Prophylactic antibiotics for preventing genital tract infection in women undergoing surgical procedures for incomplete abortion: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Findings about the effect of prophylactic antibiotics in preventing genital tract infection (GTI) associated with surgical procedures used for incomplete abortions are conflicting. Some reported a decrease in infection associated with the use of antibiotic prophylaxis, whereas others found no significant reduction in GTI. OBJECTIVE: To synthesise systematically the evidence on the effect of prophylactic antibiotics compared with placebo in women undergoing surgical procedures for incomplete abortion. SEARCH STRATEGY: In February 2020, PubMed, Embase and Cochrane Central for Register of Controlled Trials were searched for relevant published randomised controlled trials. SELECTION CRITERIA: Randomised controlled trials reporting GTI following surgical procedures for incomplete abortion and comparing antibiotic prophylaxis with placebo. DATA COLLECTION AND ANALYSIS: Meta-analysis using inverse variance heterogeneity model included subgroup and sensitivity analyses determined a priori were conducted. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). MAIN RESULTS: A total of 16 178 women who participated in 24 eligible randomised controlled trials published between 1975 and 2019 were included. Pooled estimates showed the risk of GTI following surgical procedures after incomplete abortion was significantly lower among those who had prophylactic antibiotics (relative risk [RR] = 0.72; 95% CI 0.58-0.90; I2  = 49%). There was no significant effect of antibiotics in women in low- and middle-income countries (three studies, 3579 participants, RR = 0.90; 95% CI 0.50-1.62; I2  = 63%), but it was clinically and statistically significant among women high-income countries (21 studies, 12 599 participants, RR = 0.67; 95% CI 0.53-0.84; I2  = 44%), with a strong level of evidence as assessed by GRADE. CONCLUSION: This study provides evidence that antibiotic prophylaxis is beneficial in reducing post-abortion GTI among women undergoing surgical procedures for incomplete abortion. More studies are needed from low- and middle-income countries. TWEETABLE ABSTRACT: Prophylactic antibiotics after incomplete abortion are effective in reducing GTI. More studies are needed from low- and middle-income countries.

Seasonality and community interventions in a mathematical model of Clostridium difficile transmission.

BACKGROUND: Clostridium difficile infection (CDI) is the leading cause of antibiotic-associated diarrhoea with peak incidence in late winter or early autumn. Although CDI is commonly associated with hospitals, community transmission is important. AIM: To explore potential drivers of CDI seasonality and the effect of community-based interventions to reduce transmission. METHODS: A mechanistic compartmental model of C. difficile transmission in a hospital and surrounding community was used to determine the effect of reducing transmission or antibiotic prescriptions in these settings. The model was extended to allow for seasonal antibiotic prescriptions and seasonal transmission. FINDINGS: Modelling antibiotic seasonality reproduced the seasonality of CDI, including approximate magnitude (13.9-15.1% above annual mean) and timing of peaks (0.7-1.0 months after peak antibiotics). Halving seasonal excess prescriptions reduced the incidence of CDI by 6-18%. Seasonal transmission produced larger seasonal peaks in the prevalence of community colonization (14.8-22.1% above mean) than seasonal antibiotic prescriptions (0.2-1.7% above mean). Reducing transmission from symptomatic or hospitalized patients had little effect on community-acquired CDI, but reducing transmission in the community by ≥7% or transmission from infants by ≥30% eliminated the pathogen. Reducing antibiotic prescription rates led to approximately proportional reductions in infections, but limited reductions in the prevalence of colonization. CONCLUSION: Seasonal variation in antibiotic prescription rates can account for the observed magnitude and timing of C. difficile seasonality. Even complete prevention of transmission from hospitalized patients or symptomatic patients cannot eliminate the pathogen, but interventions to reduce transmission from community residents or infants could have a large impact on both hospital- and community-acquired infections.

Hospital effect on infections after four major surgical procedures: outlier and volume-outcome analysis using all-inclusive state data.

BACKGROUND: Hospital volume is known to have a direct impact on the outcomes of major surgical procedures. However, it is unclear if the evidence applies specifically to surgical site infections. AIMS: To determine if there are procedure-specific hospital outliers [with higher surgical site infection rates (SSIRs)] for four major surgical procedures, and to examine if hospital volume is associated with SSIRs in the context of outlier performance in New South Wales (NSW), Australia. METHODS: Adults who underwent one of four surgical procedures (colorectal, joint replacement, spinal and cardiac procedures) at a NSW healthcare facility between 2002 and 2013 were included. The hospital volume for each of the four surgical procedures was categorized into tertiles (low, medium and high). Multi-variable logistic regression models were built to estimate the expected SSIR for each procedure. The expected SSIRs were used to compute indirect standardized SSIRs which were then plotted in funnel plots to identify hospital outliers. FINDINGS: One hospital was identified to be an overall outlier (higher SSIRs for three of the four procedures performed in its facilities), whereas two hospitals were outliers for one specific procedure throughout the entire study period. Low-volume facilities performed the best for colorectal surgery and worst for joint replacement and cardiac surgery. One high-volume facility was an outlier for spinal surgery. CONCLUSIONS: Surgical site infections seem to be mainly a procedure-specific, as opposed to a hospital-specific, phenomenon in NSW. The association between hospital volume and SSIRs differs for different surgical procedures.

Asymptomatic Clostridium difficile colonization in two Australian tertiary hospitals, 2012-2014: prospective, repeated cross-sectional study.

OBJECTIVES: To investigate the prevalence and risk factors for asymptomatic toxigenic (TCD) and nontoxigenic Clostridium difficile (NTCD) colonization in a broad cross section of the general hospital population over a 3-year period. METHODS: Patients without diarrhoea admitted to two Australian tertiary hospitals were randomly selected through six repeated cross-sectional surveys conducted between 2012 and 2014. Stool specimens were cultured under anaerobic conditions, and C. difficile isolates were tested for the presence of toxin genes and ribotyped. Patients were then grouped into noncolonized, TCD colonized or NTCD colonized for identifying risk factors using multinomial logistic regression models. RESULTS: A total of 1380 asymptomatic patients were enrolled; 76 patients (5.5%) were TCD colonized and 28 (2.0%) were NTCD colonized. There was a decreasing annual trend in TCD colonization, and asymptomatic colonization was more prevalent during the summer than winter months. TCD colonization was associated with gastro-oesophageal reflux disease (relative risk ratio (RRR) = 2.20; 95% confidence interval (CI) 1.17-4.14), higher number of admissions in the previous year (RRR = 1.24; 95% CI 1.10-1.39) and antimicrobial exposure during the current admission (RRR = 2.78; 95% CI 1.23-6.28). NTCD colonization was associated with chronic obstructive pulmonary disease (RRR = 3.88; 95% CI 1.66-9.07) and chronic kidney failure (RRR = 5.78; 95% CI 2.29-14.59). Forty-eight different ribotypes were identified, with 014/020 (n = 23), 018 (n = 10) and 056 (n = 6) being the most commonly isolated. CONCLUSIONS: Risk factors differ between patients with asymptomatic colonization by toxigenic and nontoxigenic strains. Given that morbidity is largely driven by toxigenic strains, this novel finding has important implications for disease control and prevention.

Putting the diabetes risk due to statins in perspective: a re-evaluation using the complementary outcome.

AIMS: Statins are used extensively to treat dyslipidemia and have been associated with significant clinical benefit that increases with dose. However, recent studies have associated statins with an excess risk of developing diabetes mellitus, which may offset the clinical benefit to patients. Adverse events related to intensive-dose statin therapy were revisited in light of recent data regarding the use of relative risks. DATA SYNTHESIS: A meta-analysis was replicated with the event of interest redefined as the complementary outcome (no-onset of diabetes). Five randomised controlled trials that compared the risk of intense-dose with moderate-dose of statin therapy for the onset of diabetes with a follow-up greater than 12 months were included in the analysis. A reduction in the risk for no-onset of diabetes was found when intensive-dose statin therapy was compared with moderate-dose statin therapy, revealing a relative risk of 0.9908 (95%CI: 0.9849-0.99679). Over two years, one more patient was harmed by diabetes onset for every 237 patients exposed to intensive-dose statin therapy (95%CI: 123-3847) compared with standard dose statin therapy. CONCLUSIONS: Statins are associated with only a very small increase in risk of diabetes mellitus. Previous research selected the outcomes with the lower baseline risks and therefore the actual risk associated with statins has been largely over-estimated.