Intraoperative Redosing of Cefazolin and Risk for Surgical Site Infection in Cardiac Surgery

Intraoperative redosing of prophylactic antibiotics is recommended for prolonged surgical procedures, although its efficacy has not been assessed. We retrospectively compared the risk of surgical site infections in 1,548 patients who underwent cardiac surgery lasting >240 min after preoperative administration of cefazolin prophylaxis. The overall risk of surgical site infection was similar among patients with (43 [9.4%] of 459) and without (101 [9.3%] of 1,089) intraoperative redosing (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.70-1.47). However, redosing was beneficial in procedures lasting >400 min: infection occurred in 14 (7.7%) of 182 patients with redosing and in 32 (16.0%) of 200 patients without (adjusted OR 0.44, 95% CI 0.23-0.86). Intraoperative redosing of cefazolin was associated with a 16% reduction in the overall risk for surgical site infection after cardiac surgery, including procedures lasting <240 min

Oltre il centenario. Note sulla riproposta dell’edizione critica di Tutte le poesie di Guido Gozzano

Nel 2016, nel centenario della morte del poeta, Mondadori ha riproposto negli Oscar, riveduta e riccamente aggiornata, l’edizione critica di Tutte le poesie di Guido Gozzano curata per i «Meridiani» da Andrea Rocca nel 1980. Le presenti Note intendono illustrare nei suoi caratteri di fondo l’operazione filologica che Rocca, con una consapevolezza critica e un’intelligenza non comuni, ha condotto negli archivi di Gozzano interrogandone strenuamente le stratificazioni, le lacune, l’eterogeneità, i cortocircuiti temporali, per illuminare di luce nuova un processo creativo sempre sospeso fra ricerca di un ordine e richiamo del caos, verità del volto e verità della maschera, come è proprio di una poesia segnata nel profondo dal rapporto mai facile dell’autore con il proprio linguaggio. Prende così densità e risalto la nozione di personalità, di evoluzione di una figura letteraria nel tempo, in un quadro mosso di congiunture e di scambi che appare subito fertile di sviluppi non appena si torni a considerare il nodo cruciale tra Simbolismo e Novecento, si tratti di d’Annunzio o della cultura letteraria francese coeva. Certo è che l’edizione gozzaniana di Rocca dimostra nel modo più luminoso e più intenso come alla ricerca filologica continui a competere un ruolo ancor oggi prodigiosamente vitale, di cui non potrà non tener conto anche l’attuale, inquieto dibattito sulle sorti della letteratura e degli studi letterari nel nostro tempo

Clinical consequences and cost of limiting use of vancomycin for perioperative prophylaxis: Example of coronary artery bypass surgery. Emerg Infect Dis

Routine use of vancomycin for perioperative prophylaxis is discouraged, principally to minimize microbial resistance to it. However, outcomes and costs of this recommendation have not been assessed. We used decisionanalytic models to compare clinical results and cost-effectiveness of no prophylaxis, cefazolin, and vancomycin, in coronary artery bypass graft surgery. In the base case, vancomycin resulted in 7% fewer surgical site infections and 1% lower all-cause mortality and saved $117 per procedure, compared with cefazolin. Cefazolin, in turn, resulted in substantially fewer infections and deaths and lower costs than no prophylaxis. We conclude that perioperative antibiotic prophylaxis with vancomycin is usually more effective and less expensive than cefazolin. Data on vancomycin&apos;s impact on resistance are needed to quantify the trade-off between individual patients&apos; improved clinical outcomes and lower costs and the future longterm consequences to society. The emergence of vancomycin-resistant enterococci has opened a new era of hardly treatable bacterial infections, and there is now evidence that more virulent common pathogens such as Staphylococcus aureus can also develop resistance to vancomycin (1,2). The use of vancomycin is hypothesized to promote the development or transmission of this resistance (3,4). Restrictive guidelines have therefore been disseminated for the use of vancomycin or teicoplanin, another glycopeptide agent (5). These guidelines include a recommendation against the routine use of vancomycin as perioperative antibiotic prophylaxis for surgical site infections. However, vancomycin is preferred for preventing infections caused by methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-resistant coagulase-negative staphylococci. This is the rationale for recommending vancomycin prophylaxis when the risk for infection from methicillinresistant pathogens is high (6-11), although no guideline has made a clear statement on when to use this alternative. Since antibiotics are commonly used for prophylaxis, liberal interpretation of the prophylaxis guidelines will clearly jeopardize efforts to limit the use of vancomycin. Vancomycin is also more expensive to purchase and administer than cephalosporins. To inform both the clinical and public policy debate with respect to the optimal prophylaxis regimen, we conducted a cost-effectiveness analysis to compare the short-and longterm consequences of using vancomycin and cefazolin as first-line perioperative prophylaxis. We focused on patients who underwent coronary artery bypass graft surgery (CABG) because this is a large, relatively homogeneous population with substantial risk for serious surgical site infection (12,13). Methods Cost-Effectiveness Analysis We developed a decision-analytic model We also conducted a reference case analysis, as recommended by the Panel on Cost-Effectiveness in Health and Medicine (14), which assumed a societal perspective and relied on a longer time horizon. The reference case was a 65-year-old man undergoing CABG surgery for stable multivessel coronary heart disease. A state-transition model incorporated the lifetime probability of death, myocardial infarction, angina, or asymptomatic coronary artery disease following CABG surgery (15,16) to estimate life expectancy, qualityadjusted life expectancy, and total lifetime costs. Future costs and benefits were discounted at an annual rate of 3%

Use of Immunoglobulins in Prevention and Treatment of Infection in Critically III Patients: Review and Critique

The study of the use of standard intravenous immunoglobulin (IVIG) preparations as adjunctive therapy for seriously ill patients is motivated bythe need to restore immunoglobulin G depleted because of trauma or surgery and/or by the need to provide patients with specific antibodies to various microorganisms. Whereas no clinical studies have shown that standard IVIG has therapeutic efficacy, some data suggest that its prophylactic use is beneficial. Antisera or IVIG prepared from individuals who are hyperimmunized with the biologically active, highly conserved core portion of the endotoxin of gram-negative bacteria confer variable degrees of protection in animal models and clinical trials. Two clinical trials with use of monoclonal antibodies to core lipopolysaccharide have been completed. Only subsets of patients with gram-negative sepsis were protected by the monoclonal antibodies, but the results of the studies were discrepant in regard to the specific characteristics of patients who benefited from the administration ofthese antibodies. Further studies will be necessary to establish whether this therapy can be recommended for critically ill patient