No abstract

Clear guidelines that address the appropriate use of prophylactic antibiotics in patients undergoing extracorporeal shock wave lithotripsy (ESWL) are not available. The purpose of this study was prospectively to evaluate the role of such antibiotics.Fifty-two patients with sterile urine (tested 3 days prior to ESWL or stent placement and not receiving antibiotics) were randomly assigned (double-blind) to receive oral placebo or norfloxacin 400 mg every 12 hours beginning 48 hours prior to ESWL, with the last dose at 6 am on the morning of the procedure. Urine cultures obtained on the first postoperative day were considered to be significant if the pure colony count exceeded 10,000/ml. No patients had perioperative sepsis. Although statistical evaluation showed no difference between the 24 évaluable norfloxacin-treated and the 25 évaluable placebo-treated patients in the frequency of urinary infection (p = 0.28), two of the patients in the placebo group, both of whom had other manipulations at the time of ESWL, had significant bacteriuria the day after treatment, and one of them was rehospitalized 4 days after ESWL for febrile urinary infection. In contrast, all patients in the norfloxacin group had sterile urine postoperatively. Although the data suggest that antimicrobial prophylaxis is not necessary in ESWL patients with sterile urine preoperatively, it is our impression that patients with a significant history of urinary infection who will have manipulations during ESWL may well benefit from prophylactic antibiotics. Further study on a larger cohort of patients will be necessary to corroborate this belief.

Current literature indicates poor survival and limb salvage rates in renal failure diabetic patients who present with ulcerated or gangrenous lower extremities. Even in those limbs that were successfully revascularized, the amputation rate was as high as 37 percent. This has led some to advocate immediate amputation when treating the threatened limb of a renal failure diabetic patient. The authors reviewed all renal failure diabetic patients in their wound registry to determine whether such pessimism was warranted. The authors then analyzed the relative roles of revascularization and aggressive wound care on long-term limb salvage. Forty-five consecutive renal failure diabetic patients with 71 wounds in 54 limbs were identified. Twenty-seven patients had chronic renal insufficiency, 15 patients had end-stage renal disease, and three patients received kidney transplants. The revascularization procedures (46 percent of all limbs) included angioplasty, femoral-popliteal, femoral-distal, and popliteal-distal bypasses. Forty-three amputations in combination with 67 soft-tissue repairs (delayed primary wound closure, skin grafts, local flaps, pedicled flaps, and free flaps) were necessary to close the defects. After a mean follow-up of over 3 years, the data indicate that 79 percent of wounds healed, 89 percent of all limbs were salvaged, and 49 percent of patients survived. Revascularization improved the threatened limb's salvage rate from negligible to a level similar to that of the adequately vascularized limb. Fifteen out of 71 wounds did not heal because of the patient's early postoperative death, ischemia not amenable to revascularization, or noncompliance. Six below-knee amputations were performed (one despite a patent bypass and five in adequately vascularized patients). The average time for wounds to heal in the revascularized patients was 79 days versus 71 days in adequately vascularized patients. There was an overall 43 percent complication rate. Of the patients who were alive after the 3-year follow-up, 73 percent were independently ambulating, whereas 27 percent were bound to wheelchair or bed. Eighty-two percent of patients were very satisfied with the salvage attempt, 18 percent were moderately satisfied, and all patients said they would go through the process again. The authors believe that salvaging the threatened extremity in the renal failure diabetic patient is justified whether or not the limb requires revascularization. Revascularization improved the limb salvage rate, patient survival, and days for wounds to heal to a level comparable to that of the adequately vascularized limb. The key to subsequently achieving high salvage rates is the quality of perioperative wound care (e.g., serial debridements, antibiotics, dressings) and the timing and selection of appropriate soft-tissue coverage.