Surgical site infections at the National Cancer Institute in Mexico: a case-control study

Does Alexis Wound Protector/Retractor Reduce the Risk of Surgical Site Infections After Open Radical Cystectomy for Bladder Cancer? Results From a Single Center, Comparative Study

OBJECTIVE

To assess if Alexis dual-ring wound protector/retractor reduced the incidence of superficial and deep incisional infection following open radical cystectomy (ORC).

METHODS

Since January 2020, all procedures were performed using the Alexis retractor. We retrospectively reviewed our ORC database and compared patients who were operated on with Alexis with the same number of consecutive patients operated with a stainless steel retractor in the previous period. Data are presented as median and (interquartile range).

RESULTS

Seventy-four patients underwent RC with Alexis (group 1) and 74 with stainless steel retractor (group 2). Median age was 73.0(13) in group 1, 73.5(14) in group 2 (P = .338). There were 59(79.7%) men in both groups. The groups were comparable in terms of comorbidities, body mass index, American Society of Anesthesiology score, and neoadjuvant chemotherapy rate. There was no statistically significant difference in type of lymph node dissection and urinary diversion, total surgical time. Postoperative stay was shorter in group 1 [8(4) days vs 9(4) in group 2, P = .012]. Group 2 had a significantly higher rate of both superficial (8.1% vs 18.9%, P = .045) and deep incisional infection (2.7% vs 14.9%, P = .009). At multivariable analysis, body mass index (OR 1.129 95% CI 1.162-1.283, P = .043) was significantly associated with higher odds of superficial incisional infection. The use of Alexis was significantly associated with lower odds of having both superficial (OR 0.274 95%CI 0.033-0.781, P = .023) and deep incisional infection (OR 0.159 95% CI 0.034-0.745, P = .020).

CONCLUSION

The use of Alexis significantly reduces the rate of superficial and deep incisional infection following ORC.

Nano zinc oxide decorated latex drainage: A promising antibacterial material prevent retrograde infection associated with drainage

Surgical site infections (SSI) represent a considerable burden for healthcare systems. Studies show retrograde infection of the drainage tube is an important cause of surgical site infection. To this end, Surgeons work in various ways to reduce the incidence of retrograde infections. Fast progress in nanoscience and nanotechnology is revolutionizing the field of medicine to improve the quality of life due to the myriad of applications stemming from their unique properties, including the antibacterial activity against pathogens. Herein, we investigate the antibacterial properties of a novel nanomaterial composed of nano zinc oxide-decorated latex drainages. These materials were produced by the hydrothermal method and characterized through field-emission scanning electron microscopy (FE-SEM), X-ray diffraction (XRD), and DLS (Dynamic light scattering techniques). Then inductively coupled plasma mass spectrometry (ICP-MS) measurements showed that nano zinc oxide on the surface of the latex drainages showed a gradient release process. The antimicrobial activity of nano zinc oxide -decorated latex drainage was evaluated against E. coli and Staphylococcus aureus, the main bacteriological agent in the retrograde infection associated with drainage. The results showed that slices and rods nano zinc oxide (SAR-ZnO) drainage tubes had the best antibacterial properties both in vivo and in vitro. In addition, the cell viability assay demonstrated that nano zinc oxide-decorated latex drainages exerted good biocompatibility. Therefore, SAR-ZnO drainage tubes can be a perfect nanomaterial against the retrograde infection associated with drainage.

The Role of Abdominal Drain Cultures in Managing Abdominal Infections

Intra-abdominal infections (IAI) are common in hospitalized patients, both in and outside of the intensive care unit. Management principles include antimicrobial therapy and source control. Typically, these infections are polymicrobial, and intra-operative samples will guide the targeted antimicrobial therapy. Although the use of prophylactic abdominal drains in patients undergoing abdominal surgery is decreasing, the use of drains to treat IAI, both in surgical and non-surgical strategies for abdominal infection, is increasing. In this context, samples from abdominal drains are often used to assist in antimicrobial decision making. In this narrative review, we provide an overview of the current role of abdominal drains in surgery, discuss the importance of biofilm formation in abdominal drains and the mechanisms involved, and review the clinical data on the use of sampling these drains for diagnostic purposes. We conclude that biofilm formation and the colonization of abdominal drains is common, which precludes the use of abdominal fluid to reliably diagnose IAI and identify the pathogens involved. We recommend limiting the use of drains and, when present, avoiding routine microbiological sampling.

The causal relationship between obesity and skin and soft tissue infections: A two-sample Mendelian randomization study

OBJECTIVE

Many observational studies have shown that obesity strongly affects skin and soft tissue infections (SSTIs). However, whether a causal genetic relationship exists between obesity and SSTIs is unclear.

METHODS

A two-sample Mendelian randomization (MR) study was used to explore whether obesity is causally associated with SSTIs using a publicly released genome-wide association study (GWAS). An inverse-variance weighted (IVW) analysis was used as the primary analysis, and the results are reported as the odds ratios (ORs). Heterogeneity was tested using Cochran's Q test and the I² statistic, and horizontal pleiotropy was tested using the MR-Egger intercept and MR pleiotropy residual sum and outlier (MR-PRESSO).

RESULTS

The results of the MR analysis showed a positive effect of BMI on SSTIs (OR 1.544, 95% CI 1.399-1.704, P= 5.86 × 10^-18). After adjusting for the effect of type 2 diabetes (T2D) and peripheral vascular disease (PVD), the positive effect still existed. Then, we further assessed the effect of BMI on different types of SSTIs. The results showed that BMI caused an increased risk of impetigo, cutaneous abscess, furuncle and carbuncle, cellulitis, pilonidal cyst, and other local infections of skin and subcutaneous tissues, except for acute lymphadenitis. However, the associations disappeared after adjusting for the effect of T2D and PVD, and the associations between BMI and impetigo or cellulitis disappeared. Finally, we assessed the effects of several obesity-related characteristics on SSTIs. Waist circumference, hip circumference, body fat percentage, and whole-body fat mass, excluding waist-to-hip ratio, had a causal effect on an increased risk of SSTIs. However, the associations disappeared after adjusting for the effect of BMI.

CONCLUSION

This study found that obesity had a positive causal effect on SSTIs. Reasonable weight control is a possible way to reduce the occurrence of SSTIs, especially in patients undergoing surgery.

Efficacy of Subcutaneous Closed Suction Drain in Reduction of Postoperative Surgical Site Infection

Background  Surgical site infections (SSIs) are the infections of wound after an invasive operative approach. It remains to be a major morbidity for patients undergoing surgeries although there have been tremendous improvements in the surgical techniques.

Different interventions to suppress the selective serotonin reuptake inhibitors have been proposed. Many of them have been routinely used by surgeons like minimizing shaving, hand washing, and preoperative antibiotics and these are well accepted. Drains are used in major abdominal surgeries, hernia repairs, breast surgeries reducing collections in closed areas. 1 Hematoma, serous fluid, and dead space in surgical incision wounds raise the risk of infection as they serve as the platform for microbial growth. Studies have proved that the usage of subcutaneous drains has lowered the chances of infection.

Results  The patients in the case group had lower incidence of SSI compared with the control group. The patients in the case group had subcutaneous drain which drained any collection that developed in the subcutaneous space. When the incidence of SSI was compared between the emergency cases and elective cases, the emergency cases showed higher propensity for SSI and increased rate for patients who had co-morbidities like diabetes mellitus, hypertension, etc. The most common organism isolated from the SSI was found to be Escherichia coli . It was also noted that the mean number of days of hospital stay was comparatively higher for the patients who developed SSI compared with patients who did not develop SSI.

Conclusion  Thus the presence of SSI adds morbidity to the patient and the patients who undergo major surgeries are likely to develop SSI postoperatively. The presence of subcutaneous closed suction drain helps in reducing the SSI to a certain extent.

Deep surgical site infections following double-dose perioperative antibiotic prophylaxis in adult obese orthopedic patients

BACKGROUND

Obesity is a risk factor for surgical site infections (SSI). Based on retrospective comparisons and pharmacology, many orthopedic centers have adopted weight- or body mass index (BMI)-related antibiotic prophylaxis.

METHODS

Double-dose prophylaxis was introduced in March 2017 for patients weighting >80 kg. The period April 2014 to March 2017 ('before') was compared to the period March 2017 to June 2019 ('after') regarding the impact on deep SSIs.

RESULTS

A total of 9318 surgeries 'before' were compared to 7455 interventions 'after' the introduction of double-dose prophylaxis. Baseline demographic characteristics (age, sex, BMI, American Society of Anesthesiologists score, and duration of surgery) were similar. In the period 'after', 3088 cases (3088/16 773; 18%) received double-dose prophylaxis. Overall, 82 deep SSIs were observed (0.5%). The pathogens were resistant to the standard cefuroxime prophylaxis in 30 cases (30/82; 37%). Excluding these prophylaxis-resistant cases and all of the five hematogenous SSIs, the remaining 47 SSIs (57%) could have been prevented by the preceding prophylaxis. Double-dosing of parenteral cefuroxime from 1.5 g to 3.0 g in obese patients did not reduce deep SSIs (hazard ratio 0.7, 95% confidence interval 0.3-1.6). In the direct group comparison among obese patients >80 kg, the double-dose prophylaxis equally failed to alter the SSI risk (3088/16 726 non-infections vs 8/47 SSI despite double-dose prophylaxis; Chi-square test, P = 0.78).

CONCLUSIONS

In this single-center before-and-after study with almost 17 000 orthopedic surgeries in adult patients, systemic doubling of the perioperative antibiotic prophylaxis in obese patients clinically failed to reduce the overall deep SSI risk.

Impact of obesity on outcome of severe bacterial infections

Introduction

Obesity is a rapidly growing global health concern with considerable negative impact on life-time expectancy. It has yet not been clarified if and how obesity impacts outcomes of severe bacterial infections. The aim of this study was to determine how body mass index impacts outcome of severe bacterial infections in a well-defined population-based cohort.

Methods

This study is based on a cohort of 2196 patients included in a Swedish prospective, population-based, consecutive observational study of the incidence of community-onset severe sepsis and septic shock in adults. All patients with weight and height documented in the medical records on admission were included.

Results

The case fatality rate (CFR) was negatively correlating with increasing BMI. Outcomes included 28-day CFR (p-value = 0.002), hospital CFR (p-value = 0.039) and 1-year CFR (p-value<0.001). When BMI was applied as continuous variable in a multiple logistic regression together with other possible covariates, we still could discern that BMI was associated with decreasing 28-day CFR (OR = 0.93, 95% CI 0.88–0.98, p-value = 0.009) and 1-year CFR (OR = 0.94, 95% CI 0.91–0.97, p-value<0.001).

Conclusion

The hypothesis and paradox of obesity being associated with higher survival rates in severe bacterial infections was confirmed in this prospective, population-based observational study.

Predictors of wound leakage in patients undergoing surgery for neck of femur fractures

AIMS

Persistent wound leakage following joint arthroplasty is a known risk for periprosthetic joint infection. Little is known of the predictors of wound leakage, particularly in patients with a fractured neck of femur. We aimed to determine patient and surgical risk factors for wound leakage in this cohort.

MATERIALS AND METHODS

All patients undergoing surgery for a fractured neck of femur at Leicester Royal Infirmary between May and August 2017 were included. Patients were identified from a prospective database and placed into two groups: those with wound leakage later than three days postoperatively and those without leakage. All previously reported potential risk factors for wound leakage were compared between groups using a chi-square test and logistic regression. A Kattan-style nomogram was also created to allow probabilities output for the regression predictive models in a visual representation.

RESULTS

Two hundred patients underwent surgery for a fractured neck of femur. Overall, 17% of patients (33/200) developed a persistent leaky wound. A multivariable model highlighted increased age (p = 0.01), raised body mass index (BMI; > 25 kg/m²; p = 0.047), diabetes (p = 0.03) and intramedullary hip screw fixation (p = 0.03) as significant risk factors for wound leakage. Patients with persistent wound leakage had significantly longer hospital admission than those without (p = 0.001).

DISCUSSION

Our analysis identified four perioperative risk factors for wound leakage following fractured neck of femur surgery. We also developed a novel tool to identify those patients at highest risk of leakage. Once identified, the aggressive management of certain medical comorbidities in these patients may help to reduce their incidence of wound issues and the prolonged admissions that result.

Susceptibility and Severity of Viral Infections in Obesity: Lessons from Influenza to COVID-19. Does Leptin Play a Role?

The recent pandemic Sars-CoV2 infection and studies on previous influenza epidemic have drawn attention to the association between the obesity and infectious diseases susceptibility and worse outcome. Metabolic complications, nutritional aspects, physical inactivity, and a chronic unbalance in the hormonal and adipocytokine microenvironment are major determinants in the severity of viral infections in obesity. By these pleiotropic mechanisms obesity impairs immune surveillance and the higher leptin concentrations produced by adipose tissue and that characterize obesity substantially contribute to such immune response dysregulation. Indeed, leptin not only controls energy balance and body weight, but also plays a regulatory role in the interplay between energy metabolism and immune system. Since leptin receptor is expressed throughout the immune system, leptin may exert effects on cells of both innate and adaptive immune system. Chronic inflammatory states due to metabolic (i.e., obesity) as well as infectious diseases increase leptin concentrations and consequently lead to leptin resistance further fueling inflammation. Multiple factors, including inflammation and ER stress, contribute to leptin resistance. Thus, if leptin is recognized as one of the adipokines responsible for the low grade inflammation found in obesity, on the other hand, impairments of leptin signaling due to leptin resistance appear to blunt the immunologic effects of leptin and possibly contribute to impaired vaccine-induced immune responses. However, many aspects concerning leptin interactions with inflammation and immune system as well as the therapeutical approaches to overcome leptin resistance and reduced vaccine effectiveness in obesity remain a challenge for future research.

Incidence and root causes of surgical site infections after gastrointestinal surgery at a public teaching hospital in Sudan

Background

Surgical site infections (SSIs) are common healthcare-associated infections and associated with prolonged hospital stays, additional financial burden, and significantly hamper the potential benefits of surgical interventions. Causes of SSIs are multi-factorials and patients undergoing gastrointestinal tract procedures carry a high risk of bacterial contamination. This study aimed to determine the prevalence, associated factors, and causing microorganisms of SSIs among patients undergoing gastrointestinal tract surgeries.

Methods

A hospital based, cross-sectional study conducted at Soba University Hospital in Khartoum, Sudan. We included all patients from all age groups attending the gastrointestinal tract surgical unit between 1st September and 31st December 2017. We collected data about the socio-demographic characteristics, risk factors of SSI, and isolated microorganisms from patients with SSIs. A Chi-square test was conducted to determine the relationship between the independent categorical variables and the occurrence of SSI. The significance level for all analyses was set at p < .05.

Results

A total of 80 participants were included in the study. The mean age was 51 +/- 16 years and most of the patients (67.5%) did not have any chronic illness prior to the surgical operation. Most of them (46.3%) of them underwent large bowel surgery. Twenty-two patients (27.5%) developed SSI post operatively and superficial SSI was the most common type of SSIs (81.8%). Occurrence of SSI was found to be associated with long operation time (p > .001), malignant nature of the disease (p > .001), intra-operative blood loss (p > .001), and intra-operative hypotension (p = .013). The most prevalent microorganism isolated from SSI patients was E coli (47.8%), followed by Enterococcus fecalis (13.0%) and combined Pseudomonas aeruginosa + E coli infection (13.0%).

Conclusions

The results showed a high prevalence of SSIs among patients attending the gastrointestinal tract surgical unit and the most prevalent microorganism isolated from them was E coli. Measures should be taken to reduce the magnitude of SSI by mitigating the identified associated factors.

Higher body mass index is an important risk factor in COVID-19 patients: a systematic review and meta-analysis

Globally, both obesity and underweight are severe health risks for various diseases. The current study systematically examined the emerging evidence to identify an association between body mass index (BMI) and COVID-19 disease outcome. Online literature databases (e.g., Google Scholar, PubMed, MEDLINE, EMBASE, Scopus, Medrixv and BioRixv) were screened following standard search strategy having the appropriate keyword such as "Obesity", "Underweight", "BMI", "Body Mass Index", "2019-nCov", "COVID-19, "novel coronavirus", "coronavirus disease". Studies published till 20^th April 2020 were included without language restriction. These studies include case reports, case series, cohort, and any other which reported BMI, overweight/obesity or underweight, and its complication with COVID-19 disease. This study observed COVID-19 infection among BMI < 25 kg/m² with prevalence of 0.60 (95%CI: 0.34-0.86, I² = - 76.77) as compared to the 0.34 (95%CI: 0.23-0.44, I² = 53.45% heterogeneity) having BMI > 25 kg/m². The results of the current study show that BMI plays a significant role in COVID-19 severity in all age groups, especially the older individuals. A panel of doctors and nursing staff should review COVID-19 patients with higher BMI with other co-morbidities (diabetes and hypertension), and they should be given increased vigilance, priority in testing, and treatment to control the associated co-morbidities. Further, the COVID-19 patients whose illness entered 7-10 days, age > 50 years, and elevated CRP levels should be given additional medical considerations. Our finding showed that the population and patients with high BMI have moderate to high risk of medical complications with COVID-19, and hence, their health status should be monitored more frequently including monitoring of blood pressure and blood glucose.

Obesity as a Risk Factor Among Hospitalized Patients with Infective Endocarditis

OBJECTIVE

Obesity contributes to diagnostic and management challenges for many hospitalized patients. The impact of obesity on in-hospital outcomes in patients with infective endocarditis has not been studied and was the focus of this investigation.

METHOD

We used the 2013 and 2014 Nationwide Inpatient Sample to identify adults ≥18 years of age with a principle diagnosis of endocarditis. We divided the sample into 2 groups based on presence of absence of obesity. Multivariate linear and logistic regression analysis was used to compare in-hospital mortality, valvular replacement, length of stay (LOS), and hospitalization charges.

RESULTS

A total of 24 494 adults 18 years and older were hospitalized with infective endocarditis, of which 2625 were classified as obese. Patients with obesity were older (mean age, 57.8 ± 0.3 vs 54.3 ± 0.6 years; P < .01), more likely to be female (50.1% vs 36.1%; P < .01), and had more comorbidities (Charlson comorbidity score ≥ 3, 50.6% vs 28.8%; P < .01). Multivariate regression analysis found no differences between the 2 groups for mortality or repairs or replacements for any valve. On evaluation of resource utilization, patients with obesity had longer average LOS (13.9 days; confidence interval [CI], 12.7-15.1 vs 12.4 days; CI, 12.0-12.8; P = .016) and higher total hospital charges (US $160 789.90; CI, $140.922.40-$180 657.50 vs US $130 627.20; CI, $123 916.70-$137 337.70; P <.01). After adjustment for LOS for total hospital charges, there was no observed difference $11436.26 (CI, -$6649.07-$29521.6; P = .22).

CONCLUSIONS

. Obesity does not significantly impact in-hospital mortality or surgical valvular interventions among patients hospitalized with infective endocarditis, but obesity is associated with increased utilization of hospital resources.

Randomized Controlled Trial to Reduce Bacterial Colonization of Surgical Drains with the Use of Chlorhexidine-Coated Dressings After Breast Cancer Surgery

BACKGROUND

Breast surgery is considered a clean surgery. However, surgical-site infection (SSI) rates are currently higher than predicted. Postoperative drains remain in situ for several days, with inevitable bacterial colonization and increased SSI risk.

METHODS

This randomized controlled trial from October 2016 to January 2018 analyzed patients undergoing breast cancer surgery. The patients were randomized to either the standard drain care group or the antiseptic dressing group (3M® Tegaderm® CHG). Drain samples taken on postoperative days (PODs) 7 and 14 were cultured as standardized in the laboratory. Colonization rates and SSI were compared between the two groups.

RESULTS

The study enrolled 104 patients with 167 surgical drains. The patients' clinical characteristics were similar in the two groups, with no statistically significant differences. Bulb fluid cultures at postoperative week (POW) 1 were positive for 42.9% of the control group and 28.9% of the antiseptic group (p = 0.06). Cultures from the POW 2 assessment were positive for 79.7% of the control group versus 54.9% of the antiseptic group (p = 0.001). Cultures from drain tubes were positive for 79.8% of the control group and 50.7% of the antiseptic group (p = < 0.001). In 11 patients, an SSI developed, 3 (5.8%) from the intervention and 8 (15.4%) from the control procedure (p = 0.11).

CONCLUSION

The study findings demonstrated that the use of antiseptics at the drain exit site significantly reduced bacterial colonization of the closed drainage system in breast cancer surgery. Semi-permeable occlusive chlorhexidine-impregnated dressings provide an opportunity to test simple, safe, and low-cost interventions that may reduce drain bacterial colonization and SSI after breast surgery.

Closed suction drain outputs at 12 and 24 hours after primary three-piece inflatable penile prosthesis surgery

This is a single-institution retrospective study of closed suction drain outputs in primary three-piece IPP cases performed between 2014 and 2017 by a single surgeon. The aim was to investigate the impact of closed suction drains (CSD) during penile prosthesis placement. One hundred and sixty-nine patients underwent intraoperative placement of a closed suction drain. Drain outputs were measured at 12 and 24 h, and postoperative complications were documented. There were no hematomas or infections observed within the patient cohort. The drain output decreased significantly between the first and subsequent 12 h period. Surgical time was associated with statistically significant increases in CSD output at 12 and 24 h with a near linear relationship between surgical times and CSD at 12 and 24 h. Penile prosthesis placement in patients on aspirin did not affect the CSD output volume. Closed suction drains should be considered in all patients undergoing placement of inflatable penile prosthesis, particularly in those cases with longer operative time.

Superficial incisional surgical site infections in emergency surgery in cancer patients: A tertiary cancer care center experience

OBJECTIVE

The objective of this study is to review the superficial incisional surgical site infections (SISSIs) in emergency surgery in cancer patients.

MATERIAL AND METHODS

The microbiological culture and sensitivity reports of patients undergoing emergency surgery for cancer of 1 year (April 2016 to March 2017) were analyzed along with the clinical factors associated with it from a surgeon's perspective.

RESULTS

Of the 308 patients who underwent surgery, SISSI rate was 11.7%. The most common organism was Escherichia coli (27%) followed by enterococci (21%). Prolongation of hospital stay was average 2 days. Mortality rate among SISSI patients was 7.9%. Concordance among ongoing antibiotic and culture was 72%.

CONCLUSION

Regular review of the current microbial spectrum and its antibiotic spectrum is required, especially in immunocompromized cancer patients.

Evaluation of the Number of Progressive Tension Sutures Needed to Prevent Seroma in Abdominoplasty with Drains: A Single-Blind, Prospective, Comparative, Randomized Clinical Trial

BACKGROUND

Seroma formation has become the most reported complication after abdominoplasties. In 2000, progressive tension sutures (PTS) were described and reported to be associated with a seroma rate of 0.1%. Surgeons worldwide use PTS to prevent seroma; however, there are discrepancies in the number of PTS commonly used, starting from five up to 35 sutures. The absence of standardization may cause a lack of seroma prevention, increased surgical time, and general hesitation to perform the technique.

OBJECTIVE

To determine whether 11 PTS are sufficient to prevent seroma in abdominoplasties.

METHODS

We performed a single-blind, prospective, comparative, randomized clinical trial of 63 healthy patients from January to December 2017. Patients were divided into groups: group 1, classic abdominoplasty without the use of PTS and drains; group 2, abdominoplasty with the use of 11 PTS and drains; and group 3, abdominoplasty with the use of 22 PTS and drains. The duration of the surgical technique, presence of clinical seroma, number of aspirations, and days to drain removal were evaluated. The Cochran-Armitage, Fisher exact, Kruskal-Wallis, and t tests were used in the statistical analyses.

RESULTS

PTS reduced the rate of seroma formation to 3.5%. Results showed that there is a benefit in using 11 PTS instead of 22 PTS because using more sutures led to an increased surgical time (30 min vs. 13 min) and possible complications. Compared to patients with PTS, those without PTS underwent more seroma aspirations and delayed drain removal.

CONCLUSIONS

Eleven PTS should be used in classic abdominoplasties.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Post-Operative Infections among Patients Undergoing Radical Cystectomy at a Tertiary Center

BACKGROUND

Post-operative infection after radical cystectomy is a common complication. It is essential to identify modifiable risk factors that can predict post-operative infection to reduce the incidence of infection after radical cystectomy. We investigated the incidence of post-operative infection, associated pathogens, and risk factors for post-operative infection after radical cystectomy.

PATIENTS AND METHODS

Patients who underwent radical cystectomy for bladder cancer in a single urologic department from 2014 to 2016 were included. Age, gender, length of stay, body mass index (BMI), diabetes mellitus, hypertension, pre-operative estimated glomerular filtration rate, hydronephrosis, smoking status, neoadjuvant chemotherapy, pathologic tumor stage, pathologic nodal stage, types of urinary diversion, laparoscopic approach, operative time, and receipt of peri-operative blood transfusion were assessed to determine the association of these factors with the risk of infection within 30 days of radical cystectomy. Risk factors were assessed for correlation with any kind of infection and separately for urinary tract infection (UTI), blood infection/septic shock (BI), and surgical site infection (SSI). Pathogens were identified in all cases of infection.

RESULTS

A total of 134 patients were included in the analysis. Post-operative infection was diagnosed in 10.45%. Urinary tract infection, BI, and SSI were diagnosed in 3.73%, 4.48%, and 7.46%, respectively. Co-infections and mixed infection were diagnosed in 50% of patients with infection. Enterococcus was the most common pathogen. On multivariable analysis, age, BMI ≥30 kg/m², and laparoscopic approach were associated with the risk of infection; odds ratios (ORs) were 1.27 (95% confidence interval [CI] 1.01-1.59), 13.07 (1.39-122.88), and 0.07 (0.01-0.78), respectively.

CONCLUSION

One-tenth of patients undergoing radical cystectomy developed an infection within 30 days of surgery. Fifty percent of patients had co-infection with UTI, SSI, and/or BI and 50% of infections were polymicrobial. Increased BMI is the strongest factor associated independently with all types of infection. Therefore, obese patients should be encouraged to lose weight pre-operatively.

Surgical Site Infection (SSI) Rates Among Patients Who Underwent Mastectomy After the Introduction of SSI Prevention Policies

Objective.

To describe the results of an intervention program to reduce the rate of surgical site infection (SSI) in the breast tumor department of a referral teaching hospital for patients with cancer.

Methods.

Preventive measures introduced in the Breast Tumor Department of the study hospital included the following: starting in July 2000, use of sterile technique for wound care; starting in 2001, use of closed antireflux silicone evacuation systems, use of perioperative antimicrobial prophylaxis, provision of feedback to surgeons, and remodeling of the ambulatory wound care clinic. We conducted surveillance of all patients who underwent mastectomy between February 1 and December 31, 2001, and the SSI rate was calculated. A case-control analysis was performed for risk factors known to be associated with SSI. Results were compared with the data from 2000.

Results.

The study included data on 385 surgeries. SSIs were registered in 52 (13.7%) of these 385, which was a rate 58.6% less than the 2000 infection rate (33.1%). Risk factors associated with SSI included concomitant chemotherapy and radiation therapy (OR, 3.6 [95% confidence interval {CI}, 1.9-7.1]), surgery performed during an evening shift (OR, 1.9 [95% CI, 1.1-3.6]), and insertion of a second drainage tube during the late postoperative period (OR, 2.8 [95% CI, 1.4-5.7]). The mean number (± SD) of postoperative visits to the outpatient wound care clinic was reduced from 11.6 ± 7.1 in 2000 to 9.2 ± 4.4 in 2001 (P< .001, Student's t test). The mean number of days that the evacuation systems were used was reduced from 19.0 to 16.0 days (P =.001, Student's t test).

Conclusions.

Continuous wound surveillance, along with feedback to surgeons, use of closed antireflux evacuation systems, and standardized practices in wound and drainage-tube care, decreased by 58.6% the rate of SSI in a breast surgical department with high rates of infection.

Body mass index and the risk of infection - from underweight to obesity

BACKGROUND

Nutritional status is a well-known risk factor for metabolic and endocrine disorders. Recent studies suggest that dietary intake also affects immune function and as a consequence infection risk.

AIMS

This reviews aims to give an overview on the effect of body weight on infection rate at different periods of life.

SOURCES

Clinically relevant prospective, cross-sectional and case-control community-based studies are summarized.

CONTENT

In children and adolescents underweight is a significant risk factor for infection especially in developing countries, probably reflecting malnutrition and poor hygienic standards. Data from industrialized countries suggest that infection rate is also increased in obese children and adolescents. Similarly, several studies suggest a U-shaped increased infection rate in both underweight and obese adults. In the latter, infections of the skin and respiratory tract as well as surgical-site infections have consistently been reported to be more common than in normal-weight participants. Paradoxically, mortality of critically ill patients was reduced in obesity in some studies.

IMPLICATIONS

Several studies in children or adults suggest that both underweight and obesity are associated with increased infection risk. However, confounding factors such as malnutrition, hygienic status and underlying disease or co-morbidities might aggravate accurate assessment of the impact of body weight on infection risk.

Patients with Risk Factors for Complications Do Not Require Longer Antimicrobial Therapy for Complicated Intra-Abdominal Infection

A prospective, multicenter, randomized controlled trial found that four days of antibiotics for source-controlled complicated intra-abdominal infection resulted in similar outcomes when compared with a longer duration. We hypothesized that patients with specific risk factors for complications also had similar outcomes. Short-course patients with obesity, diabetes, or Acute Physiology and Chronic Health Evaluation II ≥15 from the STOP-IT trial were compared with longer duration patients. Outcomes included incidence of and days to infectious complications, mortality, and length of stay. Obese and diabetic patients had similar incidences of and days to surgical site infection, recurrent intra-abdominal infection, extra-abdominal infection, and Clostridium difficile infection. Short- and long-course patients had similar incidences of complications among patients with Acute Physiology and Chronic Health Evaluation II ≥15. However, there were fewer days to the diagnosis of surgical site infection (9.5 ± 3.4 vs 21.6 ± 6.2, P = 0.010) and extra-abdominal infection (12.4 ± 6.9 vs 21.8 ± 6.1, P = 0.029) in the short-course group. Mortality and length of stay was similar for all groups. A short course of antibiotics in complicated intraabdominal infection with source control seems to have similar outcomes to a longer course in patients with diabetes, obesity, or increased severity of illness.

Sonication of Abdominal Drains: Clinical Implications of Quantitative Cultures for the Diagnosis of Surgical Site Infection

BACKGROUND

The use of drains in patients undergoing abdominal surgery has been a subject of debate for several decades. In this paper, the usefulness of quantitative cultures of sonicated abdominal drains for diagnosing surgical site of infection (SSI) and the association between culture results with patient outcome is evaluated.

METHODS

Forty-five abdominal drainage tubes from 35 patients who underwent abdominal surgery were studied. Samples were sonicated for 5 min, the sonicate was centrifuged, and the sediment was cultured on different media. Total bacterial counts were adjusted to the actual surface of the drainage tubing. Clinical information of the patients was reviewed retrospectively.

RESULTS

A relation was observed between SSI and the use of drains for more than 3 d (p = 0.0216). The presence of a suspected pathogen was related to the prevalence of SSI (p = 0.035), complications (p = 0.013), and greater leukocyte count (p = 0.048 Mann Whitney test), as well as to the use of drains for more than 3 d (p = 0.0386) and to the serous appearance of the exudates at the point of insertion of the drain (p = 0.0399). The sonication procedure showed a sensitivity of 50%, specificity of 84.2%, positive predictive value of 72.72%, and negative predictive value of 66.67% in the diagnosis of SSI. The most commonly isolated group of organisms was coagulase-negative staphylococci, being present in 18 patients (51.43%) who, however, were not associated with SSI. One or two organisms considered as pathogens were detected in 11 patients (31.43%). The more common pathogens detected were Enterobacteriae spp. (nine patients): Enterobacter aerogenes (2), Enterobacter cloacae (1), Escherichia coli (4), Klebsiella pneumoniae (1), Morganella morganii (1); and Pseudomonas aeruginosa (five patients). Candida spp. and Enterococcus spp. were detected in one patient each one.

CONCLUSIONS

The detection and quantification of organisms not present in skin microbiota after drain sonication is helpful in the diagnosis of SSI and it is associated with a worse outcome in patients. Duration of use of drainage tubes is an independent risk factor for the development of SSI.

A Prospective, Randomized, Multicenter Trial Assessing a Novel Lysine-Derived Urethane Adhesive in a Large Flap Surgical Procedure without Drains

OBJECTIVE

To evaluate the safety and effectiveness of a lysine-derived urethane adhesive as a noninvasive alternative to closed suction drains in a commonly performed large flap surgical procedure.

METHODS

One hundred thirty subjects undergoing abdominoplasty at five centers were prospectively randomized to standard flap closure with surgical drains (Control group) or a lysine-derived urethane adhesive (Treatment group) without drains. The primary outcome measured was the number of post-operative procedures, including drain removals (as the event marking the use of a surgical drain) and needle aspirations. Secondary endpoints included total wound drainage, cumulative days of treatment, and days to drain removal. A patient questionnaire evaluating quality of life measures was also administered.

RESULTS

Subjects in the Treatment group required significantly fewer post-operative procedures compared to the Control group (1.8 ± 3.8 vs. 2.4 ± 1.2 procedures; p < 0.0001) and fewer cumulative days of treatment (1.6 ± 0.4 vs. 7.3 ± 3.3; p < 0.0001). A procedure to address fluid accumulation was required for only 27.3 % of the subjects in the Treatment group versus 100 % of Control group, which by study design required the use of drains. The mean duration of use of indwelling surgical drains for the Control group was 6.9 ± 3.3 days. All fluid collections treated with percutaneous aspiration were resolved and there were no unanticipated adverse events.

CONCLUSION

The results of the study support that the use of a lysine-derived urethane adhesive is a safe and effective alternative to drains in patients undergoing a common large flap surgical procedure.

Surgical site infections after abdominal surgery: incidence and risk factors. A prospective cohort study

BACKGROUND

Abdominal surgeries have high rates of surgical site infections (SSIs), contributing to increased morbidity and mortality and costs for hospitalization. The aim of this study was to determine the SSI incidence rates and risk factors after abdominal surgeries.

METHODS

This prospective cohort study included all patients undergoing abdominal surgeries between 2005 and 2007 in the Western Galilee Medical Center in Nahariya, Israel. SSI incidence rates were calculated per 100 operations. Odds ratios (ORs) were estimated for each risk factor using univariate and multivariate analyses by logistic regression models.

RESULTS

Among 302 patients in the study cohort, the total SSI incidence rate was 22.2%. The univariate analysis defined 13 variables significantly associated with SSI: age > 60 years, lower functional status, diabetes mellitus, congestive heart failure, immunocompromising underlying disease, treatment with chemotherapy and other immunosuppressive medications, impaired immune system open cholecystectomy, laparotomy, an American Society of Anesthesiologists (ASA) score > 2, drain insertion, and 'dirty wound' classification. In multivariate regression analysis, treatment with immunosuppressive medications (OR = 2.5, 95% confidence interval (CI) = 1.099-143.443), open cholecystectomy (OR = 2.25, 95% CI = 2.242-40.109), and dirty wound classification (OR = 2.179, 95% CI = 3.80-20.551) were significantly associated with SSI.

CONCLUSIONS

The significant risk factors defined should be addressed preoperatively to decrease the risk for SSI. Wound surveillance in the post-discharge period is necessary for correct estimation of SSI rates.

Inflammation and Nutritional Science for Programs/Policies and Interpretation of Research Evidence (INSPIRE)

An increasing recognition has emerged of the complexities of the global health agenda—specifically, the collision of infections and noncommunicable diseases and the dual burden of over- and undernutrition. Of particular practical concern are both 1) the need for a better understanding of the bidirectional relations between nutritional status and the development and function of the immune and inflammatory response and 2) the specific impact of the inflammatory response on the selection, use, and interpretation of nutrient biomarkers. The goal of the Inflammation and Nutritional Science for Programs/Policies and Interpretation of Research Evidence (INSPIRE) is to provide guidance for those users represented by the global food and nutrition enterprise. These include researchers (bench and clinical), clinicians providing care/treatment, those developing and evaluating programs/interventions at scale, and those responsible for generating evidence-based policy. The INSPIRE process included convening 5 thematic working groups (WGs) charged with developing summary reports around the following issues: 1) basic overview of the interactions between nutrition, immune function, and the inflammatory response; 2) examination of the evidence regarding the impact of nutrition on immune function and inflammation; 3) evaluation of the impact of inflammation and clinical conditions (acute and chronic) on nutrition; 4) examination of existing and potential new approaches to account for the impact of inflammation on biomarker interpretation and use; and 5) the presentation of new approaches to the study of these relations. Each WG was tasked with synthesizing a summary of the evidence for each of these topics and delineating the remaining gaps in our knowledge. This review consists of a summary of the INSPIRE workshop and the WG deliberations.

Evaluating the cause of death in obese individuals: a ten-year medical autopsy study

BACKGROUND

Obesity is a growing public health problem associated with increased morbidity and rate of death. Postmortem examination is imperative to determine the cause of death, to detect clinically unsuspected disease entities, and consequently to determine the actual impact of obesity on patient mortality.

METHODS

A total of 849 adult autopsies were retrospectively reviewed. Obese (BMI ≥ 30 kg/m(2)) and nonobese patients were separately studied. The primary cause of death in each group was categorized into malignancy, infection, stroke, ischemic and nonischemic heart disease, pulmonary embolism, hemorrhage, and primary nonneoplastic diseases of different organ systems.

RESULTS

Of 849 autopsies, 32.3% were obese. The leading causes of death in the obese population were malignancy (31.4%), infection (25.9%), ischemic heart disease (12.8%), and pulmonary embolism (6.2%). Obese individuals were statistically more likely to die from pulmonary embolism and liver disease and less likely to die from neurologic diseases and nonischemic heart disease.

CONCLUSION

Autopsies on obese individuals constitute a third of all adult medical autopsies in our center. Increased death rates in the obese due to pulmonary embolism and liver disease should receive special clinical attention. Autopsy findings in the obese population should contribute to overall premortem disease detection, prevention, and management.

Diet-induced obesity attenuates endotoxin-induced cognitive deficits

Activation of the immune system can impair cognitive function, particularly on hippocampus dependent tasks. Several factors such as normal aging and prenatal experiences can modify the severity of these cognitive deficits. One additional factor that may modulate the behavioral response to immune activation is obesity. Prior work has shown that obesity alters the activity of the immune system. Whether diet-induced obesity (DIO) influences the cognitive deficits associated with inflammation is currently unknown. The present study explored whether DIO alters the behavioral response to the bacterial endotoxin, lipopolysaccharide (LPS). Female C57BL/6J mice were fed a high-fat (60% fat) or control diet (10% fat) for a total of five months. After consuming their respective diets for four months, mice received an LPS or saline injection and were assessed for alterations in spatial learning. One month later, mice received a second injection of LPS or saline and tissue samples were collected to assess the inflammatory response within the periphery and central nervous system. Results showed that LPS administration impaired spatial learning in the control diet mice, but had no effect in DIO mice. This lack of a cognitive deficit in the DIO female mice is likely due to a blunted inflammatory response within the brain. While cytokine production within the periphery (i.e., plasma, adipose, and spleen) was similar between the DIO and control mice, the DIO mice failed to show an increase in IL-6 and CD74 in the brain following LPS administration. Collectively, these data indicate that DIO can reduce aspects of the neuroinflammatory response as well as blunt the behavioral reaction to an immune challenge.

Diet modification and metformin have a beneficial effect in a fly model of obesity and mucormycosis

In an experimental model of obesity and hyperglycemia in Drosophila melanogaster we studied the effect of diet modification and administration of metformin on systemic infection with Rhizopus, a common cause of mucormycosis in diabetic patients. Female Wt-type Drosophila flies were fed regular (RF) or high-fat diet (HFD; 30% coconut oil) food with or without metformin for 48 h and then injected with R. oryzae. Survival rates, glucose and triglyceride levels were compared between 1) normal-weight flies (RF), 2) obese flies (HFD), 3) obese flies fed with RF, 4) flies continuously fed on HFD + metformin, 5) flies fed on HFD + metformin, then transferred to RF, and 6) obese flies administered metformin after infection [corrected].Glucose levels were compared across groups of non-infected flies and across groups of infected flies. Survival was significantly decreased (P = 0.003) in obese flies, while post-infection glucose levels were significantly increased (P = 0.0001), compared to normal-weight flies. Diet and administration of metformin led to weight loss, normalized glucose levels during infection, and were associated with decreased mortality and tissue fungal burden. In conclusion, diet and metformin help control infection-associated hyperglycemia and improve survival in Drosophila flies with mucormycosis. Fly models of obesity bear intriguing similarities to the pathophysiology of insulin resistance and diabetes in humans, and can provide new insights into the pathogenesis and treatment of infections in obese and diabetic patients.

Fast food fever: reviewing the impacts of the Western diet on immunity

While numerous changes in human lifestyle constitute modern life, our diet has been gaining attention as a potential contributor to the increase in immune-mediated diseases. The Western diet is characterized by an over consumption and reduced variety of refined sugars, salt, and saturated fat. Herein our objective is to detail the mechanisms for the Western diet's impact on immune function. The manuscript reviews the impacts and mechanisms of harm for our over-indulgence in sugar, salt, and fat, as well as the data outlining the impacts of artificial sweeteners, gluten, and genetically modified foods; attention is given to revealing where the literature on the immune impacts of macronutrients is limited to either animal or in vitro models versus where human trials exist. Detailed attention is given to the dietary impact on the gut microbiome and the mechanisms by which our poor dietary choices are encoded into our gut, our genes, and are passed to our offspring. While today's modern diet may provide beneficial protection from micro- and macronutrient deficiencies, our over abundance of calories and the macronutrients that compose our diet may all lead to increased inflammation, reduced control of infection, increased rates of cancer, and increased risk for allergic and auto-inflammatory disease.

Diet-induced obesity attenuates cytokine production following an immune challenge

Obesity increases susceptibility for numerous diseases and neurological disorders including cardiovascular disease, metabolic syndrome, and dementia. One factor that may contribute to the increased risk for these conditions is the development of chronic inflammation. The current study evaluated whether diet-induced obesity (DIO) affects cognitive performance by increasing neuroinflammation and prolonging the behavioral and inflammatory response to an immune challenge. Adult male C57BL/6J mice were fed a high-fat (60% fat) or control diet (10% fat) for 2 or 5 months. After consuming their respective diets for two months, sickness associated behaviors were assessed 4 and 24h after a lipopolysaccharide (LPS) or saline injection. In a separate experiment, DIO and control mice were tested for spatial learning in the water maze and challenged with LPS one month later. Peripheral cytokine production was assessed in adipose and spleen samples and the neuroinflammatory response was assessed in hippocampal, cortical, and brain samples. DIO impaired acquisition of a spatial learning task relative to control mice. However, these deficits are unlikely to be related to inflammation as DIO showed no changes in basal cytokine levels within the periphery or brain. Further, in response to LPS DIO mice showed comparable or attenuated levels of the proinflammatory cytokines interleukin-1β and interleukin-6 relative to control mice. DIO also reduced hippocampal expression of brain-derived neurotrophic factor and the pre-synaptic marker synaptophysin. Presently, the data indicate that DIO suppresses aspects of the immune response and that cognitive deficits associated with DIO may be related to reduced neurotrophic support rather than inflammation.

Obesity and infection: two sides of one coin

The prevalence of obesity has exponentially risen worldwide. The etiology of obesity is multifactorial, and genetic inheritance and behavioral/environmental causes are considered the main etiological factors. Moreover, evidence that specific infections might promote the development of obesity has steadily accumulated. Only a few works investigate the impact of obesity on the immune response to infections and the risk of infections in the obese population. The aim of this paper was to review the available data regarding the various aspects of the association between obesity and infections and to highlight the possibility that infectious agents may have an etiological role in obesity, an idea known as "infectobesity". Several microbes have been considered as possible promoter of obesity, but most of the data concern adenovirus-36 that exerts an adipogenic action mainly via a direct effect on adipose tissue leading to weight gain, at least in animal models.Obesity affects the immune response leading to an increased susceptibility to infections. Obese adults and children show an increased incidence of both nosocomial and community-acquired infections. Furthermore, obesity may alter the pharmacokinetics of antimicrobial drugs and impact on vaccine response. However, the various aspects of the association of obesity infections remain poorly studied, and a call to research is necessary to better investigate the problem.In conclusion, obesity impacts millions globally, and greater understanding of its etiology and its effects on immunity, infections, and prevention and management strategies is a key public health concern.

Antibiotic Prophylaxis in Surgery: An Observational Prospective Study Conducted in a Large Teaching Hospital in Naples

This was a 9-month observational prospective study conducted in two steps to evaluate surgical prophylaxis procedures used by surgeons in several departments of the Second University of Naples (SUN). In step 1 (4 months), we collected and analyzed data on surgical interventions and antibiotic prophylaxis. Surgeons were informed of the analysis outcome and were given an antibiotic prophylaxis protocol based on international guidelines. In step 2 (5 months), we collected data on surgical interventions and antibiotic prophylaxis, and compared them with step 1 data. The analysis of 354 forms (step 1) showed that third-generation cephalosporins were the preferred prophylactic antibiotics. The analysis of 369 forms (step 2) showed that ceftriaxone and ampicillin were the most frequently used antibiotics. Surgeons did not comply with guidelines for antibiotic prophylaxis as regards type of antibiotic and treatment duration but implementation of antibiotic prophylaxis protocols resulted in more appropriate and better timing of antibiotic prophylaxis.

A multi-disciplinary review of the potential association between closed-suction drains and surgical site infection

BACKGROUND

Despite the putative advantages conferred by closed-suction drains (CSDs), the widespread utilization of post-operative drains has been questioned due to concerns regarding both efficacy and safety, particularly with respect to the risk of surgical site infection (SSI). Although discipline-specific reports exist delineating risk factors associated with SSI as they relate to the presence of CSDs, there are no broad summary studies to examine this issue in depth.

METHODS

The pertinent medical literature exploring the relationship between CSDs and SSI across multiple surgical disciplines was reviewed.

RESULTS

Across most surgical disciplines, studies to evaluate the risk of SSI associated with routine post-operative CSD have yielded conflicting results. A few studies do suggest an increased risk of SSI associated with drain placement, but are usually associated with open drainage and not the use of CSDs. No studies whatsoever attribute a decrease in the incidence of SSI (including organ/space SSI) to drain placement.

CONCLUSIONS

Until additional, rigorous randomized trials are available to address the issue definitively, we recommend judicious use and prompt, timely removal of CSDs. Given that the evidence is scant and weak to suggest that CSD use is associated with increased risk of SSI, there is no justification for the prolongation of antibiotic prophylaxis to "cover" an indwelling drain.

The impact of obesity on the immune response to infection

There is strong evidence indicating that excess adiposity negatively impacts immune function and host defence in obese individuals. This is a review of research findings concerning the impact of obesity on the immune response to infection, including a discussion of possible mechanisms. Obesity is characterised by a state of low-grade, chronic inflammation in addition to disturbed levels of circulating nutrients and metabolic hormones. The impact of these metabolic abnormalities on obesity-related comorbidities has undergone intense scrutiny over the past decade. However, relatively little is known of how the immune system and host defence are influenced by the pro-inflammatory and excess energy milieu of the obese. Epidemiological data suggest obese human subjects are at greater risk for nosocomial infections, especially following surgery. Additionally, the significance of altered immunity in obese human subjects is emphasised by recent studies reporting obesity to be an independent risk factor for increased morbidity and mortality following infection with the 2009 pandemic influenza A (H1N1) virus. Rodent models offer important insight into how metabolic abnormalities associated with excess body weight can impair immunity. However, more research is necessary to understand the specific aspects of immunity that are impaired and what factors are contributing to reduced immunocompetence in the obese. Additionally, special consideration of how infection in this at-risk population is managed is required, given that this population may not respond optimally to antimicrobial drugs and vaccination. Obesity impacts millions globally, and greater understanding of its associated physiological disturbances is a key public health concern.

Obese mice exhibit an altered behavioural and inflammatory response to lipopolysaccharide

Obesity is associated with an increase in the prevalence and severity of infections. Genetic animal models of obesity (ob/ob and db/db mice) display altered centrally-mediated sickness behaviour in response to acute inflammatory stimuli such as lipopolysaccharide (LPS). However, the effect of diet-induced obesity (DIO) on the anorectic and febrile response to LPS in mice is unknown. This study therefore determined how DIO and ob/ob mice respond to a systemic inflammatory challenge. C57BL/6 DIO and ob/ob mice, and their respective controls, were given an intraperitoneal (i.p.) injection of LPS. Compared with controls, DIO and ob/ob mice exhibited an altered febrile response to LPS (100 μg/kg) over 8 hours. LPS caused a greater and more prolonged anorexic effect in DIO compared with control mice and, in ob/ob mice, LPS induced a reduction in food intake and body weight earlier than it did in controls. These effects of LPS in obese mice were also seen after a fixed dose of LPS (5 μg). LPS (100 μg/kg) induced Fos protein expression in several brain nuclei of control mice, with fewer Fos-positive cells observed in the brains of obese mice. An altered inflammatory response to LPS was also observed in obese mice compared with controls: changes in cytokine expression and release were detected in the plasma, spleen, liver and peritoneal macrophages in obese mice. In summary, DIO and ob/ob mice displayed an altered behavioural response and cytokine release to systemic inflammatory challenge. These findings could help explain why obese humans show increased sensitivity to infections.

Surveillance, control, and prevention of surgical site infections in breast cancer surgery: a 5-year experience

BACKGROUND

We analyzed variations in surgical site infections (SSIs) during 5 years of a prospective surveillance program and investigated possible contributors to SSIs in a cohort of patients who underwent surgery for breast cancer.

METHODS

All breast surgeries performed between January 2001 and December 2005 were registered. Patients were followed-up by direct observation for at least 30 days under standardized conditions. The main outcome studied was SSI. A case-control analysis was conducted to identify SSI-associated risk factors and to evaluate SSI variations by means of a control chart.

RESULTS

During the study period, a total of 2338 breast cancer surgeries were recorded, and 441 SSIs (18.9%) were diagnosed. SSI frequency varied across the 5-year period, with a sharp decline seen after the introduction of preventive policies. After 2002, 3 out-of-confidence limits of SSIs were observed, 2 related to the use of evacuation systems and 1 associated with a group of rotating residents. Concomitant preoperative chemoradiation (odds ratio [OR]=3.47; 95% confidence interval [CI]=2.51 to 4.80), hematoma (OR=3.05; 95% CI=1.70 to 5.52), age > or = 58 years (OR=1.83; 95% CI=1.27 to 2.65), body mass index > or = 30.8 (OR=1.58; 95% CI=1.14 to 2.18), and duration of surgery > or = 160 minutes (OR=1.73; 95% CI=1.20 to 2.50) were found to be SSI-associated risk factors.

CONCLUSIONS

After 5 years of a continuous prospective surveillance program, we were able to decrease the rate of SSIs in patients undergoing breast cancer surgery (from 33.3% in 2000 to 18.9% in 2005), identify SSI-associated risk factors, and improve the quality of care delivered to these patients.

Species distribution and antimicrobial susceptibility of gram-negative aerobic bacteria in hospitalized cancer patients

Background

Nosocomial infections pose significant threats to hospitalized patients, especially the immunocompromised ones, such as cancer patients.

Methods

This study examined the microbial spectrum of gram-negative bacteria in various infection sites in patients with leukemia and solid tumors. The antimicrobial resistance patterns of the isolated bacteria were studied.

Results

The most frequently isolated gram-negative bacteria were Klebsiella pneumonia (31.2%) followed by Escherichia coli (22.2%). We report the isolation and identification of a number of less-frequent gram negative bacteria (Chromobacterium violacum, Burkholderia cepacia, Kluyvera ascorbata, Stenotrophomonas maltophilia, Yersinia pseudotuberculosis, and Salmonella arizona). Most of the gram-negative isolates from Respiratory Tract Infections (RTI), Gastro-intestinal Tract Infections (GITI), Urinary Tract Infections (UTI), and Bloodstream Infections (BSI) were obtained from leukemic patients. All gram-negative isolates from Skin Infections (SI) were obtained from solid-tumor patients. In both leukemic and solid-tumor patients, gram-negative bacteria causing UTI were mainly Escherichia coli and Klebsiella pneumoniae, while gram-negative bacteria causing RTI were mainly Klebsiella pneumoniae. Escherichia coli was the main gram-negative pathogen causing BSI in solid-tumor patients and GITI in leukemic patients. Isolates of Escherichia coli, Klebsiella, Enterobacter, Pseudomonas, and Acinetobacter species were resistant to most antibiotics tested. There was significant imipenem -resistance in Acinetobacter (40.9%), Pseudomonas (40%), and Enterobacter (22.2%) species, and noticeable imipinem-resistance in Klebsiella (13.9%) and Escherichia coli (8%).

Conclusion

This is the first study to report the evolution of imipenem-resistant gram-negative strains in Egypt. Mortality rates were higher in cancer patients with nosocomial Pseudomonas infections than any other bacterial infections. Policies restricting antibiotic consumption should be implemented to avoid the evolution of newer generations of antibiotic resistant-pathogens.

Facial Adiposity: A Cue to Health?

Facial symmetry, averageness, sexual dimorphism, and skin colour/texture all serve as cues to attractiveness, but their role in the perception of health is less clear. This ambiguity could reflect the fact that these facial traits are not the only cues to health. We propose that adiposity is an important, but thus far disregarded, facial cue to health. Our results demonstrate two important prerequisites for any health cue. First, we show that facial adiposity, or the perception of weight in the face, significantly predicts perceived health and attractiveness. Second, we show that perceived facial adiposity is significantly associated with measures of cardiovascular health and reported infections. Perceived facial adiposity, or a correlate thereof, is therefore an important and valid cue to health that should be included in future studies.

Two-year outcomes in primary THA in obese male veterans administration medical center patients

The objective of this study was to examine the influence of obesity on the rate of infection, dislocation, and overall complications in a group of male patients undergoing primary total hip arthroplasty (THA). The study involved a retrospective review of the association of body mass index (BMI) and dislocation, infection, and complications on 255 consecutive male patients who received a THA. BMI of 40 and greater had significantly more dislocations and approached significance for infections. The present study suggests that the risk of infection and dislocation increases only in highly obese males (BMI > 40) in contrast to other studies that have reported a higher risk infection, dislocation, and complications with a BMI of obesity in females (BMI > 30).

Hyperglycemia as a risk factor for surgical site infections in patients undergoing mastectomy

BACKGROUND

The aim of this study was to evaluate the association between perioperative hyperglycemia and surgical site infections (SSIs) in patients undergoing mastectomy.

METHODS

In this nested case-control study, patients undergoing mastectomy from May 2004 to June 2006, at the National Cancer Institute (INCan), Mexico, were included. Five blood glucose values were obtained for each patient. Patients were followed prospectively by direct observation for at least 30 days.

RESULTS

A total of 260 patients were included. Patient characteristics were similar in cases and controls. Cases were older (>50 years) (P = .001) and were more frequently treated with concomitant chemoradiation (P < .0001) than controls. Fifty cases (23.8%) developed an SSI. At least 1 measurement of blood glucose value > or = 150 mg/dL increased the risk for SSI (odds ratio [OR] = 3.05; 95% confidence interval [CI] = 1.5 to 6.3; P = .006). Variables associated with SSI after logistic regression analysis included age >50 years (OR = 3.7; 95% CI = 1.5 to 9.2; P = .005), preoperative concomitant chemoradiation treatment (OR = 2.8; 95% CI = 1.4 to 5.8, P = .0004), and any blood glucose value > or = 150 mg/dL (OR = 2.9, 95% CI = 1.2 to 6.2; P = .02).

CONCLUSION

Postoperative SSI was a very frequent complication in this cohort. Our data indicate that higher blood glucose values are an independent risk factor for postoperative SSI. Preoperative concomitant chemoradiation and age > 50 years were also risk factors for developing an SSI in patients undergoing mastectomy.