Maciej Piotr Chlebicki

Preoperative chlorhexidine shower or bath for prevention of surgical site infection: A meta-analysis

BACKGROUND Chlorhexidine showering is frequently recommended as an important preoperative measure to prevent surgical site infection (SSI). However, the efficacy of this approach is uncertain. METHODS A search of electronic databases was undertaken to identify prospective controlled trials evaluating whole-body preoperative bathing with chlorhexidine versus placebo or no bath for prevention of SSI. Summary risk ratios were calculated using a DerSimonian-Laird random effects model and a Mantel-Haenzel dichotomous effects model. RESULTS Sixteen trials met inclusion criteria with a total of 17,932 patients: 7,952 patients received a chlorhexidine bath, and 9,980 patients were allocated to various comparator groups. Overall, 6.8% of patients developed SSI in the chlorhexidine group compared with 7.2% of patients in the comparator groups. Chlorhexidine bathing did not significantly reduce overall incidence of SSI when compared with soap, placebo, or no shower or bath (relative risk, 0.90; 95% confidence interval: 0.77-1.05, P = .19). CONCLUSIONS Meta-analysis of available clinical trials suggests no appreciable benefit of preoperative whole-body chlorhexidine bathing for prevention of SSI. However, most studies omitted details of chlorhexidine application. Better designed trials with a specified duration and frequency of exposure to chlorhexidine are needed to determine whether preoperative whole-body chlorhexidine bathing reduces SSI.

Antibiotic prophylaxis for preventing recurrent cellulitis: A systematic review and meta-analysis

IMPORTANCE A significant proportion of patients who have had a first episode of erysipelas or uncomplicated cellulitis will subsequently develop a recurrence. There is disagreement about how effective antibiotic prophylaxis is for preventing recurrent cellulitis. OBJECTIVE To determine if antibiotic prophylaxis is effective in preventing recurrent cellulitis compared to no prophylaxis using a systematic review and meta-analysis. DATA SOURCES Studies in any language identified by searching Medline, EMBASE, Cochrane Library, CINAHL, TRIP database, clinical practice guidelines websites, and ongoing trials databases up to 31st August 2012. Search terms included cellulitis, erysipelas, controlled clinical trial, randomized, placebo, clinical trials, randomly, and trial. STUDY SELECTION Only controlled trials comparing antibiotic prophylaxis to no antibiotic prophylaxis in patients age 16 years and above, and after 1 or more episodes of cellulitis, were included. DATA EXTRACTION AND SYNTHESIS Independent extraction of articles was done by 2 investigators using predefined data extraction templates, including study quality indicators. PROSPERO registration number: CRD42012002528. Meta-analyses were done using random-effects models. MAIN OUTCOMES AND MEASURES The primary outcome was the number of patients with a recurrence of cellulitis. Secondary outcomes were (1) the time to next episode of recurrence, (2) quality of life measures, and (3) adverse events (e.g. allergic reactions, nausea). RESULTS Five randomized controlled trials (n = 535), with 260 patients in the intervention arm and 275 in the comparator group met our inclusion criteria. 44 patients (8%) in the antibiotic prophylaxis group and 97 patients (18%) in the comparator group had an episode of cellulitis. Antibiotic prophylaxis significantly reduced the number of patients having recurrent cellulitis, with a risk ratio (RR) of 0.46 (95% CI 0.26-0.79). None of the studies reported severe adverse effects to antibiotics. There was methodological heterogeneity amongst the studies in terms of types of antibiotic used, delivery modes, number of recurrences of cellulitis at study entry, and study quality. CONCLUSION AND RELEVANCE Antibiotic prophylaxis can prevent recurrent cellulitis. Future research should aim to identify the ideal type, dosage, and duration of antibiotics for prophylaxis, as well as to identify the group of patients who will benefit most from antibiotic prophylaxis.

Role of antibiotic prophylaxis in necrotizing pancreatitis: a meta-analysis.

Several studies have yielded conflicting results on the role of antibiotic prophylaxis in improving outcomes in acute necrotizing pancreatitis. A meta-analysis was carried out to investigate the impact of antibiotic prophylaxis in the incidence of infected pancreatic necrosis and mortality.MethodologyRandomized controlled trials and cohort studies investigating impact of prophylactic systemic antibiotic used in acute necrotizing pancreatitis were retrieved from online databases. An overall analysis was done with all studies (Group 1), followed by subgroup analyses with randomized controlled trials (Group 2) and cohort studies (Group 3). Risk ratios (RR) were calculated for the impact of antibiotic prophylaxis in the incidence of infected pancreatic necrosis and mortality in each group using random effects model.ResultsEleven studies involving 864 patients were included. No significant differences in the incidence of infected pancreatic necrosis were observed with prophylactic antibiotic use in all groups. Prophylactic antibiotic use was not associated with significant differences in all-cause mortality in Group 2 (RR = 0.75; p = 0.24) but was associated with a reduction in Groups 1 (RR = 0.66, p = 0.02) and 3 (RR = 0.55, p = 0.04). There was no statistical difference in the incidence of fungal infections and surgical interventions.ConclusionAntibiotic prophylaxis does not significantly reduce the incidence of infected pancreatic necrosis but may affect all-cause mortality in acute necrotizing pancreatitis.

High Incidence of Panton-Valentine Leukocidin-Producing Staphylococcus aureus in a Tertiary Care Public Hospital in Singapore

A study of the prevalence and epidemiology of Panton-Valentine leukocidin-producing Staphylococcus aureus in a tertiary public hospital was conducted. The incidence of gene carriage among S. aureus strains causing disease was 11.6%. Results were significant for the higher incidence of gene carriage, compared with those found in previous studies.

Prospective audit and feedback in antimicrobial stewardship: is there value in early reviewing within 48 h of antibiotic prescription?

Antimicrobial stewardship programme (ASP) methodologies are not well defined, with most preferring to wait ≥72-96 h following antibiotic prescription before reviewing patients. However, we hypothesise that early ASP reviews and interventions are beneficial and do not adversely impact patient safety. This study aimed to evaluate the impact of early ASP interventions within 48 h of antibiotic prescription on patient outcomes and safety. A prospective review of ASP interventions made within 48 h of antibiotic prescription in Singapore General Hospital (SGH) from January to December 2012 was conducted. Patient demographics and outcomes were extracted from the database maintained by the ASP team. For culture-directed treatment, there was a shorter mean duration of therapy (DOT) in the accepted group compared with the rejected group (2.26 days vs. 5.56 days; P<0.001). ASP interventions did not alter the length of hospital stay (LOS), 30-day mortality, 14-day Clostridium difficile infection (CDI), 30-day re-admissions and 14-day re-infection (all P>0.05). For empirical treatment, a shorter DOT (3.61 days vs. 6.25 days; P<0.001) and decreased 30-day all-cause mortality (P=0.003) and infection-related mortality (P=0.002) were observed among patients in the accepted group compared with the rejected group. There was no significant difference in LOS, 14-day CDI and 30-day re-admission (all P>0.05). In conclusion, acceptance of early interventions recommended by ASP in SGH was associated with a reduction in DOT without compromising patient safety. This is evident even during empirical therapy when not all clinical information was available.

First outbreak of colonization and infection with vancomycin-resistant Enterococcus faecium in a tertiary care hospital in Singapore.

We report the first outbreak of vancomycin-resistant Enterococcus faecium colonization and infection among inpatients in the hematology ward of an acute tertiary care public hospital in Singapore. Two cases of bacteremia and 4 cases of gastrointestinal carriage were uncovered before implementation of strict infection control measures resulted in control of the outbreak.

Recurrent Cellulitis: Risk Factors, Etiology, Pathogenesis and Treatment

Erysipelas and uncomplicated cellulitis are common infections that tend to recur in a substantial proportion of affected patients following an initial episode, especially if the predisposing condition is chronic lymphedema. All patients who suffer an episode of cellulitis should be carefully evaluated to establish the risk of recurrence. Several predisposing conditions (such as lymphedema and skin conditions that serve as a portal of entry for bacteria) can be effectively treated in order to reduce the risk of relapse. The medical literature provides convincing evidence that antimicrobial prophylaxis can markedly reduce the frequency of relapse of erysipelas. Two recent studies performed by the ‘Prophylactic Antibiotics for the Treatment of Cellulitis at Home’ (PATCH) group have clearly confirmed the efficacy of antimicrobial prophylaxis. Penicillin remains the drug of choice. Treatment options in patients with penicillin allergy are limited by the rising prevalence of macrolide resistance among group A streptococci. Further research is required to clarify the optimal penicillin regimen as well as to develop new therapies for patients with allergy to penicillin.

A procalcitonin-based guideline promotes shorter duration of antibiotic use safely in acute pancreatitis

We read with interest the article by Hoeboer et al. Like critically ill patients in the intensive care unit (ICU), patients with acute pancreatitis (AP) develops systemic inflammatory response syndrome, which is difficult to distinguish from sepsis. Hence, physicians often prescribe broad-spectrum prophylactic antibiotics for fear of undertreatment. This is exacerbated by the fact that early studies have reported findings in favor of prophylactic antibiotics in AP. However, these positive findings have been attributed to poor study designs, and recent randomized trials have shown that routine antibiotic prophylaxis did not confer benefits, but resulted in increased hospitalization costs and antimicrobial resistance. In light of the current situation, the Singapore General Hospital (SGH) Antimicrobial Stewardship Team (ASP) developed a procalcitonin-based guideline for AP in collaboration with the General Surgery Department, to guide prudent antibiotic prescribing (Fig. 1). Procalcitonin was employed as it can predict bacterial infections in critically ill patients and allowed early diagnosis of infected necrosis in AP. While the guideline was widely implemented in SGH, adherence was not enforced and eventual adherence was autonomously decided by the primary physician. Hence, we aim to evaluate the adherence to and impact of the guideline on antibiotic utilization and patient outcomes. A retrospective study was performed for all patients admitted from JanuaryeDecember 2011 with a primary diagnosis of AP (ICD-9 code 577.0). Patients were excluded if they were severely immunosuppressed; for patients with recurrent AP, only the first episode was included. Included patients were segregated into two groups: adherence (Group I) and non-adherence to protocol (Group II). The allocation of patients to either group was decided independently by the two study members; if a lack of consensus was observed, the opinion of a third member was sought. The study was approved by the institutional ethics committee. The primary outcome was difference in intravenous antibiotic use (days of therapy); in addition, an adjusted outcome was estimated using multi-variable regression, to correct for differences in baseline. Secondary outcomes included differences in 30-day crude mortality, days to enteral feeding, days to resolution of fever and white blood cell (WBC) count. Sample size requirements were estimated based on the PRORATA trial; assuming a mean of 10.8 days therapy in the non-adherence group, approximately 95 patients per group provided power of 80% (two-sided

Evaluation of Ertapenem use with Impact Assessment on Extended-Spectrum Beta-Lactamases (ESBL) Production and Gram-Negative resistance in Singapore General Hospital (SGH)

BackgroundErtapenem (preferred choice for ESBL-producing organisms) use exhibited an increasing trend from 2006 to 2008. As extensive use of ertapenem might induce the mutation of resistant bacteria strains to ertapenem, we aimed to assess the appropriateness and impact of ertapenem-use, on ESBL production, the trends of gram-negative bacterial resistance and on the utilization of other antibiotics in our institution.MethodsInpatients who received a dose of ertapenem during 1 January 2006 to 31 December 2008, were reviewed. Pertinent patient clinical data was extracted from the pharmacy databases and assessed for appropriateness based on dose and indication. Relevant data from Network for Antimicrobial Resistance Surveillance (Singapore) (NARSS) was extracted, to cross-correlate with ertapenem via time series to assess its impact on hospital epidemiology, trends of gram-negative resistance and consumption of other antibiotics from 2006 to mid-2010.Results906 cases were reviewed. Ertapenem therapy was appropriate in 72.4% (93.7% success rate). CNS adverse events were noted in 3.2%. Readmission rate (30-day) due to re-infection (same pathogen) was 5.5%. Fifty cases had cultures growing Pseudomonas aeruginosa within 30 days of ertapenem initiation, with 25 cases growing carbapenem-resistant Pseudomonas aeruginosa.Ertapenem use increased from 0.45 DDD/100 patient days in 2006 to 1.2 DDD/100 patient days in mid-2010. Overall, the increasing trend of ertapenem consumption correlated with 1) increasing incidence-densities of ciprofloxacin-resistant/cephalosporin-resistant E. coli at zero time lag; 2) increasing incidence-densities of ertapenem-resistant Escherichia. coli and Klebsiella spp. at zero time lag; 3) increasing incidence-density of carbapenem-resistant Pseudomonas aeruginosa, at zero time lag.Increasing ertapenem consumption was significantly correlated with decreasing consumption of cefepime (R2 = 0.37344) 3 months later. It was significantly correlated with a decrease in imipenem consumption (R2 = 0.31081), with no time lag but was correlated with subsequent increasing consumption of meropenem (R2 = 0.4092) 6 months later.ConclusionErtapenem use was appropriate. Increasing Ertapenem consumption did not result in a decreasing trend of ESBL producing enterobacteriaceae and could result in the selection for multi-drug resistant bacteria.

From Penicillin-Streptomycin to Amikacin-Vancomycin: Antibiotic Decontamination of Cardiovascular Homografts in Singapore

Background In February 2012, the National Cardiovascular Homograft Bank (NCHB) became the first tissue bank outside of North America to receive accreditation from the American Association of Tissue Banks. From 2008 to 2009, NCHB had been decontaminating its cardiovascular homografts with penicillin and streptomycin. The antibiotic decontamination protocol was changed in January 2010 as amikacin and vancomycin were recommended, in order to cover bacteria isolated from post-recovery and post- antibiotic incubation tissue cultures. Aim The objective of this study is to determine the optimal incubation conditions for decontamination of homografts by evaluating the potencies of amikacin and vancomycin in different incubation conditions. Retrospective reviews of microbiological results were also performed for homografts recovered from 2008 to 2012, to compare the effectiveness of penicillin-streptomycin versus the amikacin-vancomycin regimens. Methods Based on microbiological assays stated in United States Pharmacopeia 31, potency of amikacin was evaluated by turbidimetric assay using Staphylococcus aureus, while vancomycin was by diffusion assay using Bacillus subtilis sporulate. Experiments were performed to investigate the potencies of individual antibiotic 6-hours post incubation at 4°C and 37°C and 4°C for 24 hours, after the results suggested that amikacin was more potent at lower temperature. Findings Tissue incubation at 4°C for 24 hours is optimal for both antibiotics, especially for amikacin, as its potency falls drastically at 37°C. Conclusion The decontamination regimen of amikacin-vancomycin at 4°C for 24 hours is effective. Nevertheless, it is imperative to monitor microbiological trends closely and evaluate the efficacy of current antibiotics regimen against emerging strains of micro-organisms.