Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_999_Библиотеки_им_академика_М_И_Перельмана

Once penicillin became available during World War II, it was used to prevent infec­tions in orthopaedic surgery [1]. Controversy followed, when, in 1960, Pulaski and Taylor noted that most infecting organisms in orthopaedic surgery were resistant to the antibiotics commonly used for prophylaxis at the time. They also mentioned that infection rates were higher among patients who received antibiotics. Their conclu­sion was that “routine indiscriminate antibiotic prophylaxis for elective surgical conditions served no useful purpose” [2].

Cutibacterium acnes is considered a major pathogen in shoulder surgery and may exceed even Staphylococci in prevalence [7]. It shows good sensitivity to anti­biotics commonly used for bone and joint infections, particularly beta-lactams, qui­nolones, and rifampicin. However, resistance to some antibiotics, in particular clindamycin, is emerging. Furthermore, Cutibacterium acnes, despite being an anaerobic bacterium, also shows natural resistance to metronidazole.

The optimal prophylactic antibiotic should include coverage for resistant Gram­positive as well as for common Gram-negative agents. Adequate bloodstream and tissue concentrations should be achieved along the entire procedure. Additionally, it is crucial that bacteria do not readily develop resistance to this antibiotic, consider­ing its intended widespread utilisation.

Cefazolin 2g (or 3g if >100kg body weight) IV 30–60min before skin incision, then cefazolin 2g or 3g IV every 8h for 24h is advised. In beta-lactam allergic patients the recommended protocol is vancomycin IV (15mg/kg) or clindamycin 600–900mg IV 60–90min before skin incision, then vancomycin every 12h or clindamycin 600–900mg IV every 6h for 24h [8, 18].

The task of creating a vaccine capable of preventing Staphylococcus aureus infection has proven to be formidable. This bacterium is a commensal organism found in the nasal mucosa and skin of humans, and it has developed a sophisticated arsenal speci­cally designed to evade the human immune system. However, the development of an effective vaccine holds the potential to address the escalating concerns of antibiotic resistance and the emergence of vancomycin-resistant staphylococci. Currently, there are at least ve vaccines against Staphylococcus aureus that are undergoing various stages of clinical trials. Concurrently, research has also focused on bacteriophages, monoclonal antibodies, centyrins (monoclonal antibody mimetics), and novel types of antibiotics. Some of these approaches have shown promising results in human testing. Additionally, various strategies have been explored in preclinical settings to enhance the delivery of anti-staphylococcal drugs for specic infections, including skin and soft tissue infections, implant-associated osteomyelitis, and pneumonia [24].

First generation cephalosporins are still popular; second-generation cephalosporins offer greater protection against Gramnegative bacteria, but have reduced efcacy against staphylococci. Our recent results clearly indicate a worrying increase in resistance to clindamycin [12]. The choice of vancomycin for this task also presents a number of challenges [25]. Thus, a single regimen will hardly be ideal for all patients, and risk assessment should precede prophylactic prescriptions.