Can Prophylactic Antibiotics Help Reduce The Risk Of Infection During Surgery?

Podiatric surgery can carry inherent risks including the possibility of perioperative infection. A recent article in the Journal of Bone and Joint Surgery (JBJS) offers several pertinent recommendations that aim to prevent some of the reported 780,000 surgical site infections that occur every year in the United States, according to the study authors.

Although they acknowledge that preoperative antibiotics are associated with lower rates of surgical site infections, the authors of the JBJS article say surgeons should continue antibiotics for no more than 24 hours after elective surgery of surgical treatment of closed fractures. The article also contends chlorhexidine gluconate is superior to povidone-iodine when it comes to preoperative antisepsis.

However, in regard to prophylactic antibiotics, Gary Jolly, DPM, notes “the evidence does not show that their use in elective foot and ankle surgery reduces the risk of infection despite a fairly strong trend to use prophylactic antibiotics.”

He cites his own retrospective study in the Journal of Foot and Ankle Surgery on the topic of prophylactic antibiotics. Dr. Jolly, the Chief of Podiatric Surgery at New Britain General Hospital in New Britain, Ct., also notes he is currently involved in a prospective, randomized, controlled, blinded study on this subject. With 200 patients enrolled thus far in the study, Dr. Jolly says he has seen no difference in infection rates between those taking prophylactic antibiotics and those not taking them.

Surgeons usually use a povidone-iodine base in the hospitals in which Dr. Jolly operates but he says they will use other products if faced with patients with allergies. However, he does not think this is a major issue.
Jesse Burks, DPM, has used both chlorhexidine gluconate and/or povidone-iodine. He says he has not noted any variation in perioperative infection rates anecdotally.

Pertinent Pearls For Reducing The Risk Of Infection
The JBJS authors also say the rate of postoperative infections associated with occlusive dressings is lower than that of non-occlusive dressings. Appropriately managing blood glucose levels, oxygenation and the patient’s temperature reduces the risk of postoperative infection, according to the study authors. One should consider medications and disease processes that may compromise the patient’s immune system, according to Dr. Burks, a Fellow of the American College of Foot and Ankle Surgeons.

Although Dr. Burks feels prevention of infection is “impossible,” he does offer some pearls to reduce the incidence of perioperative infection. He argues that surgeons should take responsibility for aseptic techniques throughout the entire operating room and not just for their specific technique. Dr. Burks, who practices in Little Rock, Ark., adds that surgeons should consider the infection history of the OR in which they are operating.

Dr. Jolly also advocates strict observation of sterile techniques and atraumatic tissue handling. Neal Blitz, DPM, will pre-wash the extremity with isopropyl alcohol to remove any major debris before a formal surgical prep. Dr. Blitz performs the pre-wash himself and will not delegate the task to a resident or nurse.

“It always amazing to see how much dirt and grime comes off,” notes Dr. Blitz, an attending podiatric surgeon in the Department of Orthopedics and Foot and Ankle Surgery at the Kaiser Permanente Medical Center in Santa Rosa, Calif.

Dr. Jolly also recommends limiting the time that a surgical wound is open.

“Surgeons who are slow and careless technically are more likely to see wound infections as well as other types of wound complications,” notes Dr. Jolly, a Fellow and Past President of the American College of Foot And Ankle Surgeons.

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Diabetic Neuropathy More Common In Type 2 Patients
By Brian McCurdy, Senior Editor

Although polyneuropathy can be a common complication for patients with type 1 or type 2 diabetes, an abstract presented at the recent American Diabetes Association (ADA) meeting says polyneuropathy is more prevalent in type 2 patients.

The abstract authors examined 1,194 patients with type 1 and type 2 diabetes in 40 Belgian clinics. Researchers found the prevalence of both types of neuropathy greater in those with type 2 diabetes. Specifically, the study found that 51 percent of type 2 patients had diabetic polyneuropathy and 18 percent had painful diabetic polyneuropathy. In comparison, 25 percent of type 1 patients had polyneuropathy and 6 percent had painful polyneuropathy, according to the study. Authors theorize that the higher incidence of neuropathy in type 2 patients could be attributed to metabolic syndrome associated disturbances.

Barry Rosenblum, DPM, has likewise seen a higher incidence of painful neuropathy in patients with type 2 diabetes.

“At this point, any associated findings are solely that, associated, and I have not identified anything related to the diabetes that it may be attributable to,” notes Dr. Rosenblum, an Assistant Clinical Professor of Surgery at Harvard Medical School.

The study concludes that one can diagnose neuropathy “with costless tools that do not require special expertise.” When examining patients for neuropathy, Dr. Rosenblum centers his detection on taking a good history and physical exam. As far as equipment goes, he employs a tuning fork, Semmes-Weinstein monofilament wire set, and sharp/dull discrimination. In some clinical trials, he will use the Neuropathy Symptom Score.

Studies Say Duloxetine Relieves Neuropathic Pain
By Brian McCurdy, Senior Editor

A number of medications have been under development in the past few years to treat the pain associated with diabetic peripheral neuropathic pain. A series of recent studies has concluded that duloxetine HCl (Cymbalta, Eli Lilly) is effective in reducing this pain.

The study results, which were recently published in Pain Medicine, were drawn from three 12-week, multicenter, double-blind studies of patients with painful diabetic neuropathy. The first study assigned 457 patients to receive duloxetine in doses of 20 mg QD, 60 mg QD or 60 mg BID, or a placebo. The second study assigned 334 patients to receive duloxetine in doses of 60 mg QD, 60 mg BID or placebo. The third study assigned 348 patients to receive duloxetine in doses of 60 mg QD, 60 mg BID or placebo.

Researchers assessed patient-reported outcomes via the Short Form 36 (SF-36), the interference portion of the Brief Pain Inventory (BPI), and EuroQol 5D Health Questionnaire (EQ-5D). The study measured physical function, pain, general health, vitality, social function, and mental health. In those areas, the SF-36, BPI and EQ-5D, researchers found that duloxetine was “significantly superior” to placebo.

How does duloxetine compare to other drugs indicated for diabetic neuropathic pain? Miroslav Backonja, MD, a co-author of the study, notes that since the drug has not been compared to pregabalin (Lyrica, Pfizer) or gabapentin (Neurontin, Pfizer), there is no data based on comparative randomized controlled trials. However, he does say that based on the existing large clinical expereince, all three neuropathic pain drugs are “relatively effective in relieving neuropathic pain, are well tolerated and safe.”

Duloxetine has different mechanisms of action than other medications on the market, according to Dr. Backonja. He says the drug has demonstrated efficacy in treating the pain associated with diabetic neuropathy. As he notes, the main advantage of duloxetine would be in a patient with both pain and depression related to neuropathy. In such a case, the medication could help both problems, according to Dr. Backonja, a Professor of Neurology, Anesthesiology and Rehabilitation Medicine at the University of Wisconsin School of Medicine and Public Health in Madison, Wis.

In Brief
Integra LifeSciences recently announced it has acquired IsoTis, Inc., an orthobiologics company. Integra will sell IsoTis’ products, including the demineralized bone matrix products, DynaGraft® II and OrthoBlast® II, according to a company press release.

The Podiatry Insurance Company of America (PICA) recently announced its acquisition of the podiatry book of business from Physicians’ Reciprocal Insurers (PRI). Starting with the Oct. 1, 2007 renewals, PRI will begin not renewing its policyholders, according to a company press release.

Clarification
In the table of contents for the August 2007 issue of Podiatry Today, Jack Janov, Esq., was the author of “Seven Keys To Preventing Malpractice Lawsuits.”