Antibioprophylaxis in surgery and interventional medicine (adult patients). Update 2017

Population pharmacokinetics of prophylactic cefoxitin in elective bariatric surgery patients: a prospective monocentric study

BACKGROUND

This study describes the population pharmacokinetics of cefoxitin in obese patients undergoing elective bariatric surgery and evaluates different dosing regimens for achievement of pre-defined target exposures.

METHODS

Serial blood samples were collected during surgery with relevant clinical data. Total serum cefoxitin concentrations were measured by chromatographic assay and analysed using a population PK approach with Pmetrics®. The cefoxitin unbound fraction (fu) was estimated. Dosing simulations were performed to ascertain the probability of target attainment (PTA) to achieve cefoxitin fu above minimum inhibitory concentrations (MIC) from surgical incision to wound closure. Fractional target attainment (FTA) was calculated against MIC distributions of common pathogens.

RESULTS

A total of 123 obese patients (median BMI 44.3 kg/m2) were included with 381 cefoxitin concentration values. Cefoxitin was best described by a one-compartment model, with a mean clearance and volume of distribution of 10.9 ± 6.1 L/h and 23.4 ± 10.5 L, respectively. In surgery <2 h, a 2 and a 4 g doses were sufficient for an MIC up to 4 and 8 mg/L (fu 50%), respectively. In prolonged surgery (2-4 h), only continuous infusion enabled optimal PTA for an MIC up to 16 mg/L. Optimal FTAs were obtained against Staphylococcus aureus and Escherichia Coli only when simulating with 50% cefoxitin protein binding (intermittent regimen) and regardless of the protein binding for the continuous infusion.

CONCLUSION

Intermittent dosing regimens resulted in optimal FTAs against susceptible MIC distributions of S. aureus and E. coli when simulating with 50% cefoxitin protein binding. Continuous infusion of cefoxitin may improve FTA regardless of protein binding.

STUDY REGISTRATION

Registration on ClinicalTrials.gov, NCT03306290.

Updated antimicrobial dosing recommendations for obese patients

The prevalence of obesity has increased considerably in the last few decades. Pathophysiological changes in obese patients lead to pharmacokinetic (PK) and pharmacodynamic (PD) alterations that can condition the correct exposure to antimicrobials if standard dosages are used. Inadequate dosing in obese patients can lead to toxicity or therapeutic failure. In recent years, additional antimicrobial PK/PD data, extended infusion strategies, and studies in critically ill patients have made it possible to obtain data to provide a better dosage in obese patients. Despite this, it is usually difficult to find information on drug dosing in this population, which is sometimes contradictory. This is a comprehensive review of the dosing of different types of antimicrobials (antibiotics, antifungals, antivirals, and antituberculosis drugs) in obese patients, where the literature on PK and possible dosing strategies in obese adults was critically assessed.

Predictive value of C-reactive protein for postoperative liver-specific surgical site infections

BACKGROUND

C-reactive protein is a useful biological tool to predict infectious complications, but its predictive value in detecting organ-specific surgical site infection after liver resection has never been studied. We aimed to evaluate the predictive value of c-reactive protein and determine the cut-off values to detect postoperative liver resection-surgical site infection.

METHODS

A multicentric analysis of consecutive patients with liver resection between 2018 and 2021 was performed. The predictive value of postoperative day 1, postoperative day 3, and postoperative day 5 C-reactive protein levels was evaluated using the area under the receiver operating characteristic curve. Cut-off values were determined using the Youden index in a 500-fold bootstrap resampling of 500 patients treated at 3 centers, who comprised the development cohort and were tested in an external independent validation cohort of 166 patients at a fourth center.

RESULTS

Among the 500 patients who underwent liver resection of the development cohort, liver resection-surgical site infection occurred in 66 patients (13.2%), and the median time to diagnosis was 6.0 days (interquartile range, 4.0-9.0) days. Median C-reactive protein levels were significantly higher on postoperative day 1, postoperative day 3, and postoperative day 5 in the liver resection-surgical site infection group compared with the non-surgical site infection group (50.5 vs 34.5 ng/mL, 148.0 vs 72.5 ng/mL, and 128.4 vs 35.2 ng/mL, respectively; P < .001). Postoperative day 3 and postoperative day 5 C-reactive protein-level area under the curve values were 0.76 (95% confidence interval, 0.64-0.88, P < .001) and 0.82 (95% confidence interval, 0.72-0.92, P < .001), respectively. Postoperative day 3 and postoperative day 5 optimal cut-off values of 100 mg/L and 87.0 mg/L could be used to rule out liver resection-surgical site infection, with a negative predictive value of 87.0% (interquartile range, 70.2-93.8) and 76.0% (interquartile range, 65.0-88.0), respectively, in the validation cohort.

CONCLUSION

Postoperative day 3 and postoperative day 5 C-reactive protein levels may be valuable predictive tools for liver resection-surgical site infection and aid in hospital discharge decision-making in the absence of other liver-related complications.

No benefit of direct anterior over posterolateral approach in total hip arthroplasty using dual-mobility acetabular component for femoral neck fracture

Aims

Dual-mobility acetabular components (DMCs) have improved total hip arthroplasty (THA) stability in femoral neck fractures (FNFs). In osteoarthritis, the direct anterior approach (DAA) has been promoted for improving early functional results compared with the posterolateral approach (PLA). The aim of this study was to compare these two approaches in FNF using DMC-THA.

Methods

A prospective continuous cohort study was conducted on patients undergoing operation for FNF using DMC by DAA or PLA. Functional outcome was evaluated using the Harris Hip Score (HHS) and Parker score at three months and one year. Perioperative complications were recorded, and radiological component positioning evaluated.

Results

There were 50 patients in the DAA group and 54 in the PLA group. The mean HHS was 85.5 (SD 8.8) for the DAA group and 81.8 (SD 11.9) for the PLA group (p = 0.064). In all, 35 patients in the DAA group and 40 in the PLA group returned to their pre-fracture Parker score (p = 0.641) in both groups. No statistically significant differences between groups were found at one year regarding these two scores (p = 0.062 and p = 0.723, respectively). The DAA was associated with more intraoperative complications (p = 0.013). There was one dislocation in each group, and four revisions for DAA and one for PLA, but this difference was not statistically significant. There were also no significant differences regarding blood loss, length of stay, or operating time.

Conclusion

In DMC-THA for FNF, DAA did not achieve better functional results than PLA, either at three months or at one year. Moreover, DAA presented an increased risk of intra-operative complications.

Antimicrobial Prophylaxis With Ampicillin-sulbactam Compared With Cefazolin for Esophagectomy: Nationwide Inpatient Database Study in Japan

OBJECTIVE

To assess the effect of antimicrobial prophylaxis with ampicillin-sulbactam (ABPC/SBT) compared with cefazolin (CEZ) on the short-term outcomes after esophagectomy.

BACKGROUND

CEZ is widely used for antimicrobial prophylaxis in esophagectomy without procedure-specific evidence, whereas ABPC/SBT is preferred in some hospitals to target both aerobic and anaerobic oral bacteria.

METHODS

Data of patients who underwent esophagectomy for cancer between July 2010 and March 2019 were extracted from a nationwide Japanese inpatient database. Overlap propensity score weighting was conducted to compare the short-term outcomes [including surgical site infection (SSI), anastomotic leakage, and respiratory failure] between antimicrobial prophylaxis with CEZ and ABPC/SBT after adjusting for potential confounders. Sensitivity analyses were also performed using propensity score matching and instrumental variable analyses.

RESULTS

Among 17,772 eligible patients, 16,077 (90.5%) and 1695 (9.5%) patients were administered CEZ and ABPC/SBT, respectively. SSI, anastomotic leakage, and respiratory failure occurred in 2971 (16.7%), 2604 (14.7%), and 2754 patients (15.5%), respectively. After overlap weighting, ABPC/SBT was significantly associated with a reduction in SSI [odds ratio 0.51 (95% CI: 0.43-0.60)], anastomotic leakage [0.51 (0.43-0.61)], and respiratory failure [0.66 (0.57-0.77)]. ABPC/SBT was also associated with reduced respiratory complications, postoperative length of stay, and total hospitalization costs. The proportion of Clostridioides difficile colitis and noninfectious complications did not differ between the groups. Propensity score matching and instrumental variable analyses demonstrated equivalent results.

CONCLUSIONS

The administration of ABPC/SBT as antimicrobial prophylaxis for esophagectomy was associated with better short-term postoperative outcomes compared with CEZ.

Are changes in antibiotic prophylaxis recommendations responsible for an increased risk of cefazolin allergy?

BACKGROUND

The first line of prevention of surgical site infection relies on the timely administration of antibiotic prophylaxis. First- and second-generation cephalosporins are the most recommended antibiotics in elective surgery. The incidence of cefazolin allergy has increased worldwide over the years. The sensitization mechanism of cefazolin is currently unknown, and data supporting cross-reactivity between penicillins and cephalosporins are lacking. Sensitization could occur through previous exposure either to cefazolin or to structurally related chemical agents. The objective of this study was to evaluate sensitization agents towards cefazolin.

METHODS

The OpenBabel chemoinformatics toolbox was used to search for similarities between cefazolin and other molecules in an extensive drug database. Using the pholcodine-rocuronium similarity score as a threshold, we selected drugs with the most similar structure to that of cefazolin. Exposure to those drugs and cefazolin was assessed in a cohort of patients with skin test-proven cefazolin allergy at a specialized allergy centre via a self-administered anonymous questionnaire.

RESULTS

Using the pholcodine-rocuronium similarity score as a threshold (score≥0.7), 42 molecules were found to be similar to cefazolin (all cephalosporins). Only 8 were marketed in France. None of the 14 cefazolin-allergic patients who answered the questionnaire (65% female, median age 56 years) reported exposure to any identified antibiotics. In contrast, 11 (78%) had at least one previous surgery requiring cefazolin before the index case.

CONCLUSION

Direct previous cefazolin exposure was identified in 78% of cefazolin-allergic patients. Cefazolin started to take a central place in antibiotic prophylaxis after 2010, when cefamandole usage decreased drastically. Changes in antibiotic prophylaxis over the past 14 years in France could have been the turning point for the increased incidence of cefazolin allergy.

Diagnostic value of systematic bronchial aspirate on postoperative pneumonia after pulmonary resection surgery for lung cancer: a monocentre retrospective study

OBJECTIVES

Intraoperative bacterial airway colonization seems to be associated with an increased risk of postoperative pneumonia (POP). It can be easily assessed by performing a bronchial aspirate (BA). The objective of this study is to assess the diagnostic performance of the BA to predict POP.

METHODS

We conducted a single-centre retrospective observational study over a period of 10 years, from 1 January 2011 to 30 December 2020. The population study included patients admitted for a scheduled pulmonary resection surgery for lung cancer. Patients were classified into 2 populations depending on whether or not they developed a POP. Uni- and multivariable analyses were performed to identify risk factors for developing POP. The diagnostic performance of BA was represented by its sensitivity, specificity and positive and negative predictive values.

RESULTS

A total of 1006 patients were included in the study. Uni- and multivariable analyses found that a positive BA was independently associated with a greater risk of developing POP with an odds ratio of 6.57 [4.165-10.865]; P < 0.001. Its specificity was 95%, sensitivity was 31%, positive predictive value was 66% and negative predictive value was 81%.

CONCLUSIONS

A positive intraoperative BA is an independent risk factor for POP after lung cancer surgery. Further trials are required to validate the systematic implementation of BA as an early diagnostic tool for POP.

American Society of Anesthesiologists-Physical Status Classification As An Independent Risk Factor of Surgical Site Infection After Infra-Inguinal Arterial Bypass

OBJECTIVES

The present study aimed to assess whether high-risk American Society of Anesthesiologists (ASA)-Physical Status was an independent risk factor for the development of surgical site infection (SSI) after infra-inguinal lower extremity bypass (LEB).

SUMMARY OF BACKGROUND DATA

The ASA-Physical Status Classification System assesses the overall physical status preoperatively. ASA-Physical Status is associated with postoperative morbidity and mortality. However, limited data are available on how ASA-Physical Status Class affects the development of SSI after infra-inguinal LEB.

METHODS

Patients who had undergone infra-inguinal LEB from January 1, 2015 to December 31, 2018, for obliterative arteriopathy or popliteal aneurysm at our university hospital were included. SSI risk factors were identified using multivariable logistic regression. The length of hospital stay, major limb events (MALE), major adverse cardiovascular events (MACE), and all-cause mortality were compared for patients with SSI versus those without SSI 3 months and 1- year of follow-up after the index surgery.

RESULTS

Among the 267 patients included, 30 (11.2%) developed SSI during the 3-month period and 32 (12%) at 1 year. ASA-Physical Status ≥3 [odds ratio (OR): 3.7, 95% confidence interval CI) 1.5-11.1], emergency surgery (OR: 2.7, 95% CI 1.2-6.0), general anesthesia (OR: 2.8, 95% CI 1.3-6.1), and procedure performed by a junior surgeon (OR: 2.7, 95% CI 1.3-6.0) were independently associated with SSI. At 3 months and 1 year, SSI was significantly associated with MALE (including surgical wound debridement, subsequent thrombectomy, major amputation), length of hospital stay, and all-cause mortality.

CONCLUSION

The ASA-Physical Status should be considered in medical management when an infra-inguinal LEB is considered in frail patients, to prevent surgical complications.

Impact of Penicillin Allergy-Based Alternative Antibiotics on the Risk of Postoperative Central Nervous System Infection: A Retrospective Cohort Study

BACKGROUND

Central nervous system (CNS) infection is one of the most serious complications after neurosurgery. This study aimed to analyze the effect of penicillin allergy (PA) and alternative prophylactic antibiotics on risk of postoperative CNS infection in patients undergoing neurosurgery.

METHODS

Data of patients who underwent neurosurgical procedures from January 2015 to December 2021 were analyzed retrospectively. Patients with PA were compared with patients without PA in a 1:1 ratio. A multivariate logistic regression model was used to examine whether PA was a risk factor for postoperative CNS infection.

RESULTS

Overall, 15,049 eligible neurosurgical records were reviewed, from which 578 surgical records of 556 patients with PA were matched to 578 records of 570 patients without PA. Patients with PA showed significantly lower probability to receive prophylactic cephalosporins (55.9% vs. 98.8%, P < 0.01), but significantly higher probability to receive clindamycin (41.86% vs. 1.03%, P < 0.01), than patients without PA. Multivariate analysis revealed that patients with PA were more likely to experience postoperative CNS infection than patients without PA (odds ratio = 2.03; 95% confidence interval, 1.15-3.56; P = 0.014). The incidence of postoperative CNS infection returned to a level comparable to that in general population when patients with suspected PA received prophylactic cephalosporins.

CONCLUSIONS

PA is associated with higher risk of postoperative CNS infection in patients undergoing neurosurgery. This may be attributed to the use of alternative prophylactic antibiotics other than cephalosporins, especially clindamycin.

Evaluation of the practice of surgical antibiotic prophylaxis in a Zonal Referral Hospital in Mbujimayi, Democratic Republic of the Congo (DRC)

BACKGROUND

Surgical Antibiotic Prophylaxis (SAP) is helpful in preventing patients from developing Surgical Site Infections (SSI). In Mbujimayi, the documentation on the practice of SAP is outdated and inadequate. The last study was conducted more than 5 years ago. This study aims at assessing the compliance of the practice of antibiotic prophylaxis in the surgical and obstetrics-gynecology departments of the Bonzola Zonal Referral Hospital (BZRH) compared to the international standards.

METHODS

A prospective observational study was conducted from March 2020 to March 2021 involving 324 surgical patients who received antibiotic prophylaxis. Interventions were assessed as "compliant" if all the variables individually complied with the criteria for antibiotic prophylaxis use.

RESULTS

Three hundred and twenty-four patients were enrolled in this study. Compliance was found to be 87.35% for the indication for administration; 0.31% for the choice of the molecule; 3.65% for the time of the first administration; none for the duration of antibiotic prophylaxis. Therefore, the overall compliance was nil. This study shows a significant gap when the current practice in Mbujimayi town is compared to the recommendations of international societies.

CONCLUSION

SAP is often indicated in accordance with international recommendations in Mbujimayi. However, the choice of the molecule, the dosage, the time of first administration and the duration of SAP deviate from them. Thus, the compliance of SAP is nil.

The association between penicillin allergy and surgical site infection after orthopedic surgeries: a retrospective cohort study

Background

Cephalosporins are used as first-line antimicrobial prophylaxis for orthopedics surgeries. However, alternative antibiotics are usually used in the presence of penicillin allergy (PA), which might increase the risk of surgical site infection (SSI). This study aimed to analyze the relationship between SSI after orthopedic surgeries and PA among surgical candidates and related alternative antibiotic use.

Methods

In this single-center retrospective cohort study, we compared inpatients with and without PA from January 2015 to December 2021. The primary outcome was SSI, and the secondary outcomes were SSI sites and perioperative antibiotic use. Moreover, pathogen characteristics of all SSIs were also compared between the two cohorts.

Results

Among the 20,022 inpatient records, 1704 (8.51%) were identified with PA, and a total of 111 (0.55%) SSI incidents were reported. Compared to patients without PA, patients with PA had higher postoperative SSI risk (1.06%, 18/1704 vs. 0.51%, 93/18318), shown both in multivariable regression analysis (odds ratio [OR] 2.11; 95% confidence interval [CI], 1.26-3.50; p= 0.004) and propensity score matching (OR 1.84; 95% CI, 1.05-3.23; p= 0.034). PA was related to elevated deep SSI risk (OR 2.79; 95% CI, 1.47-5.30; p= 0.002) and had no significant impact on superficial SSI (OR 1.39; 95% CI, 0.59-3.29; p= 0.449). The PA group used significantly more alternative antibiotics. Complete mediation effect of alternative antibiotics on SSI among these patients was found in mediation analysis. Pathogen analysis revealed gram-positive cocci as the most common pathogen for SSI in our study cohort, while patients with PA had higher infection rate from gram-positive rods and gram-negative rods than non-PA group.

Conclusion

Compared to patients without PA, patients with PA developed more SSI after orthopedic surgeries, especially deep SSI. The elevated infection rate could be secondary to the use of alternative prophylactic antibiotics.

Effect of oral antimicrobial prophylaxis on surgical site infection after elective colorectal surgery: multicentre, randomised, double blind, placebo controlled trial

OBJECTIVE

To investigate whether oral antimicrobial prophylaxis as an adjunct to intravenous antibiotic prophylaxis reduces surgical site infections after elective colorectal surgery.

DESIGN

Multicentre, randomised, double blind, placebo controlled trial.

SETTING

11 university and non-university hospitals in France between 25 May 2016 and 8 August 2019.

PARTICIPANTS

926 adults scheduled for elective colorectal surgery.

INTERVENTION

Patients were randomised to receive either a single 1 g dose of ornidazole (n=463) or placebo (n=463) orally 12 hours before surgery, in addition to intravenous antimicrobial prophylaxis before surgical incision.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of patients with surgical site infection within 30 days after surgery. Secondary outcomes included individual types of surgical site infections and major postoperative complications (Clavien-Dindo classification grade 3 or higher) within 30 days after surgery.

RESULTS

Of the 960 patients who were enrolled, 926 (96%) were included in the analysis. The mean age of participants was 63 years and 554 (60%) were men. Surgical site infection within 30 days after surgery occurred in 60 of 463 patients (13%) in the oral prophylaxis group and 100 of 463 (22%) in the placebo group (absolute difference -8.6%, 95% confidence interval -13.5% to -3.8%; relative risk 0.60, 95% confidence interval 0.45 to 0.80). The proportion of patients with deep infections was 4.8% in the oral prophylaxis group and 8.0% in the placebo group (absolute difference -3.2%, 95% confidence interval -6.4% to -0.1%). The proportion of patients with organ space infections was 5.0% in the oral prophylaxis group and 8.4% in the placebo group (absolute difference -3.4%, -6.7% to -0.2%). Major postoperative complications occurred in 9.1% patients in the oral prophylaxis group and 13.6% in the placebo group (absolute difference -4.5%, -8.6% to -0.5%).

CONCLUSION

Among adults undergoing elective colorectal surgery, the addition of a single 1 g dose of ornidazole compared with placebo before surgery significantly reduced surgical site infections.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02618720.

Anesthesia for digestive tract endoscopy

PURPOSE OF REVIEW

Nonoperating room anesthesia for digestive tract endoscopy has its own specificities and requires practical training. Monitoring devices, anesthetic drugs, understanding of procedures and management of complications are critical aspects.

RECENT FINDINGS

New data are available regarding risk factors for intra- and postoperative complications (based on anesthesia registries), airway management, new anesthetic drugs, techniques of administration and management of advances in interventional endoscopy procedures.

SUMMARY

Digestive tract endoscopy is a common procedure that takes place outside the operating room most of the time and has become more and more complex due to advanced invasive procedures. Prior evaluation of the patient's comorbidities and a good understanding of the objectives and constraints of the endoscopic procedures are required. Assessing the risk of gastric content aspiration is critical for determining appropriate anesthetic protocols. The availability of adequate monitoring (capnographs adapted to spontaneous ventilation, bispectral index), devices for administration of anesthetic/sedative agents (target-controlled infusion) and oxygenation (high flow nasal oxygenation) guarantees the quality of sedation and patient' safety during endoscopic procedures. Knowledge of the specificities of each interventional endoscopic procedure (endoscopic retrograde cholangiopancreatography, submucosal dissection) allows preventing complications during anesthesia.

Peri-Operative Prophylaxis in Patients of Neonatal and Pediatric Age Subjected to Cardiac and Thoracic Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs) represent a potential complication of surgical procedures, with a significant impact on mortality, morbidity, and healthcare costs. Patients undergoing cardiac surgery and thoracic surgery are often considered patients at high risk of developing SSIs. This consensus document aims to provide information on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing cardiac and non-cardiac thoracic surgery. The following scenarios were considered: (1) cardiac surgery for the correction of congenital heart disease and/or valve surgery; (2) cardiac catheterization without the placement of prosthetic material; (3) cardiac catheterization with the placement of prosthetic material; (4) implantable cardiac defibrillator or epicardial pacemaker placement; (5) patients undergoing ExtraCorporal Membrane Oxygenation; (6) cardiac tumors and heart transplantation; (7) non-cardiac thoracic surgery with thoracotomy; (8) non-cardiac thoracic surgery using video-assisted thoracoscopy; (9) elective chest drain placement in the pediatric patient; (10) elective chest drain placement in the newborn; (11) thoracic drain placement in the trauma setting. This consensus provides clear and shared indications, representing the most complete and up-to-date collection of practice recommendations in pediatric cardiac and thoracic surgery, in order to guide physicians in the management of the patient, standardizing approaches and avoiding the abuse and misuse of antibiotics.

Surgical Antimicrobial Prophylaxis in Patients of Neonatal and Pediatric Age Undergoing Orthopedic and Hand Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs) represent a potential complication in any type of surgery and can occur up to one year after the procedure in the case of implant placement. In the field of orthopedic and hand surgery, the rate of SSIs is a relevant issue, considering the need for the placement of synthesis devices and the type of some interventions (e.g., exposed fractures). This work aims to provide guidance on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing orthopedic and hand surgery in order to standardize the management of patients and to reduce, on the one hand, the risk of SSI and, on the other, the development of antimicrobial resistance. The following scenarios were considered: (1) bloodless fracture reduction; (2) reduction of unexposed fracture and grade I and II exposed fracture; (3) reduction of grade III exposed fracture or traumatic amputation; (4) cruel fracture reduction with percutaneous synthesis; (5) non-traumatic amputation; (6) emergency intact skin trauma surgery and elective surgery without synthetic media placement; (7) elective orthopedic surgery with prosthetic and/or synthetic media placement and spinal surgery; (8) clean elective hand surgery with and without bone involvement, without use of synthetic means; (9) surgery of the hand on an elective basis with bone involvement and/or with use of synthetic means. This manuscript has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies and represents, in our opinion, the most complete and up-to-date collection of recommendations regarding the behavior to be adopted in the peri-operative setting in neonatal and pediatric orthopedic and hand surgery. The specific scenarios developed are aimed at guiding the healthcare professional in practice to ensure the better and standardized management of neonatal and pediatric patients, together with an easy consultation.

Bacterial Epidemiology of Surgical Site Infections after Open Fractures of the Lower Limb: A Retrospective Cohort Study

Open lower limb fractures are common injuries, and the occurrence of infectious complications after open fractures is a usual problem. The rate of surgical site infections (SSIs) and the nature and resistance of the germs responsible for SSIs remain poorly described. Our aim was to describe the bacterial epidemiology of SSIs after surgical management of an open lower limb fracture. We conducted a retrospective monocentric cohort study from 1 January 2012 to 31 December 2020 based on the analysis of inpatient records in a non-university hospital of Ile de France region. All patients who underwent surgery for an open lower limb fracture were included. A total of 149 patients were included. In our population, 19 (12.7%) patients developed an SSI. Of these 19 patients, the sample was polymicrobial in 9 (47.4%) patients. In 9 (45%) cases, the samples identified a group 3 enterobacteria, Enterobacter cloacae being the main one in 7 (36.9%) cases. Staphylococci were identified in 11 patients, with Staphylococcus aureus in 9 (47.4%). All Staphylococcus aureus were susceptible to methicillin, and all enterobacteria were susceptible to C3G. Among all SSI, 10 (58.8%) contained at least one germ resistant to amoxicillin/clavulanic acid (AMC). The SSIs rate was 12.7%. The main pathogens identified were Enterobacter cloacae and Staphylococcus aureus. The presence of early SSI caused by group 3 Enterobacteriaceae renders current antibiotic prophylaxis protocols inadequate with AMC in half the cases.

The effect of opioid-free anesthesia protocol on the early quality of recovery after major surgery (SOFA trial): study protocol for a prospective, monocentric, randomized, single-blinded trial

Background

Since the 2000s, opioid-free anesthesia (OFA) protocols have been spreading worldwide in anesthesia daily practice. These protocols avoid using opioid drugs during anesthesia to prevent short- and long-term opioid side effects while ensuring adequate analgesic control and optimizing postoperative recovery. Proofs of the effect of OFA protocol on optimizing postoperative recovery are still scarce. The study aims to compare the effects of an OFA protocol versus standard anesthesia protocol on the early quality of postoperative recovery (QoR) from major surgeries.

Methods

The SOFA trial is a prospective, randomized, parallel, single-blind, monocentric study. Patients (n = 140) scheduled for major plastic, visceral, urologic, gynecologic, or ear, nose, and throat (ENT) surgeries will be allocated to one of the two groups. The study group (OFA group) will receive a combination of clonidine, magnesium sulfate, ketamine, and lidocaine. The control group will receive a standard anesthesia protocol based on opioid use. Both groups will receive others standard practices for general anesthesia and perioperative care. The primary outcome measure is the QoR-15 value assessed at 24 h after surgery. Postoperative data such as pain intensity, the incidence of postoperative complication, and opioid consumption will be recorded. We will also collect adverse events that may be related to the anesthetic protocol. Three months after surgery, the incidence of chronic pain and the quality of life will be evaluated by phone interview.

Discussion

This will be the first study powered to evaluate the effect of OFA versus a standard anesthesia protocol using opioids on global postoperative recovery after a wide range of major surgeries. The SOFA trial will also provide findings concerning the OFA impact on chronic pain incidence and long-term patient quality of life.

Trial registration

ClinicalTrials.gov NCT04797312. Registered on 15 March 2021

Relevance of antibiotic prophylaxis in the management of surgical emergency open hand trauma

Surgical site infection after emergency hand surgery can cause considerable morbidity and, in the most severe forms, even toxic shock syndrome. Postoperative antibiotic prophylaxis aims to reduce the number of surgical site infections. However, excessive use of antibiotics induces side-effects for patients and antibiotic resistance for society. Contrary to other orthopedic sites, there is no consensus on postoperative antibiotic prophylaxis in open hand trauma beyond analogic reasoning with no proven scientific validity. Our hypothesis was that absence of postoperative antibiotic prophylaxis after open hand trauma surgery does not affect the rate of surgical site infections. A prospective cohort study included 405 patients, operated on in the emergency hand trauma unit without intra- or post-operative antibiotic prophylaxis. Patients were followed up in consultation at 7, 14 and 30 days. Surgical site infection was defined by need for surgery for detersion and flattening, followed by curative antibiotic therapy. The surgical site infection rate was 2.22%. Four patients were lost to follow-up and counted as surgical site infection as originally planned in the worst-case analysis. There were five surgical revisions followed by antibiotic therapy. These results do not differ from those reported in the literature, and thus confirm our hypothesis that postoperative antibiotic prophylaxis is not indicated in open hand trauma management.

Population pharmacokinetic model of cefazolin in total hip arthroplasty

Cefazolin is an antibiotic recommended for infection prevention in total hip arthroplasty (THA). However, the dosing regimen necessary to achieve therapeutic concentrations in obese patients remains unclear. The aim of this study was to conduct a population analysis of cefazolin pharmacokinetics (PK) and assess whether cefazolin administration should be weight adapted in THA. Adult patients undergoing THA surgery received an injection of 2000 mg of cefazolin, doubled in the case of BMI > 35 kg/m² and total body weight > 100 kg. A population PK study was conducted to quantify cefazolin exposure over time compared to the therapeutic concentration threshold. A total of 484 cefazolin measurements were acquired in 100 patients, of whom 29% were obese. A 2-compartment model best fitted the data, and creatinine clearance determined interpatient variability in elimination clearance. Our PK simulations using a 2000 mg cefazolin bolus showed that cefazolin concentrations remained above the threshold throughout surgery, regardless of weight or renal function. A 2000 mg cefazolin single injection without adaptation to weight or renal function and without intraoperative reinjection was efficient in maintaining therapeutic concentrations throughout surgery. The optimal target concentration and necessary duration of its maintenance remain unclear.

Critically ill cancer patient's resuscitation: a Belgian/French societies' consensus conference

To respond to the legitimate questions raised by the application of invasive methods of monitoring and life-support techniques in cancer patients admitted in the ICU, the European Lung Cancer Working Party and the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique, set up a consensus conference. The methodology involved a systematic literature review, experts' opinion and a final consensus conference about nine predefined questions1. Which triage criteria, in terms of complications and considering the underlying neoplastic disease and possible therapeutic limitations, should be used to guide admission of cancer patient to intensive care units?2. Which ventilatory support [High Flow Oxygenation, Non-invasive Ventilation (NIV), Invasive Mechanical Ventilation (IMV), Extra-Corporeal Membrane Oxygenation (ECMO)] should be used, for which complications and in which environment?3. Which support should be used for extra-renal purification, in which conditions and environment?4. Which haemodynamic support should be used, for which complications, and in which environment?5. Which benefit of cardiopulmonary resuscitation in cancer patients and for which complications?6. Which intensive monitoring in the context of oncologic treatment (surgery, anti-cancer treatment …)?7. What specific considerations should be taken into account in the intensive care unit?8. Based on which criteria, in terms of benefit and complications and taking into account the neoplastic disease, patients hospitalized in an intensive care unit (or equivalent) should receive cellular elements derived from the blood (red blood cells, white blood cells and platelets)?9. Which training is required for critical care doctors in charge of cancer patients?

Perioperative administration of cefazolin and metronidazole in obese and non-obese patients: a pharmacokinetic study in plasma and interstitial fluid

OBJECTIVES

To assess plasma and tissue pharmacokinetics of cefazolin and metronidazole in obese patients undergoing bariatric surgery and non-obese patients undergoing intra-abdominal surgery.

PATIENTS AND METHODS

Fifteen obese and 15 non-obese patients received an IV short infusion of 2 g cefazolin and 0.5 g metronidazole for perioperative prophylaxis. Plasma and microdialysate from subcutaneous tissue were sampled until 8 h after dosing. Drug concentrations were determined by HPLC-UV. Pharmacokinetic parameters were calculated non-compartmentally.

RESULTS

In obese patients (BMI 39.5-69.3 kg/m2) compared with non-obese patients (BMI 18.7-29.8 kg/m2), mean Cmax of total cefazolin in plasma was lower (115 versus 174 mg/L) and Vss was higher (19.4 versus 14.2 L). The mean differences in t½ (2.7 versus 2.4 h), CL (5.14 versus 4.63 L/h) and AUC∞ (402 versus 450 mg·h/L) were not significant. The influence of obesity on the pharmacokinetics of metronidazole was similar (Cmax 8.99 versus 14.7 mg/L, Vss 73.9 versus 51.8 L, t½ 11.9 versus 9.1 h, CL 4.62 versus 4.13 L/h, AUC∞ 116 versus 127 mg·h/L). Regarding interstitial fluid (ISF), mean concentrations of cefazolin remained >4 mg/L until 6 h in both groups, and those of metronidazole up to 8 h in the non-obese group. In obese patients, the mean ISF concentrations of metronidazole were between 3 and 3.5 mg/L throughout the measuring interval.

CONCLUSIONS

During the time of surgery, cefazolin concentrations in plasma and ISF of subcutaneous tissue were lower in obese patients, but not clinically relevant. Regarding metronidazole, the respective differences were higher, and may influence dosing of metronidazole for perioperative prophylaxis in obese patients.

Guidelines for the acute care of severe limb trauma patients

GOAL

To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre.

DESIGN

A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded.

METHODS

The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations.

CONCLUSIONS

There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.

Diagnostic yield of routine daily blood culture in patients on veno-arterial extracorporeal membrane oxygenation

BACKGROUND

Bloodstream infections (BSIs) are frequent on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Performing routine blood cultures (BCs) may identify early paucisymptomatic BSIs. We investigated the contribution of systematic daily BCs to detect BSIs on V-A ECMO.

METHODS

This was a retrospective study including all adult patients requiring V-A ECMO and surviving more than 24 h. Our protocol included routine daily BCs, from V-A ECMO insertion up to 5 days after withdrawal; other BCs were performed on-demand.

RESULTS

On the 150 V-A ECMO included, 2146 BCs were performed (1162 routine and 984 on-demand BCs); 190 (9%) were positive, including 68 contaminants. Fifty-one (4%) routine BCs revealed BSIs; meanwhile, 71 (7%) on-demand BCs revealed BSIs (p = 0.005). Performing routine BCs was negatively associated with BSIs diagnosis (OR 0.55, 95% CI [0.38; 0.81], p = 0.002). However, 16 (31%) BSIs diagnosed by routine BCs would have been missed by on-demand BCs. Independent variables for BSIs diagnosis after routine BCs were: V-A ECMO for cardiac graft failure (OR 2.43, 95% CI [1.20; 4.92], p = 0.013) and sampling with on-going antimicrobial therapy (OR 2.15, 95% CI [1.08; 4.27], p = 0.029) or renal replacement therapy (OR 2.05, 95% CI [1.10; 3.81], p = 0.008). Without these three conditions, only two BSIs diagnosed with routine BCs would have been missed by on-demand BCs sampling.

CONCLUSIONS

Although routine daily BCs are less effective than on-demand BCs and expose to contamination and inappropriate antimicrobial therapy, a policy restricted to on-demand BCs would omit a significant proportion of BSIs. This argues for a tailored approach to routine daily BCs on V-A ECMO, based on risk factors for positivity.

Influence of the Obesity Phenotype on the Adequacy of Antibiotic Prophylaxis with Cefoxitin for Obese Patients Undergoing Bariatric Surgery: Lessons Learnt and Future Considerations

BACKGROUND AND OBJECTIVES

A high inter-individual variability in pharmacokinetic parameters in obese patients is observed. The objective of this study was to evaluate the effect of obesity parameters on the pharmacokinetics of cefoxitin administered for antibiotic prophylaxis during bariatric surgery.

METHODS

This a secondary analysis of a pharmacokinetic study involving 174 obese patients scheduled for bariatric surgery and receiving a 4-g dose of cefoxitin. Blood samples were collected at incision and wound closure. The total plasma concentrations were assessed utilising a validated high-performance liquid chromatography-tandem mass spectrometry method. The pharmacokinetic and pharmacodynamic target was defined as an estimated free concentration of cefoxitin at the time of wound closure >8 mg/L. Specific evaluated obesity parameters were fat body mass, fat body mass/height², lean body mass, lean body mass/height², visceral adipose tissue and presence of a metabolic syndrome.

RESULTS

A total of 174 patients (median age 47 years) with a majority of women (75.3%) and a median BMI of 44 kg/m² were analysed. The percentage of patients who met the pharmacokinetic and pharmacodynamic target was 85.1%. In the whole population, a tendency to fail to reach the target was observed with a higher lean mass over height² [OR = 0.79; 95% CI (0.62-1.01); P = 0.060]. In the female subgroup, higher lean mass over height² [OR = 0.63; 95% CI (0.41-0.97); P = 0.037] and the presence of a metabolic syndrome [OR = 0.17; 95% CI (0.03-0.83); P = 0.030] were associated with failure to reach the pharmacokinetic and pharmacodynamic target.

CONCLUSION

Obese patients with a higher lean mass and a metabolic syndrome could constitute a subgroup at risk for cefoxitin under-dosage.

Continuous Pneumatic Regulation of Tracheal Cuff Pressure to Decrease Ventilator-associated Pneumonia in Trauma Patients Who Were Mechanically Ventilated: The AGATE Multicenter Randomized Controlled Study

BACKGROUND

Ventilator-associated pneumonia (VAP) is the most frequent health care-associated infection in severely ill patients, and aspiration of contaminated oropharyngeal content around the cuff of the tracheal tube is the main route of contamination.

RESEARCH QUESTION

Is continuous regulation of tracheal cuff pressure using a pneumatic device superior to manual assessment three times daily using a portable manometer (routine care) in preventing VAP in patients with severe trauma?

STUDY DESIGN AND METHODS

In this open-label, randomized controlled superiority trial conducted in 13 French ICUs, adults (age ≥ 18 years) with severe trauma (Injury Severity Score > 15) and requiring invasive mechanical ventilation for ≥ 48 h were enrolled. Patients were randomly assigned (1:1) via a secure Web-based random number generator in permuted blocks of variable sizes to one of two groups according to the method of tracheal cuff pressure control. The primary outcome was the proportion of patients developing VAP within 28 days following the tracheal intubation, as determined by two assessors masked to group assignment, in the modified intention-to-treat population. This study is closed to new participants.

RESULTS

A total of 434 patients were recruited between July 31, 2015, and February 15, 2018, of whom 216 were assigned to the intervention group and 218 to the control group. Seventy-three patients (33.8%) developed at least one episode of VAP within 28 days following the tracheal intubation in the intervention group compared with 64 patients (29.4%) in the control group (adjusted subdistribution hazard ratio, 0.96; 95% CI, 0.76-1.20; P = .71). No serious adverse events related to the use of the pneumatic device were noted.

INTERPRETATION

Continuous regulation of cuff pressure of the tracheal tube using a pneumatic device was not superior to routine care in preventing VAP in patients with severe trauma.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT02534974; URL: www.clinicaltrials.gov.

Antibiotic prophylaxis in orthopedics-traumatology

When all rules of hygiene have been scrupulously applied, antibiotic prophylaxis (ABP) is the one remaining means of further reducing surgical site infection risk. Its efficacy in major orthopedic surgical procedures is proven. Guidelines for indications and ABP systemic administration have been long established and are able to address many questions. By extrapolation, the same protocols apply in closed fractures, whereas they are less certain in open fractures, where successive and still incomplete reassessments have been made. There are no specific ABP protocols in implant revision for mechanical or infectious causes or in high-grade open fractures, despite the high associated risk of surgical site infection. All means of prophylaxis need exploring in these contexts: various molecule combinations, and various local applications. Although ideas are by no means lacking, levels of evidence are low or undetermined. Awaiting more objective data, the focus has to be on the quality of implementation. It is easy enough to conceive of ABP in terms of the tissue pharmacokinetics of the antibiotic(s), but real-life implementation is a real organizational challenge. Optimizing practices in clearly defined indications is still the prime objective for surgical ABP.

Pharmacokinetic Model for Cefuroxime Dosing during Cardiac Surgery under Cardiopulmonary Bypass

Cefuroxime (CXM) is an antibiotic recommended for surgical site infection prevention in cardiac surgery. However, the dosing regimens commonly used do not sustain therapeutic concentrations throughout surgery. The aim of this study was to conduct a population analysis of CXM pharmacokinetics (PK), and to propose an optimized dosing regimen. Adult patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) received a 1,500 mg CXM intravenous bolus followed by a 750 mg bolus at CPB priming, then every 2 h thereafter. Model-based PK simulations were used to develop an optimized dosing regimen and evaluate its efficacy in attaining various concentration thresholds, including those recommended in US and European guidelines. In total, 447 CXM measurements were acquired in 50 patients. A two-compartment model best fit the data, with total body weight and creatinine clearance determining interpatient variability in the central and peripheral volumes of distribution, and in elimination clearance, respectively. Using our optimized dosing regimen, different dosing schemes adapted to body weight and renal function were calculated to attain total concentration thresholds ranging from 12 to 96 mg/liter. Our simulations showed that the dosing regimens recommended in US and European guidelines failed to maintain concentrations above 48 mg/liter. Our individualized dosing strategy was capable of ensuring therapeutic CXM concentrations conforming to each target threshold. Our model yielded an optimized CXM dosing regimen adapted to body weight and renal function, and sustaining therapeutic concentrations consistent with each desired threshold. The optimal target concentration and necessary duration of its maintenance in cardiac surgery still remain unclear.

[Assessment of genital microbiota: An emerging approach in assisted reproductive techniques]

The genital microbiota actively participates in women's reproductive health. Indeed, a genital dysbiosis (microbial imbalance associated with adverse effects on host health) can lead to vaginal infections (such as mycoses or bacterial vaginosis). Recent data reported that genital dysbiosis (e.g. vaginal or endometrial) was associated with fewer chances of live births in assisted reproductive technologies (ART), via decreased pregnancy rates and an increased risk of miscarriages. The presence or diversity of certain bacterial strains (in particular Gardenellavaginalis, Proteobacteria, Lactobacillusjensenii, Lactobacilluscrispatus or Atopobiumvaginae) within the genital microbiota seem to be associated with the outcomes of ART cycles, suggesting new approaches to improve ART results. In this review, we aim at presenting the state of art on the association between the female genital microbiota and ART success. The diagnostic and therapeutic approaches (i.e. probiotics, antibiotic therapy and transplantation of vaginal microbiota) in the management of patients with altered microbiota will also be discussed. The confirmation of these data in the coming years could significantly improve the management of infertile patients in ART with a more personalized approach partially based on the female genital microbiotic profile.

Is Cutibacterium acnes early surgical site infection rate related to the duration of antibiotic prophylaxis in adolescent idiopathic scoliosis surgery?

PURPOSE

Cutibacterium acnes (C. acnes) is a gram-positive anaerobic bacillus located in pilosebaceous glands, usually responsible for late postoperative surgical site infections (SSI). A recent study performed in our institution highlighted an unexpected emergence of C. acnes early SSI. One potential explanation was the change of the perioperative antibioprophylaxis (ATB) protocol, which switched from 48 h postoperative cefamandole to intraoperative only cefazoline. The aim of this study was therefore to investigate the influence of the ATB duration on the occurrence of C. acnes early SSI, by comparing the incidence rates during 3 consecutive ATB protocols.

METHODS

Between January 2007 and September 2017, all patients who underwent posterior fusion for AIS were retrospectively reviewed. Early C. acnes SSI were reported and compared between 3 periods, during which the ATB protocols were modified. January 2007-February 2012: Intraoperative Cefamandole continued 48 h (protocol 1) March 2012-August 2016: Single shot of intraoperative Cefazoline (protocol 2) September 2016-September 2017: Intraoperative Cefazoline continued 48 h (protocol 3).

RESULTS

Fifty-three early SSI (7.2%) were reported among the 732 posterior AIS fusions included. Global incidence of C. acnes infection was 2.9%. The incidence of C. acnes in early SSI increased from 0 to 4.9% between protocol 1 and 2, but was reduced to 1.7% with protocol 3.

CONCLUSIONS

Early C acnes SSI can be explained by the difficulty to eradicate this pathogen with current skin preparation procedures and some Beta-lactam antibiotics tolerance. Longer duration antibioprophylaxis is preferable to prevent from early C. acnes SSI.

Severe Obesity Increases Risk of Infection After Revision Total Hip Arthroplasty

BACKGROUND

The increasing prevalence of obesity has resulted in an increased number of revision total hip arthroplasties (rTHAs) performed in patients with a high body mass index (BMI). The aim of this study is to evaluate whether obesity negatively affects (1) complication rate, (2) reoperation and revision rate, and (3) patient-reported outcome in rTHA.

METHODS

In this registry-based study, we prospectively followed 444 rTHAs (cup: n = 265, stem: n = 57, both: n = 122) performed in a specialized high-volume orthopedic center between 2013 and 2015. The number of complications, and reoperation and revision surgery was registered until 5 years postoperatively. Oxford Hip Score (OHS) was evaluated preoperatively, and at 1 and 2 years postoperatively. Patients were categorized based on BMI to nonobese (<30 kg/m², n = 328), obese (30-35 kg/m², n = 82), and severe obese (≥35 kg/m², n = 34).

RESULTS

Severe obese patients, but not obese patients, had higher risks of complications and re-revision than nonobese patients. In particular, the risk of infection following rTHA was higher in severe obese patients (24%) compared to nonobese patients (3%; relative risk, 7.7). Severe obese patients had overall poorer OHS than nonobese patients, but improvement in OHS did not differ between severe obese and nonobese patients. No differences between obese and nonobese groups on OHS were observed.

CONCLUSION

In our study, severe obesity was associated with an increased risk of infection following rTHA. Patients with high BMI should be counseled appropriately before surgery.

Antibiotic prophylaxis with high-dose cefoxitin in bariatric surgery: an observational prospective single center study

BACKGROUND

The optimal dose of cefoxitin for antibiotic prophylaxis in obese patients remains uncertain. We evaluated the adequacy of a 4-gram dosing regimen of cefoxitin against the most frequent pathogens that infect patients undergoing bariatric surgery.

METHODS

This observational prospective study included obese patients who required bariatric surgery and a 4-gram dose of cefoxitin as an antibiotic prophylaxis. Serum concentrations were measured during surgery (incision, wound closure and in case of reinjection). The pharmacokinetic/pharmacodynamic (PK/PD) target was to obtain free cefoxitin concentrations above 4× MIC, from incision to wound closure (100% ƒT_>4xMIC). The targeted MIC was based on the worst-case scenario (the highest ECOFF value of Staphylococcus aureus, Enterobacteriaceae and anaerobic bacteria). The secondary outcomes were the factors related to underdosage.

RESULTS

Two hundred patients were included. The mean age of the patients was 46 (±12) years-old, and the mean BMI was 45.8 (±6.9) kg/m² Bypass surgery was the preferred technique (84%). The percentages of patients who met the PK/PD target (100% fT_>4xMIC) of cefoxitin were 37.3%, 1.1% and 0% for S. aureus, Enterobacteriaceae and anaerobic bacteria, respectively. BMIs below 50 kg/m² (OR 0.29, 95% CI [0.11-0.75], P = 0.0107) and a shorter duration of surgery (OR 0.97, 95% CI [0.95-0.99], P = 0.004) were associated with reaching the target concentrations.

CONCLUSIONS

In obese patients undergoing bariatric surgery, a regimen of 4 grams of cefoxitin led to an inadequate coverage for most common pathogens. A longer surgery duration and BMI over 50 kg/m² increase the risk of underdosage.

From the ICU to the operating room: how to manage the patient?

PURPOSE OF REVIEW

To outline key points for perioperative ICU optimization of nutrition, airway management, blood product preparation and transfusion, antibiotic prophylaxis and transport.

RECENT FINDINGS

Optimization entails glycemic control for all, with specific attention to type-1 diabetic patients. Transport-related adverse events may be averted with surgery in the ICU. If moving the patient is unavoidable, transport guidelines should be followed and hemodynamic optimization, airway control, and stabilization of mechanical ventilation ensured before transport. Preinduction preparation includes assessment of the airway and the provision of high-flow oxygen to prolong apneic oxygenation. Postintubation, a protective positive ventilation strategy should be employed. Ideal transfusion thresholds are 7 g/dl for hemodynamically stable adult patients, 8 g/dl in orthopedic or cardiac surgery patients as well as those with underlying cardiovascular disease. Higher transfusions thresholds may be required in specific disease states. Antimicrobial prophylaxis within 120 min of incision prevents most surgical site infections. Antibiotic therapy depends on the antibiotics being received in the ICU, the time elapsed since ICU admission, local epidemiology and the type of surgery. Tailored antimicrobial regimens may be continued periprocedurally. If more than 70% of the nutritional requirement cannot be met enterally, parenteral nutrition should be initiated within 5-7 days of surgery or earlier if the patient is malnourished.

SUMMARY

ICU patients who require surgery may benefit from appropriate perioperative management.

Intra-peritoneal abscess after an abdominal hysterectomy involving Cutibacterium avidum (former Propionibacterium avidum) highly resistant to clindamycin

Cutibacterium avidum is a gram-positive anaerobic rod belonging to the cutaneous group of human bacteria with preferential colonization of sweat glands in moist areas. The microorganism rarely cause disease, generally delayed prosthetic joint infections (PJIs). We describe the second case of intraperitoneal abscess by C. avidum after an abdominal surgery in an obese female patient and the first case after a non-prosthetic abdominal surgery due to a highly clindamycin resistant strain in a patient with underling conditions. The patient was successfully treated with surgical drainage and beta-lactam antibiotics. Although rare and apparently non-pathogenic, C. avidum may be involved in infections, especially in some high-risk patients with obesity who have undergone surgical incision involving deep folder of the skin. The microorganism was identified by phenotypic methods, MALDI-TOF MS and 16S rRNA gene sequencing. Susceptibility test should be performed in C. avidum because high level resistance to clindamycin could be present. We present a literature review of C. avidum infections.