[Prevention of nosocomial infections after cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine; a prospective, randomised study]
Ned Tijdschr Geneeskd. 2008 Mar 29;152(13):760-7
Authors: Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA
OBJECTIVE: To determine the efficacy ofperioperative decontamination of the nasopharynx and oropharynx in reducing nosocomial infection after cardiac surgery with the use of 0.12% chlorhexidine. DESIGN: Randomized, double-blind, placebo-controlled clinical trial (www.clinicaltrials.gov; identifier NCT00272675). METHODS: The trial was conducted at the Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands, from 1 August 2003-31 August 2005. Of 991 patients older than 18 years who underwent elective cardiothoracic surgery during the study interval, 954 were eligible for the study. They were given an oropharyngeal rinse and nasal ointment was applied which contained either chlorhexidine or placebo. Clinical outcomes were incidence of nosocomial infection, rate of Staphylococcus aureus nasal carriage and duration of hospital stay. RESULTS: The incidence ofnosocomial infection in the chlorhexidine and placebo groups was 19.8% and 26.2% respectively (absolute risk reduction (ARR): 6.4%; 95% CI: 1.1-11.7; p = 0.002). In particular, lower respiratory tract infections and deep surgical site infections were less common in the chlorhexidine group than in the placebo group (ARR: 6.5%; 95% CI: 2.3-10.7; p = 0.002 and 3.2%; 95% CI: 0.9-5.5; p = 0.002, respectively). For the prevention of one nosocomial infection, 16 patients needed to be treated with chlorhexidine. A significant reduction in S. aureus nasal carriage was found in the chlorhexidine group (57.5%) as compared with a reduction of 18.1% in the placebo group (p < 0.0001). Total hospital stay for patients treated with chlorhexidine was 9.5 days compared with 10.3 days in the placebo group (95% CI: 0.24-1.88; p = 0.04). CONCLUSION: Decontamination of the nasopharynx and oropharynx with chlorhexidine appeared to be an effective method to reduce nosocomial infection after cardiac surgery.
[From the Cochrane Library: ultrasonographic screening for abdominal aortic aneurysm in men aged 65 years and older: low risk of fatal aneurysm rupture]
Ned Tijdschr Geneeskd. 2008 Mar 29;152(13):747-9
Authors: Hamerlynck JV, Legemate DA, Hooft L
Abdominal aortic aneurysm (AAA) is present in 5-10% of men aged 65-79 years and is often asymptomatic. The major complication is rupture, which requires emergency surgery. The mortality rate after rupture is high: about 80% of those who reach the hospital and 50% of those undergoing emergency surgery will die. Elective surgical repair of AAA aims to prevent death from rupture; the 30-day surgical mortality rate for open surgery is approximately 5%. Currently elective surgical repair is recommended for aneurysms larger than 5-5 cm to prevent rupture. There is interest in population screening to detect, monitor and repair AAA before rupture. A Cochrane systematic review of 4 randomised studies involving 127,891 men and 9,342 women revealed a significant reduction in mortality from AAA in men aged 65-79 years who underwent ultrasonographic screening (odds ratio (OR): 0.60; 95% CI: 0.47-0.78). There was insufficient evidence to demonstrate a benefit in women. Men who had been screened underwent more surgery for AAA (OR: 2.03; 95% CI: 1.59-2.59). These findings should be considered carefully when determining whether a coordinated population-based screening programme should be introduced. A gap in the current research is the balance of benefits and risks in women. Furthermore, detailed studies are needed on how to best provide information on the potential benefits and risks to individuals who are offered screening, and on the psychological effects of screening on patients and their partners.
[A 47-year-old dog breeder with chronic polyarthritis, weight loss and high Fever.]
Z Gastroenterol. 2008 May;46(5):431-4
Authors: Kremer AE, Budenhofer U, Beuers U, Rust C
A 47-year-old dog breeder had suffered from unclassified polyarthritis for four years. During immunomodulatory therapy of an assumed seronegative chronic polyarthritis with Leflunomid and Adalimumab he developed severe systemic inflammatory disease with high fever, weight loss, and severe arthralgia. Fever and arthralgias temporarily improved under antibiotic therapy, although a causative organism had not been found. The clinical picture led to the differential diagnosis of Whipple's disease, but PAS-positive macrophages were not detected in duodenal biopsies. The diagnosis was finally based on a positive PCR result for Tropheryma whipplii, typical clinical symptoms and a complete response on adequate antibiotic long-term treatment with cotrimoxazol. The diagnosis of Whipple's disease was possibly masked by the initial antibiotic therapies. Therapies with immunomodulators, TNF-inhibitors, and corticosteroids may transform an infection with Tropheryma whipplii, normally in a subacute stage, into a septic, life-threatening disease.
