Mortality for intra-abdominal infection is associated with intrinsic risk factors rather than the source of infection

BACKGROUND

Intra-abdominal infections (IAIs) are an important cause of mortality and morbidity. Nosocomial IAIs (NIAIs) have been associated with higher mortality than community-acquired IAIs (CIAIs). We hypothesized that intrinsic risk factors were a better predictor of mortality than the type of infection.

METHODS

Patients with IAI treated at a single urban academic hospital over 8 years (June 1999-June 2007) were retrospectively reviewed. Data collected included demographics, comorbidities, source of infection, type of infection (community vs nosocomial), type of intervention (operation versus percutaneous drainage), and postoperative complications. Charlson Comorbidity Index and multiple organ dysfunction (MOD) scores were evaluated at admission and on postoperative day 7 (POD-7).

RESULTS

There were 452 patients; 234 (51.8%) had CIAI and 218 (48.2%) had NIAI. The mean age was 51.3 +/- 0.8. The most common source of CIAI was the appendix (n = 129, 28.5%); 137 patients with NIAI had postoperative infections (30.3%). When patients with appendicitis were excluded, there was no difference in mortality or complications between patients with CIAI and NIAI. Logistic regression analysis demonstrated catheter-related bloodstream infection (P < .001; OR 7.3, 95% CI, 2.5-22.2), cardiac event (P < .001; OR 6.0, 95% CI, 2.3-16.1), and age > or = 65 (P = .009; OR 3.8, 95% CI, 1.4-8.8) to be independent risk factors for mortality. Among patients who failed initial therapy, a non-appendiceal source of infection (P < .001; OR 4.7, 95% CI, 2.3-9.8) and a Charlson score > or =2 (P = .033; OR 1.6, 95% CI, 1.0-2.6) were determined to be independent risk factors. Non-appendiceal source of infection (P = .001, OR 3.3, 95% CI, 1.6-7.0) and POD-7 MOD score > or =4 (P < .001; OR 3.4, 95% CI, 1.9-6.0) were found to be independent predictors for re-intervention.

CONCLUSION

These results suggest mortality from IAI is strongly related to age and organ dysfunction; however, catheter-related bloodstream infection and postoperative cardiac events have a greater effect on outcome.

The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience

INTRODUCTION

Nonoperative management (NOM) of blunt splenic injury has become the preferred treatment for hemodynamically stable patients. The application of splenic artery embolization (SAE) in NOM has been controversial. We hypothesized that incorporation of initial use of SAE into a practice protocol for patients at high risk for NOM failure (contrast extravasation or pseudoaneurysm on computed tomography, grade 3 injury with large hemoperitoneum, grade 4 injuries) would improve patient outcomes.

METHODS

A retrospective analysis of three continuums of practice was performed: group I (January 1991-June 1998), SAE not part of routine NOM; group II (July 1998-December 2001), introduction and discretionary use of SAE; and group III (January 2002-June 2007), standardized use of initial SAE for patients considered at high risk of nonoperative failure. The primary outcome measure was the success of NOM. Failure of NOM was defined as the need for abdominal operation. Secondary outcomes were mortality, length of stay, and splenic salvage.

RESULTS

Over 16 years, 815 patients with blunt splenic injury were treated at our level 1 trauma center. There were 222 patients in group I, 195 in group II, and 398 in group III. There was an increase in the use of SAE over time with a significant improvement in the utilization of NOM (61% in group I; 82% in group II; 88% in group III; p < 0.05). This was associated with an increase in successful NOM (77%, group I; 94%, group II; 97%, group III; p < 0.0001 group I vs. group II and III). Mortality, length of stay, and splenic salvage were similar in groups II and III but significantly improved when compared with group I.

CONCLUSIONS

The increased use of initial SAE in high-risk patients expanded the successful use of NOM but was not associated with other incremental improvements.

Who is monitoring your infections: shouldn't you be?

BACKGROUND

In the era of pay for performance and outcome comparisons among institutions, it is imperative to have reliable and accurate surveillance methodology for monitoring infectious complications. The current monitoring standard often involves a combination of prospective and retrospective analysis by trained infection control (IC) teams. We have developed a medical informatics application, the Surgical Intensive Care-Infection Registry (SIC-IR), to assist with infection surveillance. The objectives of this study were to: (1) Evaluate for differences in data gathered between the current IC practices and SIC-IR; and (2) determine which method has the best sensitivity and specificity for identifying ventilator-associated pneumonia (VAP).

METHODS

A prospective analysis was conducted in two surgical and trauma intensive care units (STICU) at a level I trauma center (Unit 1: 8 months, Unit 2: 4 months). Data were collected simultaneously by the SIC-IR system at the point of patient care and by IC utilizing multiple administrative and clinical modalities. Data collected by both systems included patient days, ventilator days, central line days, number of VAPs, and number of catheter-related blood steam infections (CR-BSIs). Both VAPs and CR-BSIs were classified using the definitions of the U.S. Centers for Disease Control and Prevention. The VAPs were analyzed individually, and true infections were defined by a physician panel blinded to methodology of surveillance. Using these true infections as a reference standard, sensitivity and specificity for both SIC-IR and IC were determined.

RESULTS

A total of 769 patients were evaluated by both surveillance systems. There were statistical differences between the median number of patient days/month and ventilator-days/month when IC was compared with SIC-IR. There was no difference in the rates of CR-BSI/1,000 central line days per month. However, VAP rates were significantly different for the two surveillance methodologies (SIC-IR: 14.8/1,000 ventilator days, IC: 8.4/1,000 ventilator days; p = 0.008). The physician panel identified 40 patients (5%) who had 43 VAPs. The SIC-IR identified 39 and IC documented 22 of the 40 patients with VAP. The SIC-IR had a sensitivity and specificity of 97% and 100%, respectively, for identifying VAP and for IC, a sensitivity of 56% and a specificity of 99%.

CONCLUSIONS

Utilizing SIC-IR at the point of patient care by a multidisciplinary STICU team offers more accurate infection surveillance with high sensitivity and specificity. This monitoring can be accomplished without additional resources and engages the physicians treating the patient.

Antimicrobial agents for surgical infections

Antimicrobial drugs are useful for the empiric and definitive treatment of infections in surgical patients. They are also important agents for perioperative antimicrobial prophylaxis. The proper selection and use of these drugs is a critical skill for surgeons. Although these agents have many beneficial effects, they also possess occasional adverse effects and should not be used indiscriminately.

Fever and leukocytosis in critically ill trauma patients: it is not the blood

The diagnosis of bacteremia in critically ill patients is classically based on fever and/or leukocytosis. The objectives of this study were to determine 1) if our intensive care unit obtains blood cultures based on fever and/or leukocytosis over the initial 14 days of hospitalization after trauma; and 2) the efficacy of this diagnostic workup. An 18-month retrospective cohort analysis was performed on consecutively admitted trauma patients. Data collected included demographics, injuries, and the first 14 days maximal daily temperature, leukocyte count, and results of blood and catheter tip cultures. Fever was defined as a maximum daily temperature of 38.5 degrees C or greater and leukocytosis as a leukocyte count 12,000/mm3 or greater of blood. Five hundred ten patients were evaluated for a total of 3,839 patient-days. The mean age and injury severity score were 49 +/- 1 years and 19 +/- 1, respectively. Four hundred twenty-five blood culture episodes were obtained and 25 (6%) bacteremias were identified in 23 patients (5%). A significant association was found between obtaining blood cultures in patients with fever (relative risk [RR], 7.7), leukocytosis (RR, 1.3), and fever + leukocytosis (RR, 3.2). However, no significant association was found between these clinical signs and the diagnosis of bacteremia. In fact, fever alone was inversely associated with bacteremia. Our intensive care unit follows the common "fever workup" practice and obtains blood cultures based on the presence of fever and leukocytosis. However, fever and leukocytosis were not associated with bacteremia, suggesting inefficiency and that other factors are more important after trauma.

Fever and Leukocytosis in Critically Ill Trauma Patients: It is Not the Blood

The diagnosis of bacteremia in critically ill patients is classically based on fever and/or leukocytosis. The objectives of this study were to determine 1) if our intensive care unit obtains blood cultures based on fever and/or leukocytosis over the initial 14 days of hospitalization after trauma; and 2) the efficacy of this diagnostic workup. An 18-month retrospective cohort analysis was performed on consecutively admitted trauma patients. Data collected included demographics, injuries, and the first 14 days maximal daily temperature, leukocyte count, and results of blood and catheter tip cultures. Fever was defined as a maximum daily temperature of 38.5°C or greater and leukocytosis as a leukocyte count 12,000/mm3 or greater of blood. Five hundred ten patients were evaluated for a total of 3,839 patient-days. The mean age and injury severity score were 49 ± 1 years and 19 ± 1, respectively. Four hundred twenty-five blood culture episodes were obtained and 25 (6%) bacteremias were identified in 23 patients (5%). A significant association was found between obtaining blood cultures in patients with fever (relative risk [RR], 7.7), leukocytosis (RR, 1.3), and fever + leukocytosis (RR, 3.2). However, no significant association was found between these clinical signs and the diagnosis of bacteremia. In fact, fever alone was inversely associated with bacteremia. Our intensive care unit follows the common “fever workup” practice and obtains blood cultures based on the presence of fever and leukocytosis. However, fever and leukocytosis were not associated with bacteremia, suggesting inefficiency and that other factors are more important after trauma.

Commentary: Transfusions: weighing the risks and benefits

This commentary identifies important differences in patient groups that affect the observations in the accompanying article.

Fever and leukocytosis in critically ill trauma patients: it's not the urine

BACKGROUND

Infectious complications are a major cause of morbidity and mortality in critically ill trauma patients. Therefore, fever and leukocytosis often trigger an extensive laboratory workup that includes a urine culture (UCx). The purposes of this study were to: 1) Define the current practice for obtaining UCxs in trauma patients admitted to the surgical and trauma intensive care unit (STICU); and 2) determine if there is an association between fever or leukocytosis and urinary tract infections (UTIs) during the initial 14 hospital days.

METHODS

An 18-month retrospective cohort analysis was performed on consecutive trauma patients admitted for at least two days to the STICU at a level I trauma center. Data collected included demographics, injuries, and daily maximal temperature (T(max)), leukocyte count, and UCx results for the first 14 days. Fever and leukocytosis were defined as T(max) > or =38.5 degrees C and leukocyte count > or =12,000/mm(3), respectively. Urinary tract infections were diagnosed with a positive UCx (> or =10(5) organisms/mL of urine).

RESULTS

Five hundred ten patients were evaluated for a total of 3,839 patient-days. Their mean age and Injury Severity Score were 49 +/- 1 years and 19 +/- 1 points, respectively. Seventy-two percent were men, and 91% had sustained blunt injuries. Four hundred seven UCxs were obtained; 42 patients (8%) had 60 UTIs. The cohort had an indwelling urinary catheter for 97% of the patient-days, yielding an infection density of 16 UTIs/1,000 urinary catheter-days. There was a significant association between obtaining a UCx and fever and between fever and leukocytosis (both, p < 0.001), but no association of UTI with fever, leukocytosis, or the combination of fever and leukocytosis. Analysis using temperature and leukocyte count as continuous variables identified no temperature or leukocyte range associated with UTIs. Independent risk factors for UTI calculated by logistic regression were female sex, older age, low Injury Severity Score, and no antibiotics within 24 h before the UCx was obtained.

CONCLUSIONS

The practice of obtaining a UCx from the STICU trauma patient was related to fever and fever with leukocytosis. However, neither fever nor leukocytosis nor both were associated with UTIs. These data suggest that there is an unnecessary emphasis on UTI as a source of fever and leukocytosis in injured patients during their first 14 STICU days. Our results suggest that the paradigm for evaluating UTI as a cause of fever needs to be reevaluated in critically ill trauma patients.

Complicated skin and soft-tissue infections: diagnostic approach and empiric treatment options

Skin and soft-tissue infections are common and generally are uncomplicated at the time of initial presentation. However, these infections can worsen quickly when there are delays in presentation and treatment. Upon encountering these infections, physicians must respond quickly with an appropriate therapeutic plan and be aware of trends in microbial resistance in order to optimize patient care.

Preoperative findings predict conversion from laparoscopic to open cholecystectomy

BACKGROUND

Previous studies evaluating predictive factors for conversion from laparoscopic to open cholecystectomy have drawn conflicting conclusions. We evaluated objective preoperative variables to create an accurate, accessible risk score to predict conversion.

METHODS

A retrospective review was performed of laparoscopic cholecystectomy patients at an urban tertiary care center. Seventy characteristics were subjected to bivariate and multivariate logistic regression analysis to identify parameters that independently predict conversion to open cholecystectomy. A model was created based on this analysis.

RESULTS

Laparoscopic cholecystectomy was performed on 1377 patients for benign gallbladder disease over a 71-month period. There were 112 (8.1%) conversions to open cholecystectomy. The correlation between the preoperative clinical diagnosis and pathologic diagnosis for acute and chronic cholecystitis was 48.6% and 94.6%, respectively. Multivariate analysis identified male gender, elevated white blood cell count, low serum albumin, ultrasound finding of pericholecystic fluid, diabetes mellitus, and elevated total bilirubin as independent predictors of conversion. These 6 factors were also associated with the pathologic diagnosis of acute cholecystitis. A model to calculate the risk for conversion was created with an area under the receiver operator curve of 0.83. The risk for conversion also can be estimated based on the number of factors identified present and ranged from 2% when 1 factor was present to 89% with 6 factors.

CONCLUSIONS

These results demonstrate that conversion to open cholecystectomy can be predicted based on parameters available preoperatively. Conversion is more likely in patients who have acute cholecystitis; however, the correlation between its clinical and pathologic diagnosis is poor. Improvements in the ability to determine the risk for conversion have important implications for surgical care.

Is magnetic resonance imaging essential in clearing the cervical spine in obtunded patients with blunt trauma?

BACKGROUND

The optimal method of clearing the cervical spine (CS) in obtunded blunt trauma patients (OBTPs) remains unclear. Computed tomography (CT) identifies most injuries but may fail to detect ligamentous and spinal cord injuries. Magnetic resonance (MR) imaging has been widely used to exclude these. The purpose of this study was to evaluate whether CT of the CS (CT-CS) alone is adequate to clear the CS in OBTPs. Our hypothesis was that MR imaging of the CS (MR-CS) does not contribute relevant information and is not necessary in this patient population.

METHODS

A prospective evaluation of OBTPs with a CT-CS negative for acute trauma and an MR-CS obtained for clearance was performed at a Level I trauma center between July 1, 2004, and June 30, 2006. Data gathered included demographics, results of CT-CS and MR-CS, timing of MR-CS, Glasgow Coma Scale score at time of MR-CS, adverse events occurring while obtaining MR-CS, and cervical collar complications.

RESULTS

One hundred and fifteen patients were identified. There were 90 male patients. The mean age was 43.9 years +/- 1.9 years, mean Injury Severity Score was 24.4 +/- 1.0, and mean length of stay was 23.4 days +/- 1.2 days. The MR-CS was performed on hospital day 7.5 +/- 0.6 and the mean Glasgow Coma Scale score at the time of MR-CS was 8.3 +/- 0.3. Six MR-CS (5.2%) subsequently identified acute injuries. Findings included microtrabecular injuries, intraspinous ligament injuries, a cord signal abnormality, and a cervical epidural hematoma. None of these findings changed management and none required continued cervical collar usage. Six cervical collar complications were identified (5.2%). No adverse events related to transport or obtaining MR-CS occurred. Eliminating MR-CS would have decreased health care costs by over $250,000 during this period.

CONCLUSIONS

MR-CS may be unnecessary in the OBTP if the CT-CS is negative. Elimination of MR-CS in this population will lead to earlier removal of cervical collars, decreased cervical collar complications, protection of the patient from exposure to potential risks inherent to obtaining this study, and decreased health care costs.

Improved outcome of adult blunt splenic injury: a cohort analysis

BACKGROUND

The purpose of this study was to review our 15-year experience in the treatment of blunt splenic injury in adults. Our hypothesis was that the implementation of a change in practice, with stress on splenic preservation and splenic artery embolization for the management of splenic injury, would result in improved splenic salvage rates without negatively affecting mortality rates.

METHODS

A retrospective cohort analysis was performed on all consecutive adults with blunt splenic injury who were admitted to a Level One Trauma Center. The cohorts were defined by 2 separate 7.5-year periods (1991-1998 and 1998-2005).

RESULTS

Six hundred twenty-five patients with blunt splenic trauma were identified; 403 patients who were treated from 1998 to 2005 were compared with 222 patients whose cases had been reviewed previously (1991 to 1998). The present cohort differed in age (35 vs 40 years; P < .001) and injury severity score (27 vs 21; P < .0001). Nonoperative treatment was implemented in 136 patients (61%) in the initial cohort and 344 patients (85%) in the present cohort. The frequency of splenic artery embolization increased from 2.7% to 22.6% (P < .001). The success of nonoperative management increased from 77% to 96% (P < .001); the splenic salvage rate for all patients improved from 57% to 88% (P < .0001). Hospital mortality rates decreased from 12% to 6% (P < .001), and the mean hospital length of stay decreased from 15 to 9 days (P < .001).

CONCLUSION

These results demonstrate that the success of nonoperative management and the splenic preservation for blunt injury has improved over time. This improvement correlated with a greater use of splenic artery embolization.

Improving operating room efficiency through process redesign

BACKGROUND

Operating rooms (ORs) are important resources for patient care and revenue, yet a significant portion of OR time is taken up by nonoperative activities. We hypothesized that redesigning the process that occurs between operations would lead to a decrease in nonoperative time (NOT = room turnover time plus anesthesia induction and emergence time).

METHODS

Following a 3-month multidisciplinary planning process, a prospective study to reduce NOT was initiated in 2 of 17 ORs at a tertiary care academic medical center. Unlike previous reports, which have limited the number of participants, we constructed a process that was restricted only by case duration. The plan focused on minimizing nonoperative tasks in the OR, effecting parallel performance of activities, and reducing nonclinical disruptions. Eligible cases were those with an estimated operative time of 2 hours or less. A target NOT of 35 minutes was established. Cases of similar duration in the remaining ORs served as a concurrent control group.

RESULTS

Twenty-three surgeons, 13 anesthesiologists, and 11 nurses worked in the project ORs over a 3-month period. Residents participated in all cases. There was a significant reduction in NOT (42.2 +/- 12.9 vs 65 +/- 21.7 minutes), turnover time (26.4 +/- 11.2 vs 42.8 +/- 21.7 minutes), and anesthesia-related time (16.9 vs 21.9 minutes, all P < .001) in the project rooms compared with cases of similar duration in control ORs. Process-related delays were identified in 70% of cases when NOT exceeded the 35-minute target.

CONCLUSIONS

These results demonstrate that a coordinated multidisciplinary process redesign can significantly reduce NOT. This process is applicable to most ORs and has optimal benefit for cases of 2 hours or less in duration. The high percentage of residual process-related delays suggests that further improvements can be anticipated.

Peritonitis - the Western experience

Peritonitis is a common surgical emergency. This manuscript will provide an overview of recent developments in the management of peritonitis in the Western world. Emphasis is placed on the emergence of new treatments and their impact of outcomes.

Randomized controlled trial of moxifloxacin compared with piperacillin-tazobactam and amoxicillin-clavulanate for the treatment of complicated intra-abdominal infections

OBJECTIVE

To compare the safety and efficacy of sequential intravenous (IV) to oral (PO) moxifloxacin treatment against a standard antimicrobial regimen of IV piperacillin-tazobactam followed by PO amoxicillin-clavulanate for the treatment of adults with complicated intra-abdominal infection (cIAI).

SUMMARY BACKGROUND DATA

cIAIs are commonly due to mixed aerobic and anaerobic bacteria and require both source control and broad-spectrum antibiotic therapy.

METHODS

A prospective, double-blind, randomized, phase III comparative trial. Patients with cIAI were stratified by disease severity (APACHE II score) and randomized to either IV/PO moxifloxacin (400 mg q24 hours) or comparator (IV piperacillin-tazobactam [3.0/0.375 g q6 hours] +/- PO amoxicillin-clavulanate [800 mg/114 mg q12 hours]), each for 5 to 14 days. The primary efficacy variable was clinical cure rate at the test-of-cure visit (days 25-50). Bacteriologic outcomes were also determined.

RESULTS

: Of 656 intent-to-treat patients, 379 (58%) were valid to assess efficacy (183 moxifloxacin, 196 comparator). Demographic and baseline medical characteristics were similar between the 2 groups. Clinical cure rates at test-of-cure were 80% (146 of 183) for moxifloxacin versus 78% (153 of 196) for comparator (95% confidence interval, -7.4%, 9.3%). The clinical cure rate at test-of-cure for hospital-acquired cIAI was higher with moxifloxacin (82%, 22 of 27) versus comparator (55%, 17 of 31; P = 0.05); rates were similar for community-acquired infections (80% [124 of 156] versus 82% [136 of 165], respectively). Bacterial eradication rates were 78% (117 of 150) with moxifloxacin versus 77% (126 of 163) in the comparator group (95% confidence interval, -9.9%, 8.7%).

CONCLUSIONS

Once daily IV/PO moxifloxacin monotherapy was as least as effective as standard IV piperacillin-tazobactam/PO amoxicillin-clavulanate dosed multiple times daily for the treatment of cIAIs.

Nonoperative management of traumatic aortic injury

BACKGROUND

The standard management for patients with blunt aortic injury is surgery; however, a small number of patients have been medically managed. The outcome of these nonoperatively managed patients is unknown.

METHODS

Seven patients diagnosed as blunt aortic injury were managed without aortic surgery between January 1993 and April 2002, and their outcomes were retrospectively investigated.

RESULTS

There were three men and four women, with a mean age of 48.7+/-22.7 years and Injury Severity Score of 37.7+/-16.9. The reason for nonoperative management was refusal of surgery (2), do-not-resuscitate order (1), diffuse brain injury (2), small intimal tear (1), and technical difficulty (1). Two patients died resulting from associated injuries. Five patients are alive, and in three patients complete resolution of aortic injury was observed.

CONCLUSIONS

In selected patients with multiple associated injuries or severe comorbidity, nonoperative management after blunt aortic injury can be a treatment of choice.