 2017 and January 2019 at either Hospital A, where all devices were implanted in the arm, or at Hospital B, where all devices were implanted in the chest. Complications (rates/1,000 catheter-days and frequencies) were compared between the arm and chest locations. Results: 201 arm devices (71% female, mean age 59.4 years) and 203 chest devices (66% female, mean age 61.5 years) were assessed. Overall complication rates did not differ between the arm and chest [arm: 30 complications per 56,938 catheter-days (0.530/1,000 catheter-days) vs. chest: 47 complications per 63,324 catheter-days (0.742/1,000 catheter-days), p-value 0.173]. Periprocedural complications and mechanical malfunction also did not differ. Although prophylactic antibiotic use was higher in the chest (79.3% vs. 1.50%, p-value < 0.0001), infection rates did not differ. Arm venous thrombosis was significantly higher in the arm cohort (0.205 vs. 0.017/1,000 catheter-days, p-value 0.003) and pulmonary thromboembolism in the chest cohort (0.269 vs 0.056/1,000 catheter-days, p-value 0.002). Conclusions: While arm venous thrombosis was higher in the arm and pulmonary thromboembolism in the chest cohort, other complications were similar. Antibiotic use was more frequent in the chest cohort, while infection rates remained similar in both cohorts.

The Effect of Pharmacist-Led Intervention on Surgical Antibacterial Prophylaxis (SAP) at an Orthopedic Unit

Perioperative antibiotic use is a common reason for antibiotic misuse. Evidence suggests that adherence to SAP guidelines may improve outcomes. The purpose of this study was to analyze the impact of pharmacist-led antibiotic stewardship interventions on SAP guideline compliance. The study was conducted at an Orthopedic Department of a tertiary care medical center. SAP compliance and antibiotic exposure in the pre-intervention and intervention period was compared using chi-square, Fisher exact, and Mann-Whitney tests, as appropriate. Prophylactic antibiotic use in orthopedic joint arthroplasties (overall guideline adherence: agent, dose, frequency, duration), clinical outcomes (length of stay-LOS, number of surgical site infections-SSIs), antibiotic exposure and direct antibiotic costs were compared between pre-intervention and intervention periods. Significant improvement in mean SAP duration (by 42.9%, 4.08 ± 2.08 vs. 2.08 ± 1.90 days, p ˂ 0.001), and overall guideline adherence regarding antibiotic use (by 56.2%, from 2% to 58.2%, p ˂ 0.001) were observed. A significant decrease was observed in antibiotic exposure in SAP (by 41%, from 6.07 ± 0.05 to 3.58 ± 4.33 DDD/patient, p ˂ 0.001), average prophylactic antibiotic cost (by 54.8%, 9278.79 ± 6094.29 vs. 3598.16 ± 3354.55 HUF/patient), and mean LOS (by 37.2%, from 11.22 ± 6.96 to 7.62 ± 3.02 days, p < 0.001); and a slight decrease in the number of confirmed SSIs was found between the two periods (by 1.8%, from 3% to 1.2%, p = 0.21). Continuous presence of the clinical pharmacist led to significant improvement in SAP guideline adherence, which was accompanied by decreased antibiotic exposure and cost.

Single-dose antibiotic prophylaxis compared with multiple-dose protocol in clean pediatric neurosurgical interventions: a nonrandomized, historically controlled equivalence trial

OBJECTIVE Guidelines recommend antimicrobial prophylaxis (AMP) preoperatively for "clean" spinal and cranial surgeries, while dose and timing remain controversial. The use of multiple-dose AMP for such surgeries is under debate in the pediatric context. In this clinical study, the authors aimed to compare single-dose with multiple-dose prophylactic antibiotic usage in cranial and spinal neurosurgical interventions of pediatric patients. METHODS All neurosurgical patients aged 28 days to 18 years who underwent surgery at a single tertiary center were assessed. Three cohorts (noninstrumented clean spinal, noninstrumented cranial, and instrumented cranial interventions), each of which comprised two 50-patient arms (i.e., single-dose AMP and multiple-dose AMP), were included after propensity score–matched retrospective sampling and power analysis. Records were examined for surgical site infections. Using a previously published meta-analysis as the prior and 80% acceptance of equivalence (margin of OR 0.88–1.13), logistic regression was carried out for the total cohort and each subcohort and adjusted for etiology by consideration of multiple-dose AMP as reference. RESULTS The overall sample included 300 age- and sex-matched patients who were evenly distributed in 3 bi-arm cohorts. There was no statistical intercohort difference based on etiology or type of operation (p < 0.05). Equivalence analysis revealed nondiscriminating results for the total cohort (adjusted OR 0.65, 95% CI 0.27–1.57) and each of the subcohorts (noninstrumented clean spinal, adjusted OR 0.65, 95% CI 0.12–3.44; noninstrumented cranial, adjusted OR 0.52, 95% CI 0.14–2.73; and instrumented cranial, adjusted OR 0.68, 95% CI 0.13–3.31). CONCLUSIONS No significant benefit for multiple-dose compared with single-dose AMPs in any of the pediatric neurosurgery settings could be detected. Since unnecessary antibiotic use should be avoided as much as possible, it seems that usage of single-dose AMP is indicated.

Antibiotic overuse in obstetric and gynecologic procedures at Zagazig university hospitals: A prospective observational study

Surgical site infection (SSI) constitutes a major problem in healthcare in terms of healthcare cost, morbidity and mortality. Surgical antibiotic prophylaxis (SAP) is one of the effective strategies for SSI prevention. Poor adherence to SAP guidelines across different countries has been observed. Misuse of prophylactic antibiotics threatens patient safety and leads to an increase in the acquisition of antibiotic resistance. The aim of this study was to assess the utilization of SAP in obstetric and gynecologic procedures in terms of indication for prophylaxis, antibiotic selection, timing of administration and prophylaxis duration. A prospective observational study was conducted at the obstetrics and gynecology department of Zagazig University Hospital during the period from January 2020 to June 2020. Medical records of 264 women were recorded and evaluated. The American Society of Health-System Pharmacists (ASHP) therapeutic guidelines, World Health Organization (WHO) recommendations and The American College of Obstetricians and Gynecologists (ACOG) practice bulletin were used for data evaluation and hence women were stratified into two groups. For women who underwent procedures in which guidelines recommended the use of SAP (200 patients; 75.75%), 198 women (99%) received preoperative prophylaxis. None of women (0%) received the recommended first line antibiotic by guidelines while the most commonly used prophylactic antibiotics were Cefotaxime (86 patients; 43.43%) and Ampicillin-sulbactam (62 patients; 31.31%). Preoperative antibiotic prophylaxis timing was 0-60 minutes before skin incision. All women received postoperative prophylaxis that extended to an average of 7 days. Regarding the other group who underwent procedures in which prophylactic antibiotics weren’t recommended by guidelines (64 patients; 24.24%), 37 women (57.81%) followed the guidelines and didn’t receive SAP while 27 women (42.18%) received SAP. Poor adherence to guidelines recommendations regarding prophylactic antibiotic selection and prophylaxis duration was observed. High utilization rate of prophylactic antibiotics in procedures that didn’t require their use was reported..

Feasibility of percutaneous endoscopic gastrostomy insertion in children receiving peritoneal dialysis

Background: Peritoneal dialysis (PD) is the preferred dialysis modality for paediatric patients with end-stage kidney disease. Frequently, malnutrition is encountered. Percutaneous endoscopic gastrostomy (PEG) is the preferred mode of feeding because of its minimal invasive mode of placement and easy handling in daily life. However, reports of a high risk for early post-interventional peritonitis hampered this procedure during PD and controlled studies on the benefit of peri-interventional management to prevent peritonitis are lacking. Here, we report the safety profile of PEG insertion among a cohort of children on PD by using a prophylactic antibiotic and antifungal regimen as well as modification of the PD programme. Methods: We performed a single-centre analysis of paediatric PD patients receiving PEG placement between 2015 and 2020. Demographic data, peri-interventional prophylactic antibiotic and antifungal treatment as well as modification of the PD programme were gathered and the incidence of peritonitis within a period of 28 days after PEG was calculated. Results: Eight PD patients (median weight 6.7 kg) received PEG insertion. Antibiotic and antifungal prophylaxis were prescribed for median time of 4.0 and 5.0 days, respectively. After individual reduction of PD intensity, all patients continued their regular PD programme after a median of 6 days. One patient developed peritonitis within 24 h after PEG insertion and simultaneous surgery for hydrocele. Conclusions: Applying an antibiotic and antifungal prophylactic regime as well as an adapted PD programme may reduce the risk for peritonitis in paediatric PD patients who receive PEG procedure.

Population-Based Surveillance of Pneumococcal Infections in Children with Sickle Cell Disease before and after Prevnar 7® and Prevnar 13® Licensure: Implications for Expanded Vaccination

Before prophylactic antibiotic use, approximately 1/10 children &lt;5 years old with sickle cell disease (SCD) developed invasive pneumococcal disease (IPD) with a high risk of meningitis and death. Although the emergence of penicillin-resistance in IPD threatened benefits of penicillin prophylaxis, after licensure of the 7-valent pneumococcal polysaccharide vaccine (PCV7) in 2000, IPD rates in children with SCD decreased by over 2/3. In 2010, PCV13 (serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 19A, 19F, 18C, 23F) was licensed in children, and in 2021, two additional conjugated vaccines were approved for use in adults: PCV15 (VAXNEUVANCE®, PCV13+: 22F, 33F) and PCV20 (PREVNAR20®, PCV13+: 8, 10A, 11A, 12F, 15B, 22F, 33F). IPD rates in children with SCD over 24 years in Atlanta were evaluated to describe trends in age of infection, frequency of antibiotic resistance, non-vaccine IPD serotype distribution after vaccine licensures, and estimates for serotype coverage by newer vaccines. IPD among children with SCD, ages 0 to 4 years and 5 to 9 years, residing in the Metropolitan area of Atlanta, Georgia, USA, from 1/1/1994 through 7/31/2018, were compared to the general population. The Centers for Disease Control and Prevention (CDC)-funded Georgia Emerging Infections Program (GA EIP) Active Bacterial Core Surveillance network included initially 8 counties in 1994 and from 1997 onward, 20 counties (total populations of approximately 3.8 and 5.1 million, respectively). Two registries of patients with SCD seen at least once at one of 3 pediatric hospitals serving the region were merged and matched with GA EIP data. The serotyping and antibiotic susceptibility testing were conducted at the CDC. The study was approved by the Emory University Institutional Review Board. Data from 3 periods: pre PCV period (94-99), PCV7 period (00-09) and PCV13 period (10-18) were analyzed. Compared to the pre PCV period, overall, IPD rates decreased in children with SCD vs 91% in the RP for 0-4 years; and 80% in children with SCD vs 78% in the RP for 5-9 years (table1). The difference in IPD rates between patients with SCD and the general population increased over time: pre PCV period, relative risk (RR)=24.22 (95 % Confidence Interval [CI] 17.43,32.88), P&lt;.001; PCV 7 period, RR=32.17 (95 %CI 22.17,45.37), P&lt;.001; PCV 13 period, RR=39.18 (95 %CI 22.35,64.69) P&lt;.001. Meningitis and deaths from IPD decreased significantly in all populations examined but remained significantly higher in patients with SCD compared to RP (table 2). The mean age at IPD diagnosis for the 3 periods examined increased both in SCD and in the RP. For those with SCD (n=50), pre-PCV7 period mean age was :2.7 standard deviation (+/-) 2.3 years; for the PCV 13 period: n=19; 3.7 years +/-2.2 years p= 0.0877; for the RP: Pre-PCV period: n=1025; 1.3 +/-1.6 years; PCV 13 period: n=213; 2.2 +/-2.3 years. Overall absolute IPD rates declined for all age groups examined (table 1). Prior to PCV7 licensure, IPD in patients with SCD were significantly less likely to be penicillin susceptible (MIC &lt;0.06 µg/mL) compared to the RP: 41.9% (18/43) vs 60.0% (476/793) RR=0.70 (95% CI 0.49,1.00), p=0.025. This difference was no longer present after PCV licensure (PCV 13 period , SCD 52.9% [9/17], vs RP 48.6% [70/144]). Non PCV serotypes IPD rates increased after PCV7 licensure but remained stable after PCV13 licensure; 16% of non PCV13 serotypes during all time periods are included in PCV15, whereas PCV20 may cover between 29% and 50% depending on related serotypes cross protection (table3). Although significantly less frequent compared with pre-PCV-era, IPD can be severe in patients with SCD. Increase in IPD age was seen in both SCD and RP. Lower rates of penicillin non-susceptibility may may reflect lower exposure to penicillin prophylaxis. Newer vaccines may offer expanded coverage for children with SCD. Ongoing surveillance will help determine their effect. Vaccines that cover all serotypes are needed. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.