Antimicrobial prophylaxis in surgery: an international survey.

BACKGROUND: We investigated current clinical practice of antimicrobial prophylaxis (AMP) in surgery. METHODS: Survey administration of AMP to patients without co-morbidity or allergy undergoing surgery, among surgeons indexed as corresponding authors for articles published in general surgery, orthopedics, gynecology, and cardiac surgery journals. RESULTS: A total of 1,068 surgeons answered (response rate 68%). Of these, 26.1% do not begin infusion of the first antimicrobial dose within 1 h of incision, as suggested by guidelines, and 27.2% continue administering AMP for two or more days after surgery, including 7.6% who continue for four to seven days, in contradiction to the guidelines. There were significant differences between Europe and North America in the selection of AMP regimens. Furthermore, 19% of Europeans order infusion of the first antimicrobial dose during the incision compared with 3.9% of North Americans; 74.2% of Europeans discontinue AMP within 24 h after surgery compared with 86% of North Americans. Finally, 31% of general surgeons in North America administer supplementary oral prophylaxis for colectomy compared with only 5% of European surgeons. CONCLUSIONS: The AMP strategies in day-to-day self-reported practice differ significantly. Uniform, evidence-based practice is warranted, especially in this era of increasing antimicrobial resistance.

Lost in translation: differences in antimicrobial indication approval policies between the United States and Europe.

OBJECTIVE: Antimicrobials, like all drug products, are approved in the United States through the Food and Drug Administration (FDA) and in the European Union partly through the European Medicines Agency (EMEA). This article investigates the differences in approved indications between these 2 bodies for a series of antimicrobial agents approved during the past decade. METHODS: The antimicrobial compounds most recently approved for specific indications by both the FDA and EMEA were included in the study. Indications were recorded from the respective Web sites and compared. Differences in approved indications were considered major if one regulatory body approved an agent for treatment of a specific condition while the other did not, or if one regulatory body approved an agent only for prophylaxis while the other approved it also for treatment. Differences were considered minor when the 2 bodies approved an antimicrobial for the same condition or pathogen but with different details regarding specific clinical situations. RESULTS: Thirteen antimicrobial compounds approved by both the FDA and EMEA were included in the study, namely anidulafungin, caspofungin, dapto-mycin, doripenem, ertapenem, linezolid, micafungin, posaconazole, quinupristin/dalfopristin, retapamulin, telithromycin, tigecycline, and voriconazole. Among these 13 agents, differences in approved indications between the United States and Europe were found to be major for 6 and minor for 6. Approved indications were the same for only 1 agent. Major differences were noted for doripenem, linezolid, micafungin, quinupristin/dalfopristin, posaconazole, and telithro-mycin. Examples of major differences include the following: linezolid has a US indication for vancomycin-resistant Enterococcus faecium infections, but no similar indication in Europe; micafungin is indicated for pediatric use in Europe but not in the United States; and use of posaconazole is primarily therapeutic in Europe but preventive in the United States. Minor differences were noted for anidulafungin, caspofungin, daptomycin, ertapenem, retapamulin, and voriconazole. As an example of a minor difference, daptomycin has different indications for Staphylococcus aureus bacteremia. Tigecycline was the only agent for which the FDA and EMEA had approved identical indications. CONCLUSIONS: Differences in the indications for most antimicrobial agents were found between the United States and Europe. Because any approved indication can be viewed as scientific evidence, these differences may raise legal issues regarding the treatment of specific entities. To minimize these differences, coordination is needed between the FDA and EMEA regarding the procedures for approving indications.

Massive haemorrhage due to minimally displaced pubic ramus fracture.

Fractures of the pubic ramus are commonly seen in the emergency room, but they are thought to be minor injuries. Occasionally, these fractures might be associated with massive haemorrhage. Here we report a case of bilateral obturator artery damage due to minimal displaced pubic ramus fracture.

Impact of patient position on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials.

OBJECTIVE: The aim of this study is to summarize the effect of position (prone and semirecumbent 45 degrees ) of mechanically ventilated patients on the incidence of ventilator-associated pneumonia (VAP) and other outcomes. METHODS: A systematic search for randomized control trials (RCTs) was done. We estimated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using fixed effects model or random effects model, where appropriate. For continuous variables, we calculated the estimation of weighted mean differences. RESULTS: We analyzed data extracted from 3 RCTs studying the semirecumbent 45 degrees and 4 RCTs studying the prone position with a total of 337 and 1018 patients, respectively. The odds of developing clinically diagnosed VAP were significantly lower among patients in the semirecumbent 45 degrees position compared to patients in the supine position (OR = 0.47; 95% CI, 0.27-0.82; 337 patients). The comparison of prone vs supine position group showed a moderate trend toward better outcomes regarding the incidence of clinically diagnosed VAP among patients in the prone position (OR = 0.80; 95% CI, 0.60-1.08; 1018 patients). The subanalysis regarding the incidence of microbiologically documented VAP, the length of intensive care unit stay, and the duration of mechanical ventilation showed that patients in the semirecumbent 45 degrees position have a moderate trend toward better clinical outcomes. CONCLUSION: This meta-analysis provides additional evidence that the usual practice of back-rest elevation of 15 degrees to 30 degrees is not sufficient to prevent VAP in mechanically ventilated patients. Patients positioned semirecumbently 45 degrees have significantly lower incidence of clinically diagnosed VAP compared to patients positioned supinely. On the other hand, the incidence of clinically diagnosed VAP among patients positioned pronely does not differ significantly from the incidence of clinically diagnosed VAP among patients positioned supinely.

At what age do biomedical scientists do their best work?

Several human characteristics that influence scientific research performance, including set goals, mental and physical abilities, education, and experience, may vary considerably during the life cycle of scientists. We sought to answer the question of whether high-quality research productivity is associated with investigator's age. We randomly selected 300 highly cited scientists (50 from each of 6 different biomedical fields, specifically immunology, microbiology, neuroscience, psychology-psychiatry, clinical medicine, and biology-biochemistry). Then, we identified the top 5 highly cited articles (within 10 yr after publication adjusted for the expansion of the literature) as first author of each of them. Subsequently, we plotted the distribution of the 1500 analyzed articles of the 300 studied scientists in the eight 5-year intervals of investigator's age during the year of article publication (21-25 to 55-60 yr of age), adjusted for person-years of contribution of each scientist in the various age groups. Highly cited research productivity plotted a curve that peaked at the age group of 31-35 yr of age and then gradually decreased with advancing age. However, a considerable proportion of this highly cited research was produced by older scientists (in almost 20% of the analyzed articles, researchers were older than 50 yr). The results were similar in another analysis of the single most cited article of each studied scientist. In conclusion, high-quality scientific productivity in the biomedical fields as a function of investigator's age plots an inverted U-shaped curve, in which significant decreases take place from around 40 yr of age and beyond.