Erwin Brown

Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy

Abstract These evidence-based guidelines have been produced after a systematic literature review of a range of issues involving prevention, diagnosis and treatment of hospital-acquired pneumonia (HAP). Prevention is structured into sections addressing general issues, equipment, patient procedures and the environment, whereas in treatment, the structure addresses the use of antimicrobials in prevention and treatment, adjunctive therapies and the application of clinical protocols. The sections dealing with diagnosis are presented against the clinical, radiological and microbiological diagnosis of HAP. Recommendations are also made upon the role of invasive sampling and quantitative microbiology of respiratory secretions in directing antibiotic therapy in HAP/ventilator-associated pneumonia.

Systematic Review of Antimicrobial Drug Prescribing in Hospitals

Standardizing methods and reporting could improve interventions that reduce Clostridium difficile–associated diarrhea and antimicrobial drug resistance.

Conservative management of patients with cerebrospinal fluid shunt infections.

OBJECTIVE:In patients with cerebrospinal fluid (CSF) shunt infection, removal of the shunt and antibiotic administration is the current standard of care. In 1986, we developed a protocol for the conservative management of patients with infected but functioning shunts. Treatment was based on the administration of a combination of intraventricular and systemic antibiotics. Intraventricular antibiotics were instilled via a separate access device. The purpose of this report is to describe our experience with this therapeutic intervention. METHODS:An observational study of all patients treated for CSF shunt infection between 1986 and 2003 was undertaken. Cure was defined by sterile CSF after completion of therapy and sterile shunt components at next revision or long-term freedom from recurrent infection (follow-up period, 6–88 mo). RESULTS:In total, 43 of 122 patients with CSF shunt infections were treated conservatively according to our protocol. Overall, 84% of these patients were cured, with a 92% success rate for patients with infections caused by bacteria other than Staphylococcus aureus. This included 30 coagulase-negative staphylococcal infections, of which two were treatment failures. We abandoned conservative treatment of patients with Staphylococcus aureus infections after early experience demonstrated that the success rate (four treatment failures in seven patients) was markedly lower than that for other pathogens. During the treatment and follow-up periods, there were three deaths, two of which were unrelated to shunt infection; treatment failure could not be completely excluded in the remaining patient. There was no toxicity related to intraventricular antibiotic administration. The incidence of shunt blockage among patients who were treated conservatively was not significantly different from that among a large cohort of patients with uninfected shunts. Ten patients received part of their courses of treatment as outpatients. CONCLUSION:The success rate of conservative management of patients with CSF shunt infections caused by coagulase-negative staphylococci is comparable with those in the published literature for patients treated conventionally. This form of management avoids surgical intervention, with its attendant risks, and is safe.

Spine update: prevention of postoperative infection in patients undergoing spinal surgery.

In a climate of clinical governance and evidence-based medicine, medical audit and other procedures are being used increasingly to evaluate clinical experience and as a basis for guidelines and recommendations on best clinical practice. In some areas of surgery and medicine, however, a structured approach is not possible because the data on which the assessments depend simply do not exist or are not sufficiently robust. This is the situation that applies to the use of systemic antibiotics for the prevention of infection following both spinal surgery and diagnostic and therapeutic procedures involving violation of one or more disc spaces, to the irrigation of spinal wounds with antibiotic or antiseptic solutions and to the use of drains in spinal surgery. In such circumstances, any attempt to provide guidance on the rational use of antibiotics must be based on a critical review of the relevant literature, experience in the management of neurosurgical/orthopedic infections, and a thorough knowledge of the antimicrobials currently available. Antibiotics are used widely, perhaps even routinely, to prevent postoperative infection in patients undergoing spinal surgery, but the evidence to support the efficacy of this intervention is not robust. For the purposes of this review, the role of antibiotic prophylaxis in spinal surgery will be considered under two headings: the prevention of surgical site (wound) infection in general following spinal surgery and the prevention of discitis specifically following procedures involving one or more discs. The roles of intraoperative antibiotic or antiseptic wound irrigation and drains in patients undergoing spinal surgery are also reviewed. Prophylaxis for patients undergoing spinal implant procedures will be addressed in a subsequent Working Party report dedicated to implant-associated infections.

Use of antibiotics in penetrating craniocerebral injuries

Summary The Working Party was instituted to investigate the rationale of prophylactic and therapeutic antibiotic use in penetrating craniocerebral injuries (PCCI), and to make recommendations for current practice. A systematic review of papers on civilian and military PCCI over the past 25 and 50 years, respectively, was done via electronic databases and secondary sources, and data were evaluated. Guidelines on the removal of indriven bone or metal fragments only if further neural damage can be avoided were supported. However, no publications were identified where the data on infection or its treatment and prevention were complete or satisfactorily derived, and no controlled trials have been published. All studies were retrospective or anecdotal. Working Party recommendations are based on the data available and the professional experience and knowledge of the members. Broad-spectrum antibiotic prophylaxis is recommended for both military and civilian PCCI, including those due to sports or recreational injuries.

The management of neurosurgical patients with postoperative bacterial or aseptic meningitis or external ventricular drain-associated

This article is dedicated to the management of neurosurgical patients who develop postoperative meningitis or external ventricular drain (EVD)-related ventriculitis. Postoperative meningitis is either bacterial or aseptic, the latter occurring more commonly. However, owing to difficulties associated with distinguishing between the two processes, all patients with the clinical and laboratory features of postoperative meningitis should receive empirical antibiotic therapy; if a cultured sample of CSF is sterile after incubation for 3 days, the antibiotics can be discontinued. Patients with confirmed bacterial meningitis should be treated with one of the organism-specific regimens provided. Also provided are recommendations for the management of patients with EVD-related ventriculitis and a strategy for preventing shunt infections in patients with EVDs who undergo implantation of CSF shunts.This article is dedicated to the management of neurosurgical patients who develop postoperative meningitis or external ventricular drain (EVD)-related ventriculitis. Postoperative meningitis is either bacterial or aseptic, the latter occurring more commonly. However, owing to difficulties associated with distinguishing between the two processes, all patients with the clinical and laboratory features of postoperative meningitis should receive empirical antibiotic therapy; if a cultured sample of CSF is sterile after incubation for 3 days, the antibiotics can be discontinued. Patients with confirmed bacterial meningitis should be treated with one of the organism-specific regimens provided. Also provided are recommendations for the management of patients with EVD-related ventriculitis and a strategy for preventing shunt infections in patients with EVDs who undergo implantation of CSF shunts.

The rational use of antibiotics in the treatment of brain abscess

The Working Party was instituted to investigate the rationale of therapeutic antibiotic usage in patients with brain abscess and to make recommendations for current practice. A systematic review of English language publications on brain abscess over the last 25 years was carried out using electronic databases and secondary sources, and data were evaluated. Few publications were identified where the microbiological procedures were adequately described and many authors continue to report sterile pus in a proportion of cases. The vast majority of reports were retrospective neurosurgical assessments in which details of laboratory procedures and antibiotic regimens were missing. There are no published reports of controlled clinical trials or comparative therapeutic studies. The recommendations made by the Working Party are based on relevant published information and the expertise of Working Party members. Recommendations vary according to the location of the abscess which reflects the likely source of the infection and therefore the bacterial types most likely to be present in aspirated pus. Bacteria with multiple resistance to antimicrobial agents do not feature significantly in cases of brain abscess.The Working Party was instituted to investigate the rationale of therapeutic antibiotic usage in patients with brain abscess and to make recommendations for current practice. A systematic review of English language publications on brain abscess over the last 25 years was carried out using electronic databases and secondary sources, and data were evaluated. Few publications were identified where the microbiological procedures were adequately described and many authors continue to report sterile pus in a proportion of cases.The vast majority of reports were retrospective neurosurgical assessments in which details of laboratory procedures and antibiotic regimens were missing.There are no published reports of controlled clinical trials or comparative therapeutic studies.The recommendations made by the Working Party are based on relevant published information and the expertise of Working Party members. Recommendations vary according to the location of the abscess which reflects the likely source of the infection and therefore the bacterial types most likely to be present in aspirated pus. Bacteria with multiple resistance to antimicrobial agents do not feature significantly in cases of brain abscess.

Overwhelming cranial and spinal subdural empyema secondary to infected sacral decubitus ulcers

A 33-year-old wheelchair-bound female with longstanding multiple sclerosis was admitted with a deteriorating level of consciousness, and a dilated right pupil and ptosis. She gave a 2-week history of generalized malaise and anorexia and a 24-hour history of generalized headache and neck pain. Neurological examination revealed a right third nerve palsy and a Glasgow Coma Scale of 14, which rapidly decreased to 10. On general examination, extensive infected sacral and ischial decubitus ulcers were noted. FIG. 1. Axial CT image revealing pneumocephalus anterior to basilar artery.

Infections in neurosurgery: using laboratory data to plan optimal treatment strategies.

Laboratory services contribute to the management of patients with neurosurgical infections in a variety of ways and, in so doing, increase the likelihood of a favourable outcome. Microbiology laboratories and clinical microbiologists are able to confirm the diagnosis, identify the causative agents and facilitate optimal antimicrobial therapy. Other pathology specialties perform investigations which help neurosurgeons to differentiate between postoperative aseptic and bacterial meningitis, these disease processes being indistinguishable on clinical grounds. A broad range of variables have been evaluated to date, but only the lactate and interleukin-1β concentrations in cerebrospinal fluid have been shown to have sufficiently high sensitivities and specificities to be useful for this purpose. In preliminary studies measurement of the serum C-reactive protein concentration has been shown to be an effective criterion for monitoring the response to antibacterial therapy in patients with spinal extradural abscesses, postoperative discitis, brain abscesses and subdural empyemas, thereby enabling patients to be treated successfully with courses of these drugs that are markedly shorter than those currently recommended.

Distinguishing between Chemical and Bacterial Meningitis in Patients Who Have Undergone Neurosurgery

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