Acharya Metesh Nalin, Som Robin, Tsui Steven
Department of Surgery, Watford General Hospital, Watford, UK.
Interact Cardiovasc Thorac Surg. 2012 Feb;14(2):209-14. doi: 10.1093/icvts/ivr054. Epub 2011 Nov 30.
A best evidence topic was written according to a structured protocol. The question addressed was what the optimum antibiotic prophylaxis in patients undergoing implantation of a left ventricular assist device (LVAD) is. A total of 373 papers were found, of which 11 represented the best evidence. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Eight retrospective and two prospective studies, including one randomized controlled trial (RCT), were identified. Although highly variable, the prophylactic antibiotic protocols employed in these studies generally favour the use of vancomycin, a cephalosporin, beta-lactam and quinolone, with the option of additional fluconazole and mupirocin. However, the lack of standardized definitions for infection, and variations in the choice, timing and duration of prophylactic antibiotics complicates the interpretation of reported infection rates. Driveline and pocket infections comprised the majority of infectious complications, and were principally attributed to Gram-positive organisms, such as Staphylococcus, as well as Pseudomonas species. We conclude that a beta-lactam be used for primary prophylaxis, with vancomycin where the risk of MRSA is high. Topical mupirocin and an anti-fungal are also recommended. Prophylaxis should commence prior to device insertion, and be continued into the peri- and post-operative period. Large-scale RCTs are necessary to assess the impact of different antibiotic regimens on infection within LVAD recipients.
根据结构化方案撰写了一篇最佳证据主题文章。所探讨的问题是，接受左心室辅助装置（LVAD）植入术的患者的最佳抗生素预防方案是什么。共检索到373篇论文，其中11篇代表最佳证据。现将作者、日期、期刊、研究类型、研究人群、主要结局指标及结果制成表格列出。确定了八项回顾性研究和两项前瞻性研究，其中包括一项随机对照试验（RCT）。尽管这些研究中采用的预防性抗生素方案差异很大，但总体上倾向于使用万古霉素、头孢菌素、β-内酰胺类和喹诺酮类药物，还可选择加用氟康唑和莫匹罗星。然而，感染缺乏标准化定义，预防性抗生素在选择、时机和疗程方面存在差异，这使得对报告的感染率的解读变得复杂。驱动线和囊袋感染占感染性并发症的大多数，主要归因于革兰氏阳性菌，如葡萄球菌以及假单胞菌属。我们得出结论，对于一级预防应使用β-内酰胺类药物，在耐甲氧西林金黄色葡萄球菌（MRSA）风险高的情况下使用万古霉素。还建议使用外用莫匹罗星和抗真菌药物。预防应在装置植入前开始，并持续至围手术期和术后。有必要开展大规模随机对照试验来评估不同抗生素方案对LVAD植入受者感染情况的影响。
