Surgical antibiotic prophylaxis: is the clinical practice based on evidence? / Antibioticoprofilaxia cirúrgica: sua prática clínica está baseada em evidências?

ABSTRACT Objective: To assess the surgical antibiotic prophylaxis. Methods: This was a descriptive study performed at a public tertiary care university hospital gathering prescription, sociodemographic and hospitalization data of inpatients admitted in 2014 who used antimicrobial drugs. This data were obtained from the hospital electronic database. The antimicrobial data were classified according to the anatomical, therapeutic chemical/defined daily dose per 1,000 inpatients. An exploratory analysis was performed using principal component analysis. Results: A total of 5,182 inpatients were prescribed surgical antibiotic prophylaxis. Of the total antimicrobial use, 11.7% were for surgical antibiotic prophylaxis. The orthopedic, thoracic and cardiovascular postoperative units, and postoperative intensive care unit comprised more than half of the total surgical antibiotic prophylaxis use (56.3%). The duration of antimicrobial use of these units were 2.2, 2.0, and 1.4 days, respectively. Third-generation cephalosporins and fluoroquinolones had the longest use among antimicrobial classes. Conclusion: Surgical antibiotic prophylaxis was inadequate in the orthopedic, postoperative intensive care, thoracic and cardiovascular postoperative, gynecology and obstetrics, and otolaryngology units. Therefore, the development and implementation of additional strategies to promote surgical antibiotic stewardship at hospitals are essential.

RESUMO Objetivo: Avaliar a utilização de antibioticoprofilaxia cirúrgica. Métodos: Foi realizado um estudo descritivo em um hospital universitário de cuidado terciário por meio de coleta de dados de prescrição, sociodemográficos e de hospitalização sobre todos os pacientes internados em 2014 que utilizaram pelo menos um medicamento antimicrobiano. Esses dados foram coletados da base de dados eletrônica do hospital. O consumo de antimicrobianos foi analisado de acordo com a classificação anatômica terapêutica e química/dose diária definida por mil pacientes-dia. Realizou-se uma análise exploratória por meio da análise de componentes principais. Resultados: Um total de 5.182 pacientes internados receberam prescrição de antibioticoprofilaxia cirúrgica, que corresponde a 11,7% do total de antibióticos utilizados no hospital. As unidades de ortopedia, pós-operatória de cirurgia torácica e cardiovascular e terapia intensiva pós-operatória foram responsáveis pela utilização de mais da metade (56,3%) da antibioticoprofilaxia cirúrgica. A duração de uso desses antimicrobianos nessas unidades foi 2,2, 2,0 e 2,4 dias, respectivamente. Cefalosporinas de terceira geração e fluoroquinolonas foram as classes de antimicrobianos com tempo de utilização mais longo. Conclusão: A utilização de antibioticoprofilaxia cirúrgica foi inadequada nas unidades de ortopedia, pós-operatória de cirurgia torácica e cardiovascular, terapia intensiva pós-operatória, ginecologia e obstetrícia e otorrinolarigonlogia. Portanto, são importantes o desenvolvimento e a implantação de estratégias que promovam o uso racional de antibioticoprofilaxia cirúrgica nos hospitais.

Informe ultrarrápido de evaluación de tecnología sanitária: profilaxis antibiótica para la leptospirosis en caso de desastre natural (inundación) / Ultra-rapid report health technology assessment: antibiotic prophylaxis for leptospirosis in the event of a natural disaster (flood)

La leptospirosis es una zoonosis bacteriana causada por especies del género Leptospira que afectam a humanos y animales. Su reservorio lo constituyen los roedores y animales domésticos principalmente, y su transmisión ocurre por la contaminación de suelos y agua con la orina de estos animales. Su distribucción es amplia en países tropicales incluyendo la región del Caribe, América Central y paises de Amércia del Sur. La mayoría de las infecciones son subclínicas o leves, pero puede ocasionar cuadros clínicos graves e incluso fatales. Situaciones particularmente graves de riesgo de infección las constituyen las inundaciones, ya que aumenta el contacto con aguas contaminadas por la orina de los animales vectores. Se realizó un informe ultrarrápido de evaluación de tecnología sobre las profilaxis antibiótica para la leptospirosis en caso de inundación a pedido de las autoridades del Ministerio de Salud de la Provincia de Burenos Aires. Conclusiones: La evidencia analizada no permite determinar si existen beneficios claros en relación al uso de doxiciclina 200 ms semanal en forma profiláctica para evitar la infección por leptospirosis en caso de inundación, luego de la exposición al factor de risgo. En cambio sí se observó aumento de efectos adversos leves (náuseas y vómitos) con el empleo de dicho antibiótico. Se necesitan nuevos ensayos clínicos controlados y aleatorizados de alta calidad metodológica para poder esclarecer la efectividad de la quimioproflaxis de casos de leptospirosis epidémica relacionados a inundaciones. Intervención no recomienda evidencia heterogénea impide extraer conclusiones sobre beneficio clínico en este momento.

Minocycline-induced Periarticular Black Bones in Inflamed Joints Which Underwent Arthroplastic Reconstruction

BACKGROUND: Minocycline-induced pigmentation of bone (black bone) is well described in tooth-bearing intra-oral bone, but is less known in periarticular bone in patients who have undergone total joint arthroplasty. On a retrospective basis, we investigated the short-term clinico-radiological results of total joint arthroplasties in which the patient developed minocycline-induced periarticular black bone. METHODS: We found 5 cases (0.08%), in 4 patients, of periarticular bone pigmentation revealed during total joint arthroplasties (2 hips, 2 knees, and 1 ankle) in our series of total joint surgeries (6,548 cases) over a 10-year time period in our 3 institutes. Their mean age was 56 years at surgery. All patients had received long-term minocycline treatment. Mean dosage and duration of minocycline was 160 mg/day and 2.2 years, respectively. Minocycline had been prescribed for reactive arthritis (one), rheumatoid arthritis (two) and late infection after total joint arthroplasty (two patients). Mean follow-up period was 3.4 years after the surgeries. RESULTS: All cases had black or brown pigmentation in the periarticular bones during the surgery. There was no pigmentation in the cartilage or soft tissues of the joints. The mean Japanese Orthopaedic Association (JOA) score or Japanese Society for Surgery of the Foot (JSSF) scale for rheumatoid arthritis foot and ankle joints at latest follow-up (case 1, 66; case 2, 87; case 3, 77; case 4, 77; case 5, 80) improved compared to those of pre-surgery (case 1, 47; case 2, 45; case 3, 55; case 4, 34; case 5, 55). No implant loosening was noted on radiographic examination during the follow-up period. No abnormal bone formation, bone necrosis, hemosiderin deposition, malignancy or metallic debris was found on histological examination. CONCLUSIONS: No clinico-radiological symptoms of total joint arthroplasties showed in the patients with minocycline-induced periariticular black bone in the short-term. Systemic minocycline treatment has the potential to induce significant black pigmentation of many tissues. In particular, minocycline-induced pigmentation of periarticular bone may be accelerated by inflammation due to rheumatic or pyogenic arthritis. Surgeons should recognize the risk of bone pigmentation in inflamed joints due to the systemic treatment of minocycline and explore its influence on periarticular bone and total joint arthroplasty in the long-term.

Uso inadecuado y excesivo de antibióticos: Salud pública y salmonicultura en Chile / Injudicious and excessive use of antibiotics: Public health and salmon aquaculture in Chile

Salmón aquaculture was one ofthe major growing and exporting industries in Chile. Its development was accompanied by an increasing and excessive use oflarge amounts of antimicrobials, such as quinolones, tetracyclines and florfenicol. The examination of the sanitary conditions in the industry as part of a more general investigation into the uncontrolled and extensive dissemination of the ISA virus epizootic in 2008, found numerous and wide-ranging shortcomings and limitations in management of preventive fish health. There was a growing industrial use of large amounts of antimicrobials as an attempt at prophylaxis of bacterial infections resulting from widespread unsanitary and unhealthy fish rearing conditions. As might be expected, these attempts were unsuccessful and this heavy antimicrobial use failed to prevent viral and parasitic epizootics. Comparative analysis of the amounts of antimicrobials, especially quinolones, consumed in salmón aquaculture and in human medicine in Chile robustly suggests that the most important selective pressurefor antibiotic resistant bacteria in the country will be excessive antibiotic use in this industry. This excessive use will facilitate selection of resistant bacteria and resistance genes in water environments. The commonality of antibiotic resistance genes and the mobilome between environmental aquatic bacteria, fishpathogens and pathogens of terrestrial animáis and humans suggests that horizontal gene transfer occurs between the resistome of these apparently independent and isolated bacterial populations. Thus, excessive antibiotic use in the marine environment in aquaculture is not innocuous and can potentially negatively affect therapy of bacterial infections of humans and terrestrial animáis.

Drogas nefrotóxicas / Drug-induced nephrotoxicity

La estructura renal es sensible a la acción de fármacos, especialmente en el túbulo proximal y distal, que están constituidos por células especializadas con gran actividad metabólica dedicada al transporte de solutos. En esta comunicación se describen diversos fármacos que interfieren con el túbulo-intersticio renal en forma aguda o crónica, se explican los mecanismos de daño renal y las formas de evitarlos en el momento del uso clínico de nefrotóxicos. También se hace referencia a aquellos fármacos cuya eliminación es principalmente por filtración glomerular, por lo que su administración debe ajustarse al cálculo de esta variable funcional para evitar toxicidades en órganos y tejidos, incluido el riñón.

Kidney structure and function, especially at the proximal and distal tubule, are sensitive to the toxic action of different substances that are actively transported at those levels. This Communication describes the most common drugs that damage, in an acute or chronic form, the tubuleinterstitial segment of the renal tissue and describe some ways to prevent nephrotoxicity. Also, the paper refers to a second mechanism of damage due to drug accumulation when administered to patients with some degree of renal dysfunction. To avoid renal toxicity the prescription must be adjusted to a calculated renal clearance obtained previous drug administration.

Profilaxis antimicrobiana en cirugía mayor electiva otorrinolaringológica / Antimicrobial prophylaxis related to otorhinolaryngology elective major surgery

La profilaxis antimicrobiana disminuye las infecciones quirúrgicas, pero su empleo indiscriminado favorece el incremento de las tasas de infección, pues la resistencia bacteriana es mucho más probable en presencia de antibióticos. El objetivo de esta investigación fue evaluar los resultados de la antibioticoprofilaxis en la cirugía mayor electiva otorrinolaringológica. Se realizó una investigación retrospectiva-descriptiva del uso profiláctico de antibióticos en cirugía mayor electiva en el Servicio de Otorrinolaringología del Hospital Comandante Manuel Fajardo, durante 6 años (2001-2006). El universo estuvo constituido por 661 pacientes y se estudiaron variables como sexo, edad y criterios de respuesta terapéutica (satisfactorio e insatisfactorio). Según la envergadura de la intervención, se administró antibioticoprofilaxis oral o parenteral y se realizó cultivo del sitio de la herida quirúrgica. Predominó el sexo masculino (54,1 por ciento) y el grupo etario de 31 a 62 años. Requirió profilaxis antibiótica el 41,90 por ciento de los pacientes operados. Ocurrió un 7,9 por ciento de infecciones de la herida quirúrgica. Los microorganismos más frecuentemente aislados fueron Pseudomonas aeruginosa, Enterobacter y Escherichia coli. En las cirugías oncológicas de cabeza y cuello, el promedio de infecciones fue elevado (42,3 por ciento). La evolución tórpida se debió a la concurrencia de factores de riesgo de infección. No se reportaron eventos adversos ni complicaciones graves. En otorrinolaringología, la profilaxis antimicrobiana funciona contra una amplia gama de microorganismos, pero no ocurre así en las cirugías oncológicas

Antimicrobial prophylaxis decreases the surgical infections, but its indiscriminate use to favors the increment of infection rates and the bacterial resistance is much more probable in presence of antibiotics. The aim of present research was to evaluate the results of antibiotic prophylaxis in the otorhinolaryngology elective major surgery. A retrospective-descriptive research was made on the prophylactic use of antibiotics in this type of surgery in the Otorhinolaryngology Service of the Comandant Manuel Fajardo during 6 years (2001-2006). Sample included 661 patients and the following variables were studied: sex, age and therapeutic response criteria (satisfactory and non-satisfactory). According to the intervention complexity oral antibiotic or parenteral prophylaxis was administered carrying out a surgical hound site culture. There was a predominance of male sex (54,1 percent) and the 31 and 62 age group. The 41,90 percent of patients operated on required antibiotic prophylaxis. The was a 7,9 percent of surgical wound infections. The more frequent microorganisms were Pseudomonas aeruginosa, Enterobacter and Escherichia. In head and neck oncology surgeries infection average was high (42,3 percent). Torpid course was due to concurrence of infection risk factors. There were neither adverse events nor severe complications. In Otorhinolaryngology, antimicrobial prophylaxis works against a wide variety of microorganisms but not in the Oncology surgeries

Antibiotic prophylaxis and incisional surgical site infection following colorectal cancer surgery: an analysis of 330 cases.

OBJECTIVE: To evaluate the rate of incisional surgical site infection (SSI) following colorectal cancer surgery in a university hospital and to determine whether duration of prophylactic antibiotic administration can affect the development of this complication. MATERIAL AND METHOD: The medical records of 330 patients with colorectal cancer undergoing elective oncological resection between 2003 and 2006 at Siriraj Hospital were reviewed. Patients were divided into two groups according to the duration of antibiotic administration; group A: prophylactic antibiotics were discontinued within 24 hours after surgery and group B: antibiotics administration was extended beyond 24 hours after surgery. Data including rate of incisional SSI were analyzed. RESULTS: There were 180 males and 150 females, with a mean age of 63 years. There were 126 patients (38%) in group A and 204 patients (62%) in group B. There was no statistical difference in patient characteristics and tumor-related variables between the two groups, except tumor location. Overall rate of incisional SSI was 14.5%. The rate of incisional SSI was not statistically different between the two groups (group A 11.1% vs. group B 16.7%, p = 0.22). Patients with incisional SSI had a significantly longer hospital stay than patients without incisional SSI (15.9 vs. 8.3 days, p < 0.001). CONCLUSION: This present study found the overall rate of incisional SSI following colorectal surgery to be 14.5%. There was no significant difference in the rate of this complication between the two groups. Thus, surgeons should be encouraged to use a shorter duration of antibiotics to prevent the emergence of antibiotic-resistant bacterial infection and reduce hospital expenditure.

Les meningites bacteriennes (2eme partie)

N.A.

O emprego da antibioticoprofilaxia no tratamento cirúrgico dos dentes inclusos / The antibiotic prophylaxis in surgical treatment of impacted tooth

Os antimicrobianos são fármacos amplamente utilizados nas diversas especialidades odontológicas, podendo seu emprego ter finalidades terapêuticas ou profiláticas no controle das infecções que acometem o complexo bucomaxilofacial. Desta forma, é de extrema importância que o cirurgião-dentista esteja apto a realizar o emprego correto destas drogas, tendo discernimento sobre a necessidade, o momento e a forma de usá-las. O presente trabalho visa à discussão acerca da administração racional dos antibióticos no tratamento cirúrgico dos dentes inclusos, realizando uma abordagem crítica sobre sua utilização.

Antibiotics are drugs largely difunded at the most diverse dental specialties, and they can be used with therapeutics or prophylaxis finalities at the bucomaxillofacial infections control. So it's very important that dentist have knowledge to discern how to use these drugs, observing the necessity, when and how to use them. The objective of this article is to promote a discussion about a correct form to use the antimicrobians at the surgical treatment of the impacted tooth, with a critical approach of the theme.

Uso de antibióticos y riesgo de complicación infecciosa en biopsias prostáticas transrectales: estudio de casos y controles / Use of antibiotic and risk of infectious complications in transrectal ultrasound-guided prostatic biopsy: case-control study

La biopsia prostática transrectal ecoguiada es un procedimiento bien tolerado y con un bajo nivel de complicaciones. Éstas suelen ser hemorrágicas o infecciosas. Debido a una tasa inusualmente elevada de complicaciones infecciosas, decidimos caracterizar a este grupo de pacientes. Estudio de casos y controles. Se analizan 233 biopsias prostáticas transrectales realizadas entre el 1 de agosto de 2003 y el 31 de mayo de 2004, todas con anestesia local periprostática. Los pacientes recibieron preparación con ciprofloxacino (2 dosis de 500 mg previo al examen y 8 dosis posterior a éste) y enema fleet (2 aplicaciones previo al examen). Cuarenta y tres pacientes habían recibido previamente este antibiótico como tratamiento por distintas causas. Se registraron complicaciones en 9 pacientes (3,9 por ciento). Hubo 2 casos de orquiepididimitis, 1 de sepsis sin foco clínico y 6 casos de prostatitis aguda. En dos de estos últimos se registró un cuadro séptico concomitante. El promedio global de hospitalización fue de 5,4 días. El promedio de punciones fue de 14,3 para los pacientes con complicaciones y de 13,4 para los no complicados (p=0,15). En los 9 pacientes con complicaciones infecciosas, los urocultivos y/o hemocultivos arrojaron una Escherichia coli. Seis de ellos habían estado expuestos al ciprofloxacino por 10 o más días durante los 2 meses previos a la biopsia. Las complicaciones infecciosas fueron significativamente más prevalentes entre los pacientes previamente expuestos al ciprofloxacino que en aquellos no expuestos (p=0,0001; OR 10,1). Todas las cepas encontradas, excepto en un paciente, demostraron ser resistentes al ciprofloxacino. A su vez, todas ellas, excepto una, eran sensibles a las cefalosporinas de 3a generación. No se registró resistencia a los carbapenems. La sensibilidad a los aminoglicósidos y sulfas fue variable en cada caso. Las infecciones post biopsia pueden constituir un cuadro grave. En estos casos, el germen más frecuentemente encontrado es la E. coli y su resistencia al ciprofloxacino es alta. El uso previo de este fármaco se asocia a un importante riesgo de complicación infecciosa. En estos pacientes, debiera considerarse un esquema alternativo de profilaxis antibiótica.

Hipersensibilidad cutánea secundaria a cloramfenicol oftálmico / Cutaneous hypersensibility secondary to ophthalmic chloramphenicol in a newborn

Introducción. El cloramfenicol oftálmico es un antimicrobiano de amplio espectro que se utiliza muy frecuentemente en salas de expulsión y de urgencias, como profilaxis neonatal y en infecciones superficiales de los ojos; sus efectos adversos son muy raros, uno de ellos es la hipersensibilidad cutánea. Caso clínico. Recién nacido del sexo femenino, sana, obtenida por parto eutócico, sin asfixia y con exploración física normal; que al aplicarle las gotas de cloramfenicol oftálmico como profilaxis neonatal presentó edema y eritema bipalpebral bilateral inmediato y eritema en miembros inferiores, desapareciendo espontáneamente sin complicaciones. Se comenta la absorción sistémica de las gotas oftálmicas; los efectos adversos que se relacionan con la dosis del medicamento, así como la idiosincrasia del paciente. Conclusión. En la literatura se reporta un caso similar que presentó placas eritematosas en todo el cuerpo. Hay que tener presente, que a pesar de que el cloramfenicol oftálmico es un medicamento muy utilizado, puede producir alteraciones dermatológicas, hematológicas y gastrointestinales, las cuales son raras, debiéndose tener la suspicacia clínica necesaria para detectarlas oportunamente.

Neutropenia na criança em quimioterapia / Neutropenia in children submitted to chemotherapy

Os autores fazem uma revisão bibliográfica com o objetivo de fornecer informações que orientem o manejo de pacientes pediátricos com neutropenia secundária à quimioterapia. A profilaxia de infecções e cuidados com a criança neutropênica febril são enfatizados

Profilaxia das complicaçöes pós-operatórias no tratamento cirúrgico das doenças do intestino grosso: I - Infecçäo / Prophylaxy of the postoperative complications in the surgical treatment of the large bowel diseases: I - Infection

A infecçäo pós-cirúrgica continua sendo causa de altos índices de morbimortalidade entre os pacientes operados de doenças do intestino grosso. Os avanços nos cuidados intensivos, a anestesia moderna, as drogas de uso para a profilaxia do tromboembolismo e de complicaçöes cardiorrespiratórias e as conquistas materiais que trouxeram progressos técnicos, de certa forma, permitiram a soluçäo de problemas cirúrgicos mais complexos numa populaçäo mais idosa e de mais alto risco, com reduçäo da mortalidade precoce mas com a chance de aumento da morbidade, em geral, devido às complicaçöes infecciosas. Nesse campo houve relevantes conquistas, principalmente após as publicaçöes de Burke, enriquecidas pela descoberta de grande e diversificado número de novos e potentes antimicrobianos. Apesar disso e das novas modalidades de preparo intestinal mecânico, o índice de complicaçöes infecciosas na prática cirúrgica colorretal permanece invariável, nos últimos anos, indicando que essas duas modalidades de prevençäo atingiram o seu máximo. Se nós pretendermos diminuir ainda mais as complicaçöes sépticas decorrentes das operaçöes cirúrgicas sobre o intestino grosso devemos redirecionar nossas pesquisas para outros fatores que näo os antibióticos ou os métodos de limpeza mecânica dos cólons. Atualmente, vários estudos têm sido endereçados para a resposta imune retardada e a sisceptibilidade a infecçäo. A competência técnica do cirurgiäo tem sido, novamente, valorizada; número de operaçöes a que o paciente é submetido, número de procedimentos cirúrgicos numa mesma operaçäo, duraçäo do ato operatório, tempo de internaçäo pré-operatória, idade do paciente, seu estado nutricional, doenças associadas de repercussäo sistemica; doenças como o diabetes, a insuficiência renal, o alcoolismo crônico, o câncer, as doenças imunossupressoras ou a imunossupressäo terapêutica etc., têm recebido ênfase como fatores de risco para a infecçäo pós-operatória

Tratamento da cardite reumática / Treatment of rheumatic carditis

A cardite reumática é responsável pela grande morbidade da febre reumática sendo o seu tratamento da maior importância para a reduçäo das complicaçöes e mortalidade associadas à doença. O tratamento pode ser dividido nas seguintes etapas: profilaxia primária, estabilizaçäo hemodinâmica, tratamento anti-inflamatório e profilaxia secundária. Algumas alternativas de tratamento, como pulsoterapia, seräo abordadas.