***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: BACKGROUND --Pacemaker pocket infection is a potentially serious problem after permanent pacemaker implantation .  Antibiotic prophylaxis is commonly prescribed to reduce the incidence of this complication , but current trial evidence of its efficacy is conflicting . A large prospect i ve r and omised trial was therefore performed of antibiotic prophylaxis in permanent pacemaker implantation . The intention was firstly to determine whether antibiotic prophylaxis is efficacious in these patients and secondly to identify which patients are at the highest risk of infection . METHODS --A prospect i ve r and omised open trial of flucloxacillin ( clindamycin if the patient was allergic to penicillin ) v no antibiotic was performed in a cohort of patients undergoing first implantation of a permanent pacing system over a 17 month period .  Intravenous antibiotics were started at the time of implantation and continued for 48 hours . The trial endpoint was a repeat operation for an infective complication . RESULTS --473 patients were entered into a r and omised trial . 224 received antibiotic prophylaxis  and 249 received  no antibiotics . A further 183 patients were not r and omised but were treated according to the operator 's preference ( 64 antibiotics , 119 no antibiotics ) ; these patients are included only in the analysis of predictors of infection . Patients were followed up for a mean ( SD ) of 19(5 ) months . Among the patients in the r and omised group there were nine infections requiring a repeat operation , all in the group not receiving antibiotic ( P = 0.003 ) . In the total patient cohort there were 13 infections , all but one in the non-antibiotic group ( P = 0.006 ) . Nine of the infections presented as erosion of the pulse generator or electrode , three as septicaemia secondary to Staphylococcus aureus , and one as a pocket abscess secondary to Staphylococcus epidermidis . Infections were significantly more common when the operator was inexperienced ( < or = 100 previous patients ) , the operation was prolonged , or after a repeat operation for non-infective complications ( principally lead displacement ) . Infection was not significantly more common in patients identified preoperatively as being at high risk ( for example patients with diabetes mellitus , patients receiving long term steroid treatment ) , although there was a trend in this direction . CONCLUSIONS --Antibiotic prophylaxis significantly reduced the incidence of infective complications requiring a repeat operation after permanent pacemaker implantation . It is suggested that antibiotics should be used routinely Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more To investigate the usefulness of a st and ard surgical preparation in prevention of surgical site contamination , 49 consecutive patients undergoing foot or ankle surgery were r and omly assigned to st and ard preparation with chlorhexidine gluconate home scrubs and preoperative povidone-iodine or to st and ard preparation plus preoperative preparation with 70 % alcohol . Results were available for all 49 patients . Cultures were positive for normal aerobic bacteria from the toes of nine of 26 patients ( 35 % ) receiving st and ard surgical preparation and from the toes of 13 of 23 patients ( 57 % ) receiving st and ard preparation plus alcohol ( P=0.12 ) . No patient had a positive culture for anaerobic organisms or clinical evidence of infection or wound problems .  St and ard surgical preparation did not provide a completely sterile field , and the inclusion of alcohol added no benefit BACKGROUND Currently , there are various antiseptics used for cleaning the skin before surgery , but there is no st and ard procedure in practice . Chlorhexidine and povidone-iodine are the most preferred compounds among antiseptics . Both are proved to be safe and effective for skin disinfection . In this study , our aim was to investigate the combined effects of chlorhexidine and povidone-iodine on the skin 's flora before neurosurgical intervention , consecutively . METHODS R and omly , 50 cranial and 50 spine neurosurgery cases were assigned to the study . The first culture was obtained after hair removal and before cleaning the skin with any antiseptic . The second culture was obtained after the skin had been cleaned with chlorhexidine for 3 minutes . Then , the skin was cleaned twice with povidone-iodine for 30 seconds , and the third and fourth cultures were taken from the skin incision area . Bacteria were identified by means of st and ard laboratory identification methods . Positive culture results were compared statistically among order of cultures obtained . RESULTS In the first culture evaluation , 39 ( 33 cnS , 6 Stapylococcus aureus ) of 50 cranial sample s and 37 ( 33 cnS , 4 S aureus ) of 50 spine sample s showed reproduction . In the second culture , 9 cranial and 5 spine sample s showed reproduction of cnS. In the third and fourth cultures , no growth was observed ( P < .001 ) . CONCLUSION Three minutes ' cleaning of the incision area with chlorhexidine , followed by 30-second cleaning with povidone-iodine , could be a sufficient disinfection procedure for preoperative preparation of the skin in patients undergoing a neurosurgical procedure BACKGROUND Treatment of Staphylococcus aureus colonization before surgery reduces risk of surgical site infection ( SSI ) . The regimen of nasal mupirocin ointment and topical chlorhexidine gluconate is effective , but cost and patient compliance may be a barrier . Nasal povidone-iodine solution may provide an alternative to mupirocin . METHODS We conducted an investigator-initiated , open-label , r and omized trial comparing SSI after arthroplasty or spine fusion in patients receiving topical chlorhexidine wipes in combination with either twice daily application of nasal mupirocin ointment during the 5 days before surgery or 2 applications of povidone-iodine solution into each nostril within 2 hours of  surgical incision .  The primary study end point was deep SSI within the 3 months after surgery . RESULTS In the modified intent-to-treat analysis , a deep SSI developed after 14 of 855 surgical procedures in the mupirocin group and 6 of 842 surgical procedures in the povidone-iodine group ( P = .1 ) ; S. aureus deep SSI developed after 5 surgical procedures in the mupirocin group and 1 surgical procedure in the povidone-iodine group ( P = .2 ) . In the per protocol analysis , S. aureus deep SSI developed in 5 of 763 surgical procedures in the mupirocin group and 0 of 776 surgical procedures in the povidone-iodine group ( P = .03 ) . CONCLUSIONS Nasal povidone-iodine may be considered as an alternative to mupirocin in a multifaceted approach to reduce SSI . TRIAL REGISTRATION Clinical Trials.gov identifier : NCT01313182 Introduction Surgical site infection ( SSI ) is a significant cause of postoperative morbidity and mortality . Effective preoperative antisepsis is a recognised prophylactic , with commonly used agents including chlorhexidine ( CHG ) and povidone-iodine ( PVI ) . However , there is emerging evidence to suggest an additional benefit when they are used in combination . Methods We analysed data from our prospect i ve SSI data base on patients undergoing clean cranial neurosurgery between October 2011 and April 2014 . We compared the case-mix adjusted odds of developing a SSI in patients undergoing skin preparation with CGH or PVI alone or in combination .  Results SSIs were detected in 2.6 % of 1146 cases . Antisepsis with PVI alone was performed in 654 ( 57 % ) procedures , while 276 ( 24 % ) had CHG alone and 216 ( 19 % ) CHG and PVI together . SSIs were associated with longer operating time ( p<0.001 ) and younger age ( p=0.03 ) . Surgery type ( p<0.001 ) and length of operation ( p<0.001 ) were significantly different between antisepsis groups . In a binary logistic regression model , CHG and PVI was associated with a significant reduction in the likelihood of developing an SSI ( adjusted odds ratio [ AOR ] 0.12 , 95 % confidence interval [ CI ] 0.02 - 0.63 ) than either agent alone . There was no difference in SSI rates between CHG and PVI alone ( AOR 0.60 , 95 % CI 0.24 - 1.5 ) . Conclusions Combination skin preparation with CHG and PVI significantly reduced SSI rates compared to CHG or PVI alone . A prospect i ve , r and omized study validating these findings is now warranted Objective Central venous catheter (CVC)-related infections may be caused by micro-organisms introduced from the skin surface into deeper tissue at the time of CVC insertion . The optimal disinfection regimen to avoid catheter-related infections has not yet been defined . This study compares three different approaches . Design Prospect i ve r and omised trial . Setting A tertiary care hospital . Patients and participants One hundred nineteen patients scheduled electively to receive 140 CVCs . Interventions Skin disinfection was performed with either povidone-iodine 10 % ( PVP-iodine ) , chlorhexidine 0.5%/propanol 70 % , or chlorhexidine 0.5%/propanol 70 % followed by PVP-iodine 10 % . Prior to disinfection , a swab from the site of insertion was taken for culture . CVCs were removed if no longer needed or infection was suspected . All catheters were cultured quantitatively after removal . Measurement and results Bacteria could be isolated from 20.7 % of the catheter tips . Bacterial growth was found in 30.8 % of the catheters placed after skin disinfection with povidone-iodine , in 24.4 % after disinfection with propanol/chlorhexidine and in 4.7 % after disinfection with propanol/chlorhexidine followed by povidone-iodine ( p=0.006 ) . In 15 cases , the same organism was isolated from the skin swab and the catheter tip . Ten of these paired isolates showed the same pattern in a pulsed-field gel electrophoresis analysis . Conclusions Skin disinfection with propanol/chlorhexidine followed by PVP-iodine was superior in the prevention of microbial CVC colonisation compared to either of the regimens alone . These results support the concept that catheter infections can originate from bacterial translocation at the time of catheter insertion A prospect i ve study was performed to describe the density of bacterial counts on the skin of neurosurgical patients and examine the association between total colony-forming unit ( cfu ) counts of skin flora at the operative site and surgical site infection ( SSI ) . Two skin cultures were obtained , immediately before and after skin preparation , from the operative sites of 609 neurosurgical patients . SSI surveillance that used Centers for Disease Control/National Nosocomial Infection Surveillance definitions was performed . Predictors for high bacterial counts and SSI among craniotomies were analyzed by means of logistic regression . Neither pre- nor postpreparation counts were associated with SSI . Other SSI risk factors were obesity ( relative risk [ RR ] , 2.5 ) , duration of surgery ( RR , 1.3 for every additional 30 minutes ) and age ( RR , 0.7 for each additional 10 years ) . Duration of skin preparation was not correlated with postpreparation cfu counts . We were unable to detect an association between preoperative bacterial skin counts and SSI Eradication of bacterial flora from the foot , especially the nailfolds and toe webspaces , through surgical preparation remains a challenge . All previous studies have involved healthy patients undergoing elective foot and ankle surgery or healthy volunteers . However , the patient with diabetes is considered an immunocompromised host with decreased ability to combat invasive bacterial infections . The use of an efficacious surgical preparation is therefore of paramount importance . The author conducted a prospect i ve study involving patients with diabetes with and without ulceration who underwent the current " best evidence available " surgical preparation ( i.e. , chlorhexidine gluconate [ 4 % ] scrub followed by alcohol impregnated with iodine [ 1 % ] solution ) . Qualitative aerobic cultures before and after completion of this surgical preparation technique were obtained from the hallux nailfold ; second , third , and fourth toe webspaces ( as one culture ) ; and distal anterior tibia . A total of 120 organisms were cultured before surgical preparation with 64 in the elective group and 56 in the ulcerated group . The most commonly isolated organism was methicillin-resistant Staphylococcus epidermidis , which was identified in 46 pre-preparation cultures ( 38.3 % ) . This was followed by methicillin-sensitive S. epidermidis ( 16.7 % ) and " other " organisms ( 10.0 % ) . There was a significant reduction for both numbers of organisms identified and positive cultures for the 3 most commonly isolated organisms after surgical preparation . Based on the results of this study , the surgical preparation used here appears 
    Output:
    
Conclusions and Relevance There is emerging , albeit low- quality , evidence in favor of combination CHG and PVI preoperative antisepsis .