title: Adherence to international antimicrobial prophylaxis guidelines in cardiac surgery: a Jordanian study demonstrates need for quality improvement. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Comparative study of prophylactic antibiotics in cardiac surgery. Clindamycin versus cephalothin. Pneumonia after cardiac surgery is predictable by tracheal aspirates but cannot be prevented by prolonged antibiotic prophylaxis. Antibiotic prophylaxis for cardiac surgery in Australia. Comparative efficacy of teicoplanin and cefazolin for cardiac operation prophylaxis in 3027 patients. The ESPRIT Group. Incidence and risk factors for ventilator-associated pneumonia after major heart surgery Respiratory tract infections after cardiac surgery: impact on hospital morbidity and mortality. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. Antibiotic prophylaxis in cardiac operations. Cardiac surgery in a high-risk group of patients: is prolonged postoperative antibiotic prophylaxis effective? Cefamandole versus cefonicid prophylaxis in cardiovascular surgery: a prospective study.
abstract: BACKGROUND Antimicrobial prophylaxis in cardiac surgery has been demonstrated to lower the incidence of surgical site infection ( SSI ) . Inappropriate antimicrobial prophylaxis , such as inappropriate selection of the antimicrobial agent or inappropriate dosing regimen , can increase the prevalence of antibiotic resistant strains , prolong hospital stay , cause adverse reactions , and negatively affect an institution 's pharmacy budget for antibiotics . In developing countries such as Jordan , where the role of clinical pharmacists is still in its primary stages , the first step in establishing an organized clinical pharmacy service is the evaluation of current practice to determine the need for improvement . OBJECTIVE To assess the degree of adherence to international guidelines for antimicrobial prophylaxis practice in cardiac surgery performed at Queen Alia Heart Institute ( QAHI ) in Amman , Jordan , as part of an attempt to determine opportunities for clinical pharmacist intervention . METHODS For a total of 236 patients who were admitted for cardiac surgery to QAHI - the only official referral hospital for cardiac patients in Jordan - between November 19 , 2006 , and January 22 , 2007 , the antimicrobial prophylaxis indication , choice , duration , dose , dosing interval , and timing appropriateness were assessed against 3 international guidelines using a pre-tested , structured clinical data collection form that was completed by 2 of the authors who work at QAHI . The study design was prospect i ve . All patients who were scheduled for surgery were monitored daily during their inpatient stay until discharge and then were tracked in the outpatient clinic for 2 months following surgery . Data regarding antimicrobial prophylaxis indication , choice , duration , dose , dosing interval , and timing appropriateness were collected during the patient 's inpatient stay ; data collection was performed periodically thereafter as data became available until the end of the 2-month follow-up . The 3 guidelines agreed that ( a ) antimicrobial prophylaxis should be given to all patients undergoing cardiac surgeries ; ( b ) the first- or second-generation cephalosporins ( cefazolin or cefuroxime ) are the antibiotics of choice , and vancomycin use is reserved for cases of allergy to beta-lactams or if presumed or known methicillin-resistant Staphylococcus aureus ( MRSA ) colonization is present ; ( c ) the timing of the first dose should be within 60 minutes prior to the skin incision ; and ( d ) the duration of antimicrobial prophylaxis should not be longer than 48 hours . RESULTS Adherence to all antimicrobial prophylaxis guidelines was not achieved for any study patients . For the 6 evaluated criteria , ( 1 ) indication : in 100 % of patients the appropriate decision was made to use antimicrobial prophylaxis in concordance with guidelines ; ( 2 ) choice : only 1.7 % of patients received the antibiotic of choice ; ( 3 ) duration : 39.4 % of patents received antimicrobial prophylaxis for a total duration of 48 hours or less in concordance with guidelines , and for 58.9 % of patients , duration was longer than recommended ; ( 4 ) dose : 27.9 % of patients received an appropriate dose ; ( 5 ) dosing interval : only 13.0 % of patients received an appropriate dosing interval , and none of the doses of antimicrobial prophylaxis used at induction of anesthesia was repeated in operations that lasted longer than the half-life of the antibiotic used ; and ( 6 ) timing : 99.1 % of patients received antimicrobial prophylaxis dose within 60 minutes prior to skin incision as recommended by guidelines , but 97.0 % of patients received an unnecessary midnight dose of intravenous antibiotic the night before surgery . CONCLUSION Study findings indicate that adherence to international guidelines for antimicrobial prophylaxis is far from optimal in QAHI , leading to the inappropriate administration of many antibiotics . Developing local hospital guidelines , as well as giving the clinical pharmacist a central role in the administration , monitoring , and intervention of antimicrobial prophylaxis may improve the current practice BACKGROUND Despite evidence supporting short antibiotic prophylaxis ( ABP ) , it is still common practice to continue ABP for more than 48 hours after coronary artery bypass graft ( CABG ) surgery . METHODS AND RESULTS To compare the effect of short ( < 48 hours ) versus prolonged ( > 48 hours ) ABP on surgical site infections ( SSIs ) and acquired antimicrobial resistance , we conducted an observational 4-year cohort study at a tertiary-care center . An experienced infection control nurse performed prospect i ve surveillance of 2641 patients undergoing CABG surgery . The main exposure was the duration of  ABP  , and main outcomes were the adjusted rate of SSI and the isolation of cephalosporin-resistant enterobacteriaceae and vancomycin-resistant enterococci ( acquired antibiotic resistance ) . Adjustment for confounding was performed by multivariable modeling . A total of 231 SSIs ( 8.7 % ) occurred after a median of 16 days , including 93 chest-wound infections ( 3.5 % ) and 13 deep-organ-space infections ( 0 . 5 % ) . After 1502 procedures using short ABP , 131 SSIs were recorded , compared with 100 SSIs after 1139 operations with prolonged ABP ( crude OR , 1.0 ; CI , 0.8 to 1.3 ) . After adjustment for possible confounding , prolonged ABP was not associated with a decreased risk of SSI ( adjusted OR , 1.2 ; CI , 0.8 to 1.6 ) and was correlated with an increased risk of acquired antibiotic resistance ( adjusted OR , 1.6 ; CI , 1.1 to 2.6 ) . CONCLUSIONS Our findings confirm that continuing ABP beyond 48 hours after CABG surgery is still widespread ; however , this practice is ineffective in reducing SSI , increases antimicrobial resistance , and should therefore be avoided A r and omized , prospect i ve study of the relative effectiveness of clindamycin versus cephalothin was performed in 263 adult patients having cardiac surgery from September , 1977 , to August , 1978 . There were no statistically significant differences in frequency of postoperative infections in these two antibiotic groups . Wound infection developed in 6.5 percent of the cephalothin group and 3.2 percent of the clindamycin group . Urinary tract infection developed in 5.6 percent of the clindamycin group and 2.1 percent of the cephalothin group . Four bacteremic episodes occurred in the clindamycin-treated patients , and one episode of bacteremia occurred in a cephalothin-treated patient . No cases of endocarditis occurred during the study . Clindamycin deserved consideration as an alternative prophylactic agent to cephalothin for cardiac surgery BACKGROUND The purpose of this study was to assess the value of tracheal aspirate as a predictor of pneumonia after coronary artery bypass grafting and to evaluate the efficacy of prolonged perioperative antibiotic prophylaxis . METHODS Tracheal aspirates of 500 patients undergoing coronary artery bypass grafting were taken immediately after intubation and analyzed for microorganisms by Gram stain and semiquantitative microbiologic cultures . All patients received 2 g ceftriaxone as a single-dose perioperative antibiotic prophylaxis before operation . Results of Gram stains were available before the patients were transferred to the intensive care unit . After the results were known , both groups of patients ( positive Gram stain , group 1 ; negative Gram stain , group 2 ) were r and omly assigned to either conventional antibiotic prophylaxis ( A ) , consisting of ceftriaxone 2 g on postoperative day 1 , or prolonged antibiotic prophylaxis ( B ) , with ticarcillin + clavulanic acid 3 x 5.2 g during 72 hours . RESULTS From 500 patients , 91 had a positive Gram stain whereas 409 had a negative one . The incidence of pneumonia was significantly higher in patients with preoperative positive tracheal aspirates ( 15.3 % ) than in patients with a negative one ( 3.6 % ; p < 0.01 ) . However , prolonged prophylaxis did not reduce the rate of postoperative pneumonia , which was as high as 13 % in untreated positive patients versus 17 % in treated positive patients , and 2 % in untreated negative patients versus 4 % in treated patients . In patients who had pneumonia , there was a high correlation between the microorganisms found in preoperative aspirates and those observed when aspirates were repeated ( 100 % correlation in patients with conventional antibiotic prophylaxis and 87 % in those with prolonged prophylaxis ) . CONCLUSIONS Early postoperative pneumonia ( < 7 days ) is most likely caused by microorganisms that colonize the respiratory tract before operation . The risk of pulmonary infection after coronary artery bypass grafting can be predicted from the preoperative tracheal aspirates . Prolonged perioperative antibiotic prophylaxis has no efficacy in reducing the incidence of pulmonary infections OBJECTIVE To evaluate national practice for antibiotic prophylaxis in cardiac surgery with respect to the use of protocol s , agent selection and duration of administration . DESIGN , SETTING AND PARTICIPANTS Two point-prevalence surveys of intensive care units in 24 public and 27 private hospitals performing cardiac surgery in Australia , conducted in 2004 and 2008 , using a structured telephone question naire of the attending senior intensive care clinician in each unit . MAIN OUTCOME MEASURES Existence of a protocol in the unit for antibiotic prophylaxis , specific antibiotic agents used and their duration of administration . RESULTS Between 2004 and 2008 , reported protocol use increased from 58 % to 80 % ( P = 0.02 ) , while concordance with version 13 of the Australian Therapeutic guidelines : antibiotic for both choice of agent and timing ( duration of administration ) remained around 10 % . Use of multiple agents was common , as was continued antibiotic administration after completion of surgery . Over 4 years , the proportion of cardiac surgical units reporting  vancomycin administration  for routine valve surgery prophylaxis doubled to 62 % ( P < 0.001 ) . CONCLUSION Despite an increase in reported protocol use for antibiotic prophylaxis in cardiac surgery , concordance with national antibiotic guidelines remained low , with duration of antibiotic administration deviating most from recommendations . Prophylactic  vancomycin  use appears to have increased substantially in recent years . Clinical implementation of recommended perioperative cardiac surgical antibiotic prophylaxis may not occur until supported by evidence from either a large prospect i ve r and omised study or st and ardised national surveillance of cardiac surgical site infection rates OBJECTIVE Cephalosporins , especially cefazolin , are widely used in the prevention of postoperative wound infections after cardiac operations . As more and more Staphylococcus aureus and Staphylococcus epidermidis strains are becoming resistant to cephalosporins and other antibiotics , alternative agents , such as glycopeptides , are often used as prophylaxis . We performed a multicenter double-blind r and omized controlled trial comparing teicoplanin , a glycopeptide antibiotic , with cefazolin . METHODS A total of 3027 adult patients undergoing elective coronary artery bypass grafting , valve operations , or both were r and omized to a single dose of teicoplanin ( 15 mg/kg ) or a 2-day course of cefazolin ( 2 g initial dose , followed by 1 g every 8 hours for 6 more doses ) . Patients were followed up for a total of 6 months postoperatively . The primary objective was to compare , between groups , the incidence of surgical infections up to 30 days postoperatively . Secondary objectives were incidence of other infections , other complications , and death . RESULTS A total of 3027 patients were r and omized to receive either teicoplanin ( n = 1518 ) or cefazolin ( n = 1509 ) . Thirty days postoperatively , there was a trend to more deep sternotomy wound infections in the teicoplanin group ( 31 vs 18 , P = . 087 ) , which became significant by 6 months ( 36 vs 19 , P = .032 ) . One hundred percent of the gram-positive strains infecting patients were susceptible to teicoplanin , whereas 8.3 % were resistant to cefazolin . Pneumonia and urinary tract infections were more common in the teicoplanin group . Deep wound infections of the leg were more common in the cefazolin group . CONCLUSIONS Cefazolin was more effective prophylaxis than teicoplanin against postoperative wound infections after elective cardiac operations . Infection rates were low with either treatment Purpose Major heart surgery ( MHS ) patients are a particularly high-risk population for nosocomial infections . Our objective was to identify risk factors for ventilator-associated pneumonia ( VAP ) in patients undergoing MHS .  Methods Prospect i ve study including 1,844 patients operated from 2003 to 2006 . Results Overall 106 patients ( 140 episodes ) developed one or more episodes of VAP ( 5.7 % , 22.2 episodes per 1,000 days of mechanical ventilation ) . VAP incidence was 45.9 % in those patients requiring more than 48 h of MV . Enterobacteriaceae ( 32.8 ) , Pseudomonas aeruginosa ( 28.6 % ) and Staphylococcus aureus ( 27.1 % , of which 65.8 % were methicillin resistant ) were the principal microorganisms causing VAP . The independent risk factors for VAP were : age > 70 , perioperative transfusions , days of mechanical ventilation , reintubation , previous cardiac surgery , emergent surgery and intraoperative inotropic support . Median length of stay in the ICU for patients who developed VAP or not was , respectively , 25.5 versus 3 days ( P < 0.001 ) , and mortality was , respectively , 45.7 versus 2.8 % in both population s ( P < 0.001 ) . We developed a predictive preoperative score with a sensitivity of 93 % and a specificity of 40 % . Conclusions VAP is common in patients undergoing MHS that require more than 48 h of MV .  In that “ high-risk ” population , innovative preventive measures should be developed and applied AIM Nosocomial pneumonia ( NP ) and tracheobronchitis after cardiac surgery are associated with worse outcomes . The aim of this study was to identify risk factors associated with NP and tracheobronchitis after cardiac surgery and to determine the impact of these infections on hospital morbidity and mortality . METHODS We evaluated 1600 adult patients undergoing cardiac surgery under st and ard cardiopulmonary bypass .  Data were collected prospect ively . All NP and tracheobronchitis episodes were confirmed by a semiquantitative culture of endotracheal aspirate . Logistic regression analysis was done to identify risk factors for respiratory tract infection and mortality . RESULTS The rate of NP was 1.2 % ( 15.6 episodes per 1000 days of mechanical ventilation ) and that of tracheobronchitis was 1.6 % ( 21 episodes per 1000 days of mechanical ventilation ) . Significant independent risk factors for respiratory tract infection ( pneumonia or tracheobronchitis ) were : left ventricular ejection fraction < 30 % ( P = 0.001 ) , chronic renal failure ( P < 0.0001 ) and urgent surgery ( P < 0.0001 ) . Patients with NP had significantly higher mortality ( 42 % versus 0.9 % , P < 0.0001 ) than patients without respiratory tract infection . The median hospital length of stay was significantly longer in patients with pneumonia ( 42 days ) and tracheobronchitis ( 28 days ) than in patients without any respiratory tract infection ( 11 days , P < 0.0001 ) . CONCLUSION NP after cardiac surgery is associated with severe outcomes . Independent risk markers for respiratory tract infection were left ventricular ejection fraction < 30 % , chronic renal failure and urgent surgery BACKGROUND R and omized , controlled trials have shown that prophylactic antibiotics are effective in preventing surgical-wound infections . However , it is uncertain how the timing of antibiotic administration affects the risk of surgical-wound infection in actual clinical practice . METHODS We prospect ively monitored the timing of antibiotic prophylaxis and studied the occurrence of surgical-wound infections in 2847 patients undergoing elective clean or " clean-contaminated " surgical procedures at a large community hospital . The administration of antibiotics 2 to 24 hours before the surgical incision was defined as early ; that during the 2 hours before the incision , as preoperative ; that during the 3 hours after the incision , as perioperative ; and that more than 3 but less than 24 hours after the incision , as postoperative . RESULTS Of the 1708 patients who received the prophylactic antibiotics preoperatively , 10 ( 0.6 percent ) subsequently had surgical-wound infections . Of the 282 patients who received the antibiotics perioperatively , 4 ( 1.4 percent ) had such infections ( P = 0.12 ; relative risk as compared with the preoperatively treated group , 2.4 ; 95 percent confidence interval , 0.9 to 7.9 ) . Of 488 patients who received the antibiotics postoperatively , 16 ( 3.3 percent ) had wound infections ( P less than 0.0001 ; relative risk , 5.8 ; 95 percent confidence interval , 2.6 to 12.3 ) . Finally , of 369 patients who had antibiotics administered early , 14 ( 3.8 percent ) had wound infections ( P less than 0.0001 ; relative risk , 6.7 ; 95 percent confidence interval , 2.9 to 14.7 ) . Stepwise logistic-regression analysis confirmed that the administration of antibiotics in the preoperative period was associated with the lowest risk of surgical-wound infection . CONCLUSIONS We conclude that in surgical practice there is considerable variation in the timing of prophylactic administration of antibiotics and that administration in the two hours before surgery reduces the risk of wound infection This clinical trial , which was composed of 1,031 adults undergoing cardiac operations , compared the efficacy of a single dose of 1 g of ceftriaxone with a 48-our regimen consisting of flucloxacillin and gentamicin . There was no significant difference ( p = 0.89 ) in the overall incidence of major infections : 30 of 515 patients ( 5.8 % ; 95 % confidence interval , 5.4 % to 6.2 % ) taking ceftriaxone and 29 of 516 patients ( 5.6 % ; 95 % confidence interval , 5.2 % to 6.0 % ) taking flucloxacillin and gentamicin . Subgroup analyses , with a lower statistical power , failed to show a significant difference between patients who received ceftriaxone and those who received flucloxacillin/gentamicin :  major sternal wound infections arose in 2.7 % of the patients taking ceftriaxone versus 1.6 % in those on the 48-hour regimen ( p = 0.20 ) and major limb wound infections arose in 4.2 % and 5.4 % , respectively ( p = 0.44 ) . Single-dose prophylaxis was associated with fewer intravenous administrations ( 864 doses versus 9,570 doses ) and cost less ( A$ 17,248 versus A$ 78,510 ) . Although the regimen that included gentamicin was associated with the greatest biochemical impairment of renal function , the overall toxicity for both groups was low . We conclude that a single dose of ceftriaxone provided cost-efficient prophylaxis for adults undergoing cardiac operations when compared with a 48-hour regimen of gentamicin and flucloxacillin . The general principle revealed by our data is that the short-term administration of an appropriate antibiotic regimen represents optimal prophylaxis for patients undergoing cardiac procedures OBJECTIVE In a prospect i ve , r and omized study , postoperatively prolonged antibiotic prophylaxis is evaluated in a high-risk group of patients undergoing cardiac operations . These patients had postoperative low cardiac output necessitating inotropic support and intraaortic balloon pumping . METHODS Between January 1991 and 1994 , 53 patients were enrolled in the study ( 42 men , mean age 65 years ) . All patients received the usual perioperative ( 24 hours ) cefazolin prophylaxis . In the study group ( n = 28 ) a prolonged regimen of prophylaxis with ticarcillin/clavulanate was performed for 2 days and vancomycin was added in a low dose until removal of the intraaortic balloon pump . The control group ( n = 25 ) did not receive a prolonged regimen of prophylaxis . Follow-up ended at hospital discharge . RESULTS Early mortality was 7 of 28 patients ( 25 % ) in the prophylaxis group and 8 of 25 patients ( 32 % ) in the control group ( p = 0.397 ) . Defined infections ( pneumonia , n = 22 ; sepsis , n = 8 ; deep sternal wound infection , n = 2 ) occurred in 50 % of the study group and 68 % of the control group ( p = 0.265 ) . In all patients with septicemia , only coagulase-negative staphylococci could be isolated from the bloodstream ( 5 patients in the prophylaxis group vs 3 in the control group ) . Infectious parameters were controlled daily and did not differ significantly between groups . A total of 1158 bacteriologic tests were performed ( blood cultures , n = 389 ; intravascular catheters , n = 208 ; bronchial aspirates , n = 411 ; intraaortic balloon pumps , n = 42 ; wound secretions , n = 108 ) showing bacterial growth in 322 ( 28 % ) without a significant difference between the groups . In the prophylaxis group , 13 intravascular catheters and intraaortic balloon pumps showed bacterial growth versus 11 in the control group . No side effects were seen . CONCLUSIONS In a high-risk group of patients undergoing cardiac operations , infectious outcome could not be effectively influenced by an additional and prolonged postoperative prophylaxis regimen with low-dose vancomycin and ticarcillin/clavulanate . Low-dose vancomycin did not reduce the rate of infections or colonizations of intravascular catheters with gram-positive organisms We r and omized 400 patients who were scheduled for an elective cardiovascular operation involving median sternotomy to receive cefam and ole nafate or cefonicid in a prospect i ve double-blind study . Three hundred fifty-seven patients were evaluable for prophylactic efficacy . Chest wound and donor site infections and early prosthetic valve endocarditis occurred more frequently with cefonicid ( 11 patients , 6.3 % ) than with cefam and ole ( 4 patients , 2.2 % ) ( p = 0.05 ) . Three patients , all in the cefonicid group , required sternal debridement to control postoperative deep wound infections . Twenty-five miscellaneous postoperative infections ( urinary tract infection , pneumonia , intravenous site infection , bacteremia , sepsis , Clostridium difficile diarrhea ) occurred in 16 patients ( 9.19 % ) in the cefonicid group and four in 4 patients ( 2.19 % ) in the cefam and ole group ( p = 0.003 ) . These data indicate that cefam and ole is superior to cefonicid in preventing both surgical wound infections and miscellaneous nonsurgical infections after cardiovascular operations
target: There was no advantage of regimens lasting > 48 h post-operation .
  In the comparison of glycopeptides versus β-lactams , an advantage of glycopeptides was observed when comparators were given for similar duration and for β-lactams when given for a longer duration than the glycopeptides .
  There was no significant advantage of high antibiotic dosing .
  Evidence supports second- or third-generation cephalosporins for cardiac surgery prophylaxis and points at a possible advantage of prophylaxis prolongation up to 48 h post-operatively
background: BACKGROUND Antibiotic prophylaxis is recommended in cardiac surgery .
  Current debate concerns the type of antibiotic(s ) , dosing and the duration of prophylaxis .