[HSF] Re: Post op antibiotics

[David Harris]

Thanks. I will need to look at my data for exact
number of patients treated.There were quite a few
valve patients who developed a fever, and raised CRP,
and the CRP normalised after about  2 weeks, so we
stopped treatment then, as there was no evidence of
endocarditis. We then repeated the CRP on follow up to
make sure it did not peak again, which did occur in 2
patients and they were fully treated.

Another patient was spiking fevers for 2 weeks, and
the CRP took a month to normalise, so we treated him
for 6 weeks.

Another difficult personality discharged herself after
a week, and CRP went up again. She did not want IV Rx
so was put on oral antibiotics. CRP continued to
climb, and another week later I persuaded her to be
admitted (by a colleague), she did not respond well to
Rx by this stage, and had a redo done.

There was definitely a correlation between the rate of
elevation and severity of the sickness. After seeing
the CRP spike, and then tracking it, it will rapidly
rise, and there will be a slight delay in the clinical
picture but this will be more than obvious within the
next day.

Dave


--- Michael Firstenberg <msfirst at gmail.com> wrote:

> very interesting observations - you need to write it
> up.
> 
> If the CRPs went up and you started abx without an
> obvious source -  
> how long did you treat?
> was there any correlation between the rate of
> elevation and severity  
> of illness?
> 
> wetting my appetite for more data!
> 
> We did a lot of TEG on our VAD patients and while
> the data was very  
> hard to get our hands around sudden (i.e. one day to
> the next)  
> changes in TEG predicted an infection usually a day
> or two in  
> advance.  I think there is a lot to be learned from
> these  
> inflammatory markers - the Cards use them a lot for
> predicting or  
> understanding AMIs.
> 
> 
> 
> -michael
> 
> 
> 
> On Oct 1, 2007, at 8:32 PM, David Harris wrote:
> 
> > Dear Ahmed, and Hal
> >
> > Sorry for the late reply, have been on vacation.
> >
> > As far as I know there is no literature reference
> to
> > back this up...although I am also the first to
> look at
> > evidence based concepts, an absence of literature
> > reference at this stage does not mean there is no
> > validity in the concept.
> >
> > I first started to do the CRP levels in all my
> > patients in 2000, when I started to do a
> randomised
> > study in my OPCAB patients. At that stage I was
> > already doing 70% OPCAB, but was wondering if I
> was
> > really doing the right thing, and also having
> local
> > criticism, thought I would then randomise all my
> > patients for the next year or so. I collected
> about
> > 120 patients in each group, and did post op
> cardiac
> > enzymes and inflammatory markers in all patients.
> What
> > we did find was that the OPCAB patients had a
> > statistically significant decrease in duration of
> > ventilation, CRP level, low cardiac output, and
> enzyme
> > release.
> >
> > We sent it in for publication to the European
> Journal,
> > and it was rejected, and we did not bother further
> (in
> > retrospect a mistake, as I have seen that
> persistence
> > does work!).
> >
> > What we also found, though, was that the CRP
> levels
> > helped to identify patients developing early
> sepsis
> > such as pneumonia (CRP > 350 day 1 or 2, it should
> > never be more than this),and helped identify
> patients
> > developing mediastinitis (rising CRP, after it has
> > started to drop). Usually it should be < 100 by
> day 5,
> > and if it is more than this we repeat after a few
> days
> > to make sure it is still going down. If it is >
> 100 by
> > day 7, then do not be surprised if this patient
> has
> > more chest pain than usual (Dressler`s),
> especially if
> > it takes a while to settle. A subsequent peak in
> CRP
> > is interesting to note, as this, in my personal
> > experience correlates with mediastinitis (or
> possible
> > endocarditis in valve patients). STarting
> treatment
> > has always aborted a disaster, in my experience,
> but
> > at the same time the patient has still become
> sick,
> > with cellulitis and fever, and in one case, in a
> > diabetic the patient developed SIRS 2 days after
> > initiating treatment, and had to be transferred to
> icu
> > (2 days prior to this I was about to send him
> home,
> > until I got the CRP result).
> >
> > The intensivists that look after my patients
> always do
> > a procalcitonin level if the CRP is high, or if
> they
> > suspect sepsis, but in my experience, I do not
> find
> > this too useful as an early indicator, but find
> the
> > CRP TREND more useful.
> >
> > If there is a significant CRP peak (after it has
> > dropped), and I cannot identify a local source of
> > sepsis, then usually I start them on Vancomycin
> and
> > Amicasin, or just Teicoplanin if the kidneys are
> bad
> >
> > It will be interesting to see what other surgeons`
> > findings will be. You will find you will do lots
> of
> > CRP levels, and initially it will seem useless,
> but
> > you will find it interesting when you match it
> with
> > the patient`s clinical recovery, and rewarding
> when
> > you detect the odd potential disaster
> >
> > Dave Harris
> >
> > --- A <alsadd at ksu.edu.sa> wrote:
> >
> >> Dave:
> >> I add my voice to Hal's very interesting concept
> CRP
> >> level as a marker for a
> >> potential mediastinitis. In your case what
> >> antibiotic do you start the
> >> patient on and for how long if the CRP level is
> >> rising? Reference please.
> >> Thank you for this info
> >>
> >> Ahmed
> >>
> >> -----Original Message-----
> >> From: openheart-l-bounces at lists.hsforum.com
> >> [mailto:openheart-l-bounces at lists.hsforum.com] On
> >> Behalf Of David Harris
> >> Sent: Saturday, September 22, 2007 2:16 PM
> >> To: OpenHeart-L at lists.hsforum.com
> >> Subject: RE: [HSF] Re: Post op antibiotics
> >>
> >> For CABG patients 24 hrs.
> >>
> >> For valves, until lines and drains out.
> >>
> >> Then track the CRP levels every second day to
> make
> >> sure the trend is downward, and there is no peak
> >> just
> >> before discharge. This way you can avoid
> >> mediastinitis, as you can treat it as it starts.
> >> Since doing this have not had a single case of
> >> sternal
> >> sepsis in the last 700 patients, but have had CRP
> >> peaks which we then confirm the next day, then
> >> treat.
> >> Some developed cellulitis a few days afterwards,
> >> while
> >> on treatment, but we were able to avoid
> >> debridements.
> >>
> >> Dave Harris
> >>
> >>
> >> --- Adam Saltman <aes.md.phd at hotmail.com> wrote:
> >>
> >>> It is actually policy at our institution now to
> >>> discontinue all prophylactic antibiotics
> according
> >>> to a time schedule. For general surgery patients
> >>> this is after 24 hours, and for cardiac patients
> >> it
> >>> is 48 hours (which actually has no data behind
> it,
> >>> just some hysterical cardiac surgeons). This is
> >> now
> >>> becoming a nation-wide initiative in the
> >> prevention
> >>> of infection by drug-resistant organisms... But
> as
> 
=== message truncated ===


Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon        
Suite 207                                
Kuils River Private Hospital,        
PO Box 1200, Kuils River, 7579, Cape Town, South Africa.            
Tel +27-21-9006411             
Fax +27-21-9006412      Mobile +27-83-3309587