Cefotaxime [HR 756], a third generation cephalosporin with pronounced antibacterial activity
against the Enterobacteriaceae, was assessed in serious and problem antibiotic resistant infection. Good clinical success was achieved without observed untoward effects. The study suggests that due to its properties, cefotaxime could be used as a first-line antibiotic provided that the clinical situation warrants the use of a cephalosporin or aminoglycoside.
Key words - cefotaxime [HR 756], serious surgical infection, antibiotic resistant infection.
A case of Aeromonas hydrophila infection complicating an open Rolando's fracture of the hand is reported. Only two cases, both complicating open tibial fractures have been reported in the literature previously.' ,2 The organism was resistant to the usual antimicrobial (ampicillin and cloxacillin) used in the management of open fractures at University Hospital, Kuala Lumpur. The severity of the infection is largely dependent on the resistance of the host, and could vary from a locally spreading necrotizing cellulitis without systemic signs to a frank septicaemia with serious consequences. Early diagnosis with adequate debridement of the wound and appropriate antimicrobial to which the organisms are sensitive, are essential for effective control.
Perforated appendicitis, with its increased complication rate, today still poses a formidable problem in the Kuala Lumpur General Hospital. Out of 1694 emergency operations performed by our unit in 1987, there were 927 appendicectomies. A retrospective study of these cases showed 126 cases of perforated appendicitis, which were then subjected to detailed analysis. We have a diagnostic accuracy of 81% and perforation rate of 18%. In addition, it is interesting to note the racial differences in the relationship of diagnostic accuracy to perforation rate. Perforation is associated with an increased wound infection rate. Transperitoneal drainage in perforated appendicitis did not lead to a lower incidence of wound infection or improve postoperative performance. Distinguishing between perforated and non-perforated appendicitis may be difficult. Perforation could occur while awaiting operation. We recommend the early administration of systemic antibiotics should appendicectomy be delayed and the cautious use of drains in cases of perforated appendicitis.
A prospective randomised controlled study was conducted over a 6 month period on the value of administering prophylactic antibiotics in patients undergoing emergency caesarean section at the Ipoh General Hospital. A total of 222 patients were randomised to receive 24 hours of ampicillin (500 mg per dose), cefoperazone (1 gm per dose) or no antibiotics. In all parameters of patient morbidity, the group receiving cefoperazone showed significantly better results as compared to the group not receiving antibiotics. The ampicillin group also had favourable results but generally not achieving statistical significance. Prophylactic antibiotics appear to be beneficial and consideration should be given to make it a routine in all emergency caesarean sections.
A 19-year-old Malay male succumbed to a septicaemia caused by Chromobacterium violaceum 11 days after onset of illness. The organism is a common soil saprophyte and may be considered as contaminant on culture. It is essential to recognise its clinical significance in purulent processes so that appropriate therapy can be instituted. We report the first fatal case of Chromobacterium violaceum infection in the University Hospital, Kuala Lumpur.
A survey on the use of antibiotics in surgical prophylaxis was carried out in seven Malaysian hospitals. Details of antibiotic prescriptions were obtained through questionnaires completed by the prescriber. A total of 430 such prescriptions was analysed. A large number of different antibiotic regimens were used for a variety of surgical procedures. The majority of prescriptions (70%) were issued for procedures where such prophylaxis was probably not necessary. Antibiotics were also often prescribed for durations that were longer than necessary. There is an urgent need to educate surgeons and standardize surgical prophylactic regimens in order to reduce cost and combat the emergence of antibiotic resistance.
A prospective study of 94 burned children was carried out from January 1993 to October 1994. Scalding was the predominant cause of injury affecting mainly toddlers between 1 and 3 years old. Ninety-six per cent of the injuries occurred at home. There was 1 death following an 81% flame burns. An intense campaign to make parents aware of the hazards is required as almost all the injuries were preventable.
With the increase in the number of orthopaedic surgeons and the aggressive marketing by manufacturing companies, high technology orthopaedic surgery is being more frequently carried out in Malaysia. Post-operative sepsis complicating this type of surgery can have disastrous consequences. No data is available in this country on the incidence of post-operative infection in Orthopaedic Surgery. The aim of this study was to determine the incidence of post-operative infection. A retrospective survey of 703 patients undergoing elective Orthopaedic Surgery in the year 1991 was carried out. We found an overall post-operative infection rate of 6.8% and a deep infection rate of 3.3%. This figure of 3.3% is higher than the internationally accepted figure of less than 2%. A need for ongoing surveillance and concerned effort to reduce the infection rate is stressed.
A 31-year-old Pakistani man was admitted to hospital after sustaining a Grade I compound fracture of the mid-shaft of the left tibia and fibula following a motor vehicle accident. He developed septicaemic shock, acute renal failure and Group A streptococcal necrotizing fasciitis of the left leg. The patient underwent an above knee amputation followed by disarticulation of the left hip with extensive debridement. He was treated with benzylpenicillin, vancomycin, inotropes and continuous haemodialysis and survived without further sequelae. Subsequently, skin grafting was done over the wound site. This case highlights the role of Group A streptococcus as a cause of this rare and life-threatening infection.
From January 1992 to January 1996, thirty-three patients with persistent clinical and functional knee instability due to anterior cruciate insufficiency underwent ACL reconstruction using central third of the bone-patellar ligament-bone graft. An early experience was presented with average follow-up of 9.8 months (range six to thirty-three months). There thirty-two male and two females. The average age was twenty-four months. Eighty-three percent were involved in football injury. The average time interval from initial injury to operation was twenty-five months. Majority presented with knee pain and giving way. Meniscal tear was the commonest associated injury in more than 70 percent; the lateral meniscus being more frequently injured (42 percent) than the medial meniscus (15 percent). Using modified criteria by Paterson and Trickey (1986), nine patients (27 percent) had good results and twenty-two (67 percent) has satisfactory results. Two patients (6 percent) who had post-operative infection were graded as poor. Functional stability was achieved in twenty-eight (85 percent) and instability persisted in five (15 percent). There were marked clinical improvement in the Lachman and anterior drawer grading post-operatively. The accelerated rehabilitation programme was effective in obtaining early clinical improvement and in reducing post-operative knee stiffness.
Four patients underwent reconstruction of anterior cranial fossa of skull defects between November 1997 and January 1998. All of them had traumatic anterior cranial fossa defect and were reconstructed with lyophilised bovine cortical bone graft. There was no cerebrospinal fluid leakage, meningitis, extradural abscess or other infections. This study demonstrates that the use of bovine bone graft in the reconstruction of anterior base defects is safe.
Matched MeSH terms: Surgical Wound Infection/prevention & control
The results of 109 primary total hip arthroplasties in 92 patients performed in Hospital Kuala Lumpur from January 1987 to December 1996 were reviewed after a mean follow-up of 30.8 months. There were 22 males and 70 females with the average age of 49.9 years (range 19 to 94 years). Chinese females comprised the largest group of patients (52.2%). Avascular necrosis was the most common diagnosis (33.1%) followed by hip dysplasia and primary osteoarthritis (17.4%). The procedure was performed more on the right hip (64.2%) compared to the left (35.8%). All patients received prophylactic antibiotics but none were given deep vein thrombosis prophylaxis. The Charnley prosthesis was most commonly used and the majority of the arthroplasties were cemented (60.5%). About 80% of the THA were performed via the lateral approach. The functional hip score improved from an average of 8.9 to 15.0 with 66.3% of the patients categorized as good and excellent results. There were 16 patients (17.4%) with poor outcome. The most common complications encountered were dislocation (10.1%), aseptic loosening (9.2%) and periprosthetic fracture (5.5%). Other complications were deep infection (1.8%), deep vein thrombosis (0.9%), trochanteric osteotomy complications (1.8%), superficial infection (7.3%), urinary tract infection (5.5%), pressure sore (3.7%) and respiratory complication (1.8%). Fifteen hips (13.8%) required revision. The causes for revision were aseptic loosening, dislocation and infection. Technical anomalies were recognized as one of the factors contributing to poor results. Five-year survival rate was 87.3%. Better results can be expected with increasing experience and technical skulls.
Sixty-seven primary THR surgeries in 57 patients between January 1992 and December 1998 were reviewed after a mean follow-up of 35.9 months. The rate of superficial and deep wound infections were 11.9% and 1.5% respectively. The most common organism in superficial wound infection was Staphylococcus aureus. The factors that were significantly associated with superficial wound infection were diabetes mellitus (p= 0.0230) obesity (p=0.0088). The patients who developed superficial wound infection have a significantly longer duration of surgery compared to patients without infection (p=0.014). However, there was no significant difference between the mean age among patients with and without superficial wound infection (p=0.814).
Sixty percent of open fracture wounds are contaminated at the time of injury. Despite that, the necessity for sequential multiple cultures and sensitivity studies for open fractures and their interpretation are still controversial. Predebridement, intraoperative, postoperative swabs and swabs in established infection for culture and sensitivity study were taken in 33 open tibial fractures over a 6 months period. 39.3% of predebridement swabs grew bacteria with the majority yielding gram-positive organism. None of the patients developed infection with similar organisms. 24.2% of the postoperative swabs grew bacteria, of which 75% were gram-negative. 50% of the patients with positive postoperative swabs developed infection. Thus, the role of sequential multiple cultures and sensitivity studies are not helpful in management of open fracture.
One hundred primary TKR surgeries done between January 1994 and December 1999 were reviewed after a mean follow-up of 37.4 months. The rate of superficial and deep wound infection were 2% and 9% respectively. The most common organism in wound infection was Staphylococcus aureus. The factors that were significantly associated with superficial wound infection were diabetes mellitus (p = 0.005) and rheumatoid arthritis (p = 0.0000). The factors that were significantly associated with deep wound infection were diabetes mellitus (p = 0.000). There was no significant difference between duration of surgery, and the mean age among patients with and without wound infections.
Antibiotics are often administered in elective colorectal surgery to prevent wound infection. The tendency for surgeons to prolong the administration of prophylactic antibiotic therapy in the postoperative period is a well-known fact. The aim of this study was to elucidate the pattern of prophylactic antibiotic utilization in elective colorectal surgery and to determine if evidence-based medicine is employed in relation to this practice.
Management of severe open tibial fracture with neurovascular injury is difficult and controversial. Primary amputation is an acceptable option as salvaging the injured, insensate, and ischaemic limb may result in chronic osteomyelitis and non-functional limb. We report a case of open tibial fracture associated with segmental bone and soft tissue loss, posterior tibial nerve and artery injuries, which was further complicated by chronic osteo-myelitis treated with composite vascularised osteocutaneous fibula and sural nerve graft. Functional outcome of the injured limb at one-year follow-up was satisfactory: the patient was capable of achieving full weightbearing and was able to appreciate crude touch, pain, proprioception, and temperature at the plantar aspect of the foot. There was no pressure sore or ulceration.