Necrotizing acute pancreatitis induced by Salmonella infection.

A case of salmonellosis complicated by hemorrhagic pancreatitis is presented. It is emphasized that removal of the gallbladder when stones are present is mandatory in sepsis induced by salmonellosis in the bile-pancreatic region, in spite of modem antibiotic treatment.

Fosfomycin/metronidazole compared with doxycycline/metronidazole for the prophylaxis of infection after elective colorectal surgery. A randomised double-blind multicentre trial in 517 patients.

OBJECTIVE: To find out if fosfomycin together with metronidazole was any better than doxycycline with metronidazole for the prophylaxis of infection before elective colorectal operations. DESIGN: Multicentre, double blind, random control trial. SETTING: Nine Swedish hospitals. SUBJECTS-559 patients admitted for elective colorectal operations. INTERVENTIONS: Fosfomycin 8 g and metronidazole 1 g before operation and fosfomycin 8 g eight hours afterwards, or doxycycline 400 mg and metronidazole 1 g before operation, and placebo eight hours afterwards. MAIN OUTCOME MEASURES: Incidence of all types of infection, mortality, and side effects. RESULTS: There were no significant differences between the groups for any of the outcome measures studied, the overall abdominal infection rates (wound, deep, and septicaemia) being 4.6% and 7.4%, and the remote infection rates (pneumonia, urinary tract, and central venous line) 15.1% and 12.8%, respectively. Of the predictors studied, only duration of operation was significantly related to risk of infection. CONCLUSION: The combination of fosfomycin and metronidazole was as safe and effective as that of doxycycline and metronidazole in preventing infections after elective colorectal operations.

Evaluation of preoperative computed tomography in gastric malignancy.

Ninety patients with gastric malignancy underwent computed tomography (CT) before surgery. The CT findings regarding neoplastic invasion of adjacent organs and metastasis or enlarged lymph nodes were compared with the findings at laparotomy (85 cases) or autopsy (5 cases), thus permitting evaluation of the diagnostic accuracy of CT and its usefulness for predicting resectability. When present, neoplastic invasion of adjacent organs was overestimated or underestimated by CT in 21 cases. Invasion of adjacent organs according to CT was false positive in 17 cases and false negative in 11 cases. When liver metastasis or enlarged regional or distant lymph nodes were present, CT overestimated or underestimated their extent in 17 cases, and the diagnosis was false positive in one case and false negative in 33 cases. The positive and negative predictive values of CT concerning resectability of the tumor were 81% and 64%, respectively. Routine preoperative CT in gastric malignancy is concluded to be of limited value and surgical exploration, when feasible, remains the method of choice.

Incisional infection after colorectal surgery in obese patients.

In a prospective study of 189 colorectal operations, the subcutaneous fat layer in the abdominal incisional wound was measured for correlation with wound infection. The infection rate was 20% when the fat layer was greater than or equal to 3.5 cm and 6.8% when the thickness was less than or equal to 3 cm (statistically significant difference). This c. threefold rise indicates that in obese patients special attention should be directed to antibiotic and other prophylaxis against incisional infection.

Stratified duration of prophylactic antimicrobial treatment in emergency abdominal surgery. Metronidazole-fosfomycin vs. metronidazole-gentamicin in 381 patients.

Consecutive adult patients requiring emergency abdominal surgery were randomly allocated to preoperative treatment with metronidazole-gentamicin (M-G) or metronidazole-fosfomycin (M-F). Postoperative continuation of antibiotics depended on the estimated risk of septic complications. Peroperatively the cases were stratified as group A, acute inflamed appendicitis, or absence of septic disorder--no postoperative antibiotics, group B, gangrenous appendicitis or cholecystitis or intestinal obstruction without resection, or operations with contamination regarded as minor (gastrotomy or enterotomy)--three further doses of antibiotics, or group C, perforated appendicitis, perforation of the alimentary tract, generalized peritonitis or gross contamination--antibiotics continued for 5 days. Assessment for septic complications was made in 381 patients (191 M-G, 190 M-F). The total incidence was 4.8% (M-G 7.8%, M-F 1.6%, p less than 0.01). The difference was mainly due to higher infection rate in patients stratified to group C and randomized to M-G. Stratification thus permitted restricted duration of antibiotic treatment with a low septic complication rate, significantly less with M-F than with M-G regimen.

A controlled trial of a plastic wound ring drape to prevent contamination and infection in colorectal surgery.

A controlled, randomized study of the efficacy of a plastic wound ring drape (Opdrape, Triplus) to prevent contamination and infection in elective colorectal operations is reported. Seventy patients were operated upon with the wound ring drape and 70 patients without. All patients received preoperative systemic antibiotic prophylaxis. Abdominal wound infection was observed in seven of 70 (10 per cent) patients with the wound ring drape and six of 70 (9 per cent) without (N.S.). An operative swab for bacteriologic evaluation was obtained from 85 per cent of the wounds. There was no evidence that the drape protected the wound from contamination with intestinal bacterial flora. It was concluded that the wound ring drape prevents neither contamination nor infection.

Comparison of systemic prophylaxis with metronidazole/placebo and metronidazole/fosfomycin in colorectal surgery. A clinical study demonstrating the need for additional anti-aerobic prophylactic cover.

The aim of this randomized double-blind study comparing the efficacy of two prophylactic regimens, metronidazole/placebo (n = 23) and metronidazole/fosfomycin (n = 26) was two-fold. First, to evaluate the need for anti-aerobic cover in addition to short-term systemic administration of metronidazole against anaerobes in colorectal surgery. Secondly, to explore the prophylactic effect of fosfomycin on aerobes of intestinal origin. An unacceptably high rate of surgical sepsis (16.3%) forced premature conclusion of the study after 49 patients had entered it. All surgical and remote infections occurred in the metronidazole/placebo group and were caused solely by aerobes. Anaerobic sepsis was not seen at all and the surgical infection rate was 34.8%. No septic complications occurred in the 26 patients (0%) receiving metronidazole/fosfomycin (p less than 0.01). Thus the study demonstrated both the need to administer an effective anti-aerobic agent in addition to metronidazole in colorectal surgery and the efficacy of fosfomycin in preventing aerobic sepsis of intestinal origin. Adverse reactions to the two drugs were not observed and resistance did not occur.

Systemic prophylaxis in colorectal surgery a comparison between tinidazole and doxycycline.

43 patients were the subject of a comparative trial of the use of tinidazole (n = 22) and doxycycline (n = 21) in the prevention of surgical sepsis in elective colorectal surgery. The trial was open, prospective and randomized with prophylactic treatment instituted parenterally immediately before the operation. Topical ampicillin was supplemented in eight cases with fecal spillage. All patients underwent a standard preoperative mechanical preparation of the bowel. At the end of the trial period, there was one superficial aerobic abdominal wound infection and one deep anaerobic infection in the tinidazole group. Anastomotic dehiscence occurred in one patient treated with doxycycline. There were no significant differences in the results obtained with the two drugs and both regimens appear to be highly effective in the prevention of deep anaerobic postoperative sepsis in elective colorectal surgery.

Systemic prophylaxis with doxycycline in surgery of the colon and rectum.

A prospective double-blind study on the effects of doxycycline as a prophylactic antimicrobial in elective colonic surgery is presented. One hundred-eighteen patients were evaluated. Fifty-eight were treated and 60 were controls. Two hundred milligrams, doxycycline or placebo (two capsules) were given orally four to six hours prior to surgery and 100 mg or placebo (one capsule) for five days postoperatively. Doxycycline levels in serum and tissues were determined and related to the MICvalues of the contaminants of the operative field. A significantly lower incidence of abdominal wound sepsis, intra-abdominal complications, and septicemia was recorded in the doxycycline group compared to the control group, 12.1 and 45% respectively. The prophylactic effect was most pronounced in patients with a negative wound culture upon closure. Macroscopical peritoneal contamination was associated with less severe consequencies in the doxycycline group. Infections in the perineal field, 3/15 vs 8/17, appeared alone in the doxycycline group, whereas they were combined with abdominal sepsis in 6/8 among the controls. Treatment also reduced the incidence of repeat laparotomy due to septic complications, 0 vs 8. Thus systemic per and postoperative prophylaxis with doxycycline significantly reduced both the incidence and the severity of postoperative sepsis in potentially contaminated elective colorectal surgery without any adverse reactions.

The effect on total antimicrobial consumption and hospitalization time after prophylactic treatment with doxycycline in colorectal surgery.

The effect of routine antimicrobial prophylaxis on hospitalization and the total consumption of antimicrobials in colorectal surgery was evaluated in a prospective and controlled study, where the incidence of abdominal wound sepsis was significantly reduced from 41.6% in the control (n = 60) to 8.6% in the doxycycline group (n = 58). Concomitantly, the average number of postoperative hospital days decreased significantly from 23.4+/-17.9 to 16.4+/-8.2 (p less than 0.01). This difference was more prominent in cases with postoperative abdominal sepsis, where the average number was 35.8 days in the control and 22.8 days in the doxycycline group. In the latter group only 19% of the patients required antimicrobial therapy during the postoperative course, compared with 65% of the patients in the control group. The period of exposure to antimicrobials amounted to 48.3% (451 days) of the postoperative hospital stay in the doxycycline vs. 53.3% (747 days) in the control group. Thus, prophylaxis significantly reduced the rate of wound sepsis, the time of and the need for hospitalization, the total consumption of and the time of exposure to antimicrobials.

Effects of ampicillin on intracellular levels of adenosine triphosphate in bacterial cultures related to antibiotic susceptibility.

Short time effects of ampicillin on viability and levels of intracellular ATP were studied in bacterial cultures and a close relationship between intracellular ATP levels and viability was demonstrated. The connection between the effects observed and MIC values is discussed. The possibility of using the phenomenon for rapid antibioitc susceptibility testing was studied in clinical isolates incubated for 2 hours followed by luciferase assay of intracellular ATP. A positive correlation was demonstrated between ampicillin-induced decreases in intracellular ATP and inhibitory zone diameters, as measured by the agar diffusion technique.

Combined fractures of the femoral and tibial shafts in the same limb.

This paper reports a study of ipsilateral fractures of the femoral and tibial shafts in 21 patients treated according to a detailed plan including shock treatment, prophylaxis against fat embolism, soft-tissue and fracture treatment. Death due to hypovalaemic shock was eliminated and the incidence of fat emboliism (9-5%) reduced in comparison with an earlier series. The tibial fracture was stabilized by plaster or internal fixation as soon as conditions allowed. In most cases the femoral fracture was treated by medullary mailing. Results have improved compared with earlier series. All fractures healed within 15 months, and functional end results have been excellent in the majority of the surviving patients (89%).

A rapid semiautomated bioassay of gentamicin based on luciferase assay of bacterial adenosine triphosphate.

A rapid semiautomated bioassay of gentamicin in serum based on the effect of gentamicin on intracellular adenosine triphosphate (ATP) levels in bacterial cultures is presented. The ATP assay was performed with the firefly luciferin/luciferase system and results were compared with an agar diffusion technique. The lower limit of detection was set at 1 microgram/ml. The accuracy of the ATP assay expressed as a recovery of gentamicin over the range 1--8 microgram/ml was 98--103% and S.D. varied between 11-15%. The reproducibility was approximately within the same limits. Other antibiotics tested did not interfere with the determination of gentamicin. 112 clinical serum specimens containing gentamicin alone (N = 55) or in combination with other antibiotics (N = 57) were assayed and results with the two methods compared (r = 0.94). Volumes required were 0.1 ml serum and results were available within 3 h.

A 14-month study of severe non-wound infectious complications in general surgery.

A retrospective study of serious non-wound infectious complications in general surgery during at 14-month period is reported. A prospective study on wound infections in available from the same institution and period. Septicemia, intraabdominal and intrathoracal abscesses and rare cases of osteomyelitis occurred in 1.3% of all treated patients, whereas postoperative wound infection developed in 7.5% of primarily non-infected patients. Mortality was significantly higher among patients with serious infections than in all patients nursed during the same period. Severe postoperative infectious complications was in fact the third most common cause of death and accounted for 14% of the mortality of the clinic. This rate rises to close to 50% when death from incurable disease is excluded. Septicemia carried a significantly higher mortality rate than intraabdominal abscesses. The risk of a serious infection developing was significantly higher in operations on the small or large intestine than after appendectomies or biliary operations. Gram negative bacteria dominated, especially in cases with a fatal outcome. Contributing factors such as malignancy, preoperative infection or macroscopic peroperative wound soiling, were more common in patients where a serious infectious complication developed postoperatively.