Posts filed under ‘Profilaxis Antibiótica en Cirugía – PAC’

Decolonization in Prevention of Health Care-Associated Infections.

Clin Microbiol Rev. April 2016 V.29 N.2 P.201-22.

Septimus EJ1, Schweizer ML2.

Author information

1 Hospital Corporation of America, Nashville, Tennessee, USA Texas A&M Health Science Center, College of Medicine, Houston, Texas, USA Edward.septimus@hcahealthcare.com.

2 University of Iowa Carver College of Medicine, Iowa City, Iowa, USA Iowa City VA Health Care System, Iowa City, Iowa, USA University of Iowa College of Public Health, Iowa City, Iowa, USA.

Abstract

Colonization with health care-associated pathogens such as Staphylococcus aureus, enterococci, Gram-negative organisms, and Clostridium difficile is associated with increased risk of infection.

Decolonization is an evidence-based intervention that can be used to prevent health care-associated infections (HAIs).

This review evaluates agents used for nasal topical decolonization, topical (e.g., skin) decolonization, oral decolonization, and selective digestive or oropharyngeal decontamination. Although the majority of studies performed to date have focused on S. aureus decolonization, there is increasing interest in how to apply decolonization strategies to reduce infections due to Gram-negative organisms, especially those that are multidrug resistant.

Nasal topical decolonization agents reviewed include mupirocin, bacitracin, retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, photodynamic therapy, omiganan pentahydrochloride, and lysostaphin.

Mupirocin is still the gold standard agent for S. aureus nasal decolonization, but there is concern about mupirocin resistance, and alternative agents are needed. Of the other nasal decolonization agents, large clinical trials are still needed to evaluate the effectiveness of retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, omiganan pentahydrochloride, and lysostaphin.

Given inferior outcomes and increased risk of allergic dermatitis, the use of bacitracin-containing compounds cannot be recommended as a decolonization strategy.

Topical decolonization agents reviewed included chlorhexidine gluconate (CHG), hexachlorophane, povidone-iodine, triclosan, and sodium hypochlorite. Of these, CHG is the skin decolonization agent that has the strongest evidence base, and sodium hypochlorite can also be recommended. CHG is associated with prevention of infections due to Gram-positive and Gram-negative organisms as well as Candida.

Conversely, triclosan use is discouraged, and topical decolonization with hexachlorophane and povidone-iodine cannot be recommended at this time.

There is also evidence to support use of selective digestive decontamination and selective oropharyngeal decontamination, but additional studies are needed to assess resistance to these agents, especially selection for resistance among Gram-negative organisms.

The strongest evidence for decolonization is for use among surgical patients as a strategy to prevent surgical site infections.

PDF

http://cmr.asm.org/content/29/2/201.full.pdf+html

May 12, 2017 at 7:45 am

Eradication of methicillin-resistant Staphylococcus aureus carriage: a systematic review.

Clin Infect Dis. Apr 1, 2009 V.48 N.7 P.922-30.

Ammerlaan HS1, Kluytmans JA, Wertheim HF, Nouwen JL, Bonten MJ.

Author information

1 Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands. H.Ammerlaan@umcutrecht.nl

Abstract

A systematic review was performed to determine the effectiveness of different approaches for eradicating methicillin-resistant Staphylococcus aureus carriage. Twenty-three clinical trials were selected that evaluated oral antibiotics (7 trials), topically applied antibiotics (12 trials), or both (4 trials). Because of clinical heterogeneity, quantitative analysis of all studies was deemed to be inappropriate, and exploratory subgroup analyses were performed for studies with similar study populations, methods, and targeted bacteria. The estimated pooled relative risk of treatment failure 1 week after short-term nasal mupirocin treatment, compared with placebo, was 0.10 (range, 0.07-0.14). There was low heterogeneity between study outcomes, and effects were similar for patients and healthy subjects, as well as in studies that included only methicillin-susceptible S. aureus carriers or both methicillin-susceptible S. aureus and methicillin-resistant S. aureus carriers. The development of drug resistance during treatment was reported in 1% and 9% of patients receiving mupirocin and oral antibiotics, respectively. Short-term nasal application of mupirocin is the most effective treatment for eradicating methicillin-resistant S. aureus carriage, with an estimated success of rate of 90% 1 week after treatment and approximately 60% after a longer follow-up period.

PDF

https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/cid/48/7/10.1086/597291/2/48-7-922.pdf?Expires=1494547126&Signature=C-3w0qidaoRa7nD1JLkVurTsGPMZt6nFPH~~ukmz~Wrdd2rLVyc4nFgZ5uT0RDQSwfwFtWB2QPZw8l7HjcKFHWaiSy8qEDU3uZM28k~O4MHJYjd~B86s2~s8-xP9j04r6TKdnJ2lsY3VZLXEb22vNGmERggjk4B2h7DUCAJGXBBba-7AixeOYEbLumFS8-5SmkCgBSKsKsa8UWzqmXJWZrQDlgMLMzqAUURfPITtO9AoiLUzDH~bVNd5zCozVmfpbxf3nAVk4cZVekXwNiAH3SYHOKfVd3YomfEzd5~tBxRwwqnxDp8kvCJtB1oFv9HNMf3Jy1GdMCnjNuyVrA1cQg__&Key-Pair-Id=APKAIUCZBIA4LVPAVW3Q

May 10, 2017 at 7:11 pm

Gram-negative prosthetic joint infections: risk factors and outcome of treatment.

Clin Infect Dis. 2009 Oct 1;49(7):1036-43

Hsieh PH, Lee MS, Hsu KY, Chang YH, Shih HN, Ueng SW.

Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No. 5, Fu-Hsing St., 333 Kweishian, Taoyuan, Taiwan. hsiehph@adm.cgmh.org.tw

BACKGROUND:

Little information is available regarding the demographic characteristics and outcomes of patients with prosthetic joint infection (PJI) resulting from gram-negative (GN) organisms, compared with patients with PJI resulting from gram-positive (GP) organisms.

METHODS:

We performed a retrospective cohort analysis of all cases of PJI that were treated at our institution during the period from 2000 through 2006.

RESULTS:

GN microorganisms were involved in 53 (15%) of 346 first-time episodes of PJI, and Pseudomonas aeruginosa was the most commonly isolated pathogen (21 [40%] of the 53 episodes). Patients with GN PJI were older (median age, 68 vs. 59 years; P<.001) and developed infection earlier (median joint age, 74 vs. 109 days; P<.001) than those with GP PJI. Of the 53 episodes of GN PJI, 27 (51%) were treated with debridement, 16 (30%) with 2-stage exchange arthroplasty, and 10 (19%) with resection arthroplasty. Treating GN PJI with debridement was associated with a lower 2-year cumulative probability of success than treating GP PJI with debridement (27% vs. 47% of episodes were successfully treated; P=.002); no difference was found when a PJI was treated with 2-stage exchange or resection arthroplasty. A longer duration of symptoms before treatment with debridement was associated with treatment failure for GN PJI, compared with for GP PJI (median duration of symptoms, 11 vs. 5 days; P=.02).

CONCLUSIONS:

GN PJI represents a substantial proportion of all occurrences of PJI. Debridement alone has a high failure rate and should not be attempted when the duration of symptoms is long. Resection of the prosthesis, with or without subsequent reimplantation, as a result of GN PJI is associated with a favorable outcome rate that is comparable to that associated with PJI due to GP pathogens.

PDF

https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/cid/49/7/10.1086/605593/2/49-7-1036.pdf?Expires=1491958662&Signature=IxAKWF6-WgKZaPGD72JDtgQ9EfZuwpmNFPVdR-BdK33eRJu1GUZJXyCJ7ri9ZaJ-a4T2iy6Mj1nesDu5OTWvIfp2j5XaVprK679YVFFTXrSfwHRKFO8JDumpQWlBnByaEbCEsj~ky9lFBC~~2xrpArBj31INcTvo1vLo5sICnAjdiELud-7DVPsbupIMI7ZE3HJiWJFNiP8FGIgyiCEeD2EhGUieinh7IbChHW6tjzh5v-AIB1LCiQzHPaVo8QPMbu9HH7ggA0JlS7YXjwhwJJfdjYU4pgWxeBL9p464aVUmZWotZzoN-lNM46Wyryl4U1xrPETeCZOVC1u8fGMdNQ__&Key-Pair-Id=APKAIUCZBIA4LVPAVW3Q

April 7, 2017 at 10:07 pm

Is asymptomatic bacteriuria a risk factor for prosthetic joint infection?

Clin Infect Dis. 2014 Jul 1;59(1):41-7.

Sousa R1, Muñoz-Mahamud E2, Quayle J3, Dias da Costa L1, Casals C2, Scott P3, Leite P1, Vilanova P2, Garcia S2, Ramos MH4, Dias J5, Soriano A6, Guyot A7.

Author information

Departments of Orthopaedics.

1 Department of Orthopaedics

2 Department of Orthopaedics, Bone and Joint Infection Unit.

3 Department of Orthopaedics.

4 Microbiology, Centro Hospitalar do Porto-Hospital de Santo António.

5 Department of Biostatistics, Administração Regional de Saúde do Norte, Porto, Portugal.

6 Department of Infectious Diseases, Hospital Clínic of Barcelona, Spain.

7 Department of Microbiology, Frimley Park Hospital, Frimley, United Kingdom.

Abstract

BACKGROUND:

Infection is a major complication after total joint arthroplasty. The urinary tract is a possible source of surgical site contamination, but the role of asymptomatic bacteriuria (ASB) before elective surgery and the subsequent risk of infection is poorly understood.

METHODS:

Candidates for total hip or total knee arthroplasty were reviewed in a multicenter cohort study. A urine sample was cultured in all patients, and those with ASB were identified. Preoperative antibiotic treatment was decided on an individual basis, and it was not mandatory or randomized. The primary outcome was prosthetic joint infection (PJI) in the first postoperative year.

RESULTS:

A total of 2497 patients were enrolled. The prevalence of ASB was 12.1% (303 of 2497), 16.3% in women and 5.0% in men (odds ratio, 3.67; 95% confidence interval, 2.65-5.09; P < .001). The overall PJI rate was 1.7%. The infection rate was significantly higher in the ASB group than in the non-ASB group (4.3% vs 1.4%; odds ratio, 3.23; 95% confidence interval, 1.67-6.27; P = .001). In the ASB group, there was no significant difference in PJI rate between treated (3.9%) and untreated (4.7%) patients. The ASB group had a significantly higher proportion of PJI due to gram-negative microorganisms than the non-ASB group, but these did not correlate to isolates from urine cultures.

CONCLUSIONS:

ASB was an independent risk factor for PJI, particularly that due to gram-negative microorganisms. Preoperative antibiotic treatment did not show any benefit and cannot be recommended.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4305141/pdf/ciu235.pdf

April 6, 2017 at 8:30 am

Methicillin-Resistant and Methicillin-Sensitive Staphylococcus aureus Screening and Decolonization to Reduce Surgical Site Infection in Elective Total Joint Arthroplasty

Journal of Arthroplasty September 2016 V.31 N.9 P.144–147

Scott M. Sporer, Thea Rogers, Linda Abella

Background

Deep infection after elective total joint arthroplasty remains a devastating complication. Preoperative nasal swab screening for Staphylococcus aureus colonization and subsequent treatment of colonized patients is one proposed method to identify at-risk patients and decrease surgical site infections (SSIs). The purpose of this study was to determine whether a preoperative staphylococcus screening and treatment program would decrease the incidence of SSI in elective joint arthroplasty patients.

Methods

Since January 2009, a total of 9690 patients having an elective joint arthroplasty were screened before surgery for Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA) with nares swabs. All patients with positive nare colonization for MSSA and MRSA were treated with mupirocin and chlorhexidine gluconate showers for 5 days before surgery. MRSA patients received vancomycin preoperatively and were placed in contact isolation. All elective arthroplasty patients used chlorhexidine gluconate antiseptic cloths the evening prior and the day of surgery. Perioperative infection rates were compared from 1 year before implementation to 5 years after implementation of this screening protocol.

Results

SSI rates have decreased from 1.11% (prescreening) to 0.34% (nasal screening; P < .05) after initiation of the process. Staphylococcus was identified in 66.7% of the SSI infections before nasal screening and in 33.3% of the SSI after routine screening (P > .05).

Conclusion

The addition of MRSA and/or MSSA nares screening along with a perioperative decolonization protocol has resulted in a decreased SSI rate by 69%.

abstract

http://www.arthroplastyjournal.org/article/S0883-5403(16)30157-7/fulltext

PDF

http://www.arthroplastyjournal.org/article/S0883-5403(16)30157-7/pdf

November 26, 2016 at 11:02 am

Prevention of Periprosthetic Joint Infection.

Arch Bone Jt Surg. April 2015 V.3 N.2 P.72-81.

Shahi A1, Parvizi J1.

Author information

1Alisina Shahi MD Javad Parvizi MD, FRCS The Rothman Institute of Orthopaedics at Thomas Jefferson University, Philadelphia, PA.

Abstract

Prosthetic joint infection (PJI) is a calamitous complication with high morbidity and substantial cost. The reported incidence is low but it is probably underestimated due to the difficulty in diagnosis. PJI has challenged the orthopaedic community for several years and despite all the advances in this field, it is still a real concern with immense impact on patients, and the healthcare system. Eradication of infection can be very difficult. Therefore, prevention remains the ultimate goal. The medical community has executed many practices with the intention to prevent infection and treat it effectively when it encounters. Numerous factors can predispose patients to PJI. Identifying the host risk factors, patients’ health modification, proper wound care, and optimizing operative room environment remain some of the core fundamental steps that can help minimizing the overall incidence of infection. In this review we have summarized the effective prevention strategies along with the recommendations of a recent International Consensus Meeting on Surgical Site and Periprosthetic Joint Infection.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4468618/pdf/ABJS-3-72.pdf

November 20, 2016 at 8:44 pm

Population Pharmacokinetics and Dosing Regimen Optimization of Meropenem in Cerebrospinal Fluid and Plasma in Patients with Meningitis after Neurosurgery

Antimicrob. Agents Chemother. November 2016 V.60 N.11 P.6619-6625

Cheng Lu, Yuyi Zhang, Mingyu Chen, Ping Zhong, Yuancheng Chen, Jicheng Yu, Xiaojie Wu, Jufang Wu, and Jing Zhang

aInstitute of Antibiotics, Huashan Hospital Affiliated to Fudan University, Shanghai, China

bKey Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China

cDepartment of Neurosurgery, Huashan Hospital Affiliated to Fudan University, Shanghai, China

Meropenem is used to manage postneurosurgical meningitis, but its population pharmacokinetics (PPK) in plasma and cerebrospinal fluid (CSF) in this patient group are not well-known.

Our aims were to (i) characterize meropenem PPK in plasma and CSF and (ii) recommend favorable dosing regimens in postneurosurgical meningitis patients.

Eighty-two patients were enrolled to receive meropenem infusions of 2 g every 8 h (q8h), 1 g q8h, or 1 g q6h for at least 3 days. Serial blood and CSF samples were collected, and concentrations were determined and analyzed via population modeling.

Probabilities of target attainment (PTA) were predicted via Monte Carlo simulations, using the target of unbound meropenem concentrations above the MICs for at least 40% of dosing intervals in plasma and at least of 50% or 100% of dosing intervals in CSF.

A two-compartment model plus another CSF compartment best described the data. The central, intercentral/peripheral, and intercentral/CSF compartment clearances were 22.2 liters/h, 1.79 liters/h, and 0.01 liter/h, respectively.

Distribution volumes of the central and peripheral compartments were 17.9 liters and 3.84 liters, respectively. The CSF compartment volume was fixed at 0.13 liter, with its clearance calculated by the observed drainage amount.

The multiplier for the transfer from the central to the CSF compartment was 0.172. Simulation results show that the PTAs increase as infusion is prolonged and as the daily CSF drainage volume decreases.

A 4-hour infusion of 2 g q8h with CSF drainage of less than 150 ml/day, which provides a PTA of >90% for MICs of ≤8 mg/liter in blood and of ≤0.5 mg/liter or 0.25 mg/liter in CSF, is recommended. (This study has been registered at ClinicalTrials.gov under identifier NCT02506686.)

PDF

http://aac.asm.org/content/60/11/6619.full.pdf+html

November 19, 2016 at 7:59 am

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