Neuro-intensive treatment targeting intracranial hypertension improves outcome in severe bacterial meningitis: an intervention-control study.

OBJECTIVE: To evaluate the efficacy of early intracranial pressure (ICP)-targeted treatment, compared to standard intensive care, in adults with community acquired acute bacterial meningitis (ABM) and severely impaired consciousness. DESIGN: A prospectively designed intervention-control comparison study of adult cases from September 2004 to January 2012. PATIENTS: Included patients were confirmed ABM-cases, aged 16-75 years, with severely impaired mental status on admission. Fifty-two patients, given ICP-targeted treatment at the neuro-intensive care unit, and 53 control cases, treated with conventional intensive care, were included. All the patients received intensive care with mechanical ventilation, sedation, antibiotics and corticosteroids according to current guidelines. Additional ICP-treatment in the intervention group included cerebrospinal fluid drainage using external ventricular catheters (n = 48), osmotherapy (n = 21), hyperventilation (n = 13), external cooling (n = 9), gram-doses of methylprednisolone (n = 3) and deep barbiturate sedation (n = 2) aiming at ICP <20 mmHg and a cerebral perfusion pressure of >50 mmHg. MEASUREMENTS: The primary endpoint was mortality at two months and secondary endpoint was Glasgow outcome score and hearing ability at follow-up at 2-6 months. OUTCOMES: The mortality was significantly lower in the intervention group compared to controls, 5/52 (10%) versus 16/53 (30%; relative risk reduction 68%; p<0.05). Furthermore, only 17 patients (32%) in the control group fully recovered compared to 28 (54%) in the intervention group (relative risk reduction 40%; p<0.05). CONCLUSIONS: Early neuro-intensive care using ICP-targeted therapy, mainly cerebrospinal fluid drainage, reduces mortality and improves the overall outcome in adult patients with ABM and severely impaired mental status on admission

Effectiveness of single vs multiple doses of prophylactic intravenous antibiotics in implant-based breast reconstruction : A randomized clinical trial

Importance: Multiple-dose antibiotic prophylaxis is widely used to prevent infection after implant-based breast reconstruction despite the lack of high-level evidence regarding its clinical benefit. Objective: To determine whether multiple-dose antibiotic prophylaxis is superior to single-dose antibiotic prophylaxis in preventing surgical site infection (SSI) after implant-based breast reconstruction. Design, Setting, and Participants: This prospective, multicenter, randomized clinical superiority trial was conducted at 7 hospitals (8 departments) in Sweden from April 25, 2013, to October 31, 2018. Eligible participants were women aged 18 years or older who were planned to undergo immediate or delayed implant-based breast reconstruction. Follow-up time was 12 months. Data analysis was performed from May to October 2021. Interventions: Multiple-dose intravenous antibiotic prophylaxis extending over 24 hours following surgery, compared with single-dose intravenous antibiotic. The first-choice drug was cloxacillin (2 g per dose). Clindamycin was used (600 mg per dose) for patients with penicillin allergy. Main Outcomes and Measures: The primary outcome was SSI leading to surgical removal of the implant within 6 months after surgery. Secondary outcomes were the rate of SSIs necessitating readmission and administration of intravenous antibiotics, and clinically suspected SSIs not necessitating readmission but oral antibiotics. Results: A total of 711 women were assessed for eligibility, and 698 were randomized (345 to single-dose and 353 to multiple-dose antibiotics). The median (range) age was 47 (19-78) years for those in the multiple-dose group and 46 (25-76) years for those in the single-dose group. The median (range) body mass index was 23 (18-38) for the single-dose group and 23 (17-37) for the multiple-dose group. Within 6 months of follow-up, 30 patients (4.3%) had their implant removed because of SSI. Readmission for intravenous antibiotics because of SSI occurred in 47 patients (7.0%), and 190 women (27.7%) received oral antibiotics because of clinically suspected SSI. There was no significant difference between the randomization groups for the primary outcome implant removal (odds ratio [OR], 1.26; 95% CI, 0.69-2.65; P = .53), or for the secondary outcomes readmission for intravenous antibiotics (OR, 1.18; 95% CI, 0.65-2.15; P = .58) and prescription of oral antibiotics (OR, 0.72; 95% CI, 0.51-1.02; P = .07). Adverse events associated with antibiotic treatment were more common in the multiple-dose group than in the single-dose group (16.4% [58 patients] vs 10.7% [37 patients]; OR, 1.64; 95% CI, 1.05-2.55; P = .03). Conclusions and Relevance: The findings of this randomized clinical trial suggest that multiple-dose antibiotic prophylaxis is not superior to a single-dose regimen in preventing SSI and implant removal after implant-based breast reconstruction but comes with a higher risk of adverse events associated with antibiotic treatment. Trial Registration: EudraCT 2012-004878-26

The intracranial pressure (ICP; mmHg) as noted at operation (external ventricular drainage: n = 48; parenchymal ICP-monitor: n = 4), and the highest levels of ICP, noted continuously during episodes >5 min, at the neuro-intensive care unit (NICU), related to the outcome at follow-up after 2–6 months in the intervention per protocol group.

<p>GOS = Glasgow outcome score.</p><p>*These patients ended up as follows;</p><p>a) Two with GOS 3, two with GOS 4.</p><p>b) Four with GOS 4.</p><p>c) One with GOS 3, four with GOS 4.</p><p>d) Two with GOS 4.</p

The main characteristics regarding demographic, etiological, clinical, and laboratory data, not identifying any significant difference between the intervention and control group, including comparison of the reaction level scale (RLS) values that were converted from Glasgow coma score (GCS) in the intervention group [27], [43].

<p>LP = lumbar puncture. Csf = cerebrospinal fluid.</p><p>When data was missing the numbers of patients with available data are shown [in brackets].</p>a<p>Malignancy/immunosuppresion: n = 10, Alcoholism: n = 5, Diabetes: n = 3, Splenectomized: n = 1, CSF-leakage: n = 1,</p>b<p>Malignancy/immunosuppresion: n = 5, Alcoholism: n = 3, Diabetes: n = 3, Splenectomized: n = 2, CSF leakage: n = 2.</p>c<p><i>S aureus</i>: n = 2, <i>L monocytogenes</i>: n = 1.</p>d<p><i>S aureus</i>: n = 4, <i>H influenzae</i>: n = 2, <i>L monocytogenes</i>: n = 1, <i>S pyogenes</i> geoup C: n = 1, <i>E cloacae</i>: n = 1.</p>e<p>Two tailed Fisher's exact test for proportions and Student T-test for normally distributed values.</p

The algorithm for inclusion and exclusion of patients.

<p>Inclusion criteria were: 1) age 16–75 years, 2) severely impaired mental status on admission, and 3) confirmed acute bacterial meningitis (ABM). Patients were initially included in the intervention group based on clinical suspicion of ABM with or without cerebrospinal fluid analysis. SQRM = Swedish National Quality Registry for ABM. ICP = intracranial pressure. NICU = neuro-intensive care unit. ICU = intensive care unit.</p

Outcomes at follow-up after 2–6 months in the intervention group and in the controls.

<p>NICU = neuro-intensive care unit. GOS = Glasgow outcome score.</p><p>*p<0.05 with two-tailed Fisher's exact test when comparing the intention to treat group, and the per protocol group, with the control group.</p>a<p>Patients included as final controls according to inclusion and exclusion criteria.</p

Intracranial pressure (ICP)-targeting therapy used in the intervention group, (n = 52, external ventricular drainage; n = 48, parenchymal ICP-monitor; n = 4).

<p>Csf = cerebrospinal fluid; NICU = neuro-intensive care unit.</p

The algorithm for treatment of increased intracranial pressure (ICP) in the neuro-intensive care unit (n = 52).

<p>An external ventricular drainage (EVD) was established at operation in 50 patients with initial cerebrospinal fluid (Csf) drainage in 48 of these. A parenchymal ICP-monitor (Codman) was inserted in four cases. Bolus doses of Mannitol were administered in five cases prior to neuro-intervention. The shaded numbers represent different patients.</p

The highest levels of intracranial pressure (ICP), as observed continuously during episodes of more than 5 min, in the neuro-intensive care unit after initial cerebrospinal fluid drainage at operation; n = 52 (external ventricular drainage; n = 48, parenchymal ICP-monitor; n = 4).

<p>The highest levels of intracranial pressure (ICP), as observed continuously during episodes of more than 5 min, in the neuro-intensive care unit after initial cerebrospinal fluid drainage at operation; n = 52 (external ventricular drainage; n = 48, parenchymal ICP-monitor; n = 4).</p