Clinical and economic outcomes of hospital acquired pneumonia in intra-abdominal surgery patients

Effect of perioperative oral care on postoperative infections in patients with cancer: A systematic review and meta-analysis

AIM

This systematic review aimed to assess the effect of non-pharmacologic perioperative oral hygiene care on reduced incidence of postoperative pneumonia (PP), surgical site infection (SSI), and the length of hospital stay in patients with cancer, and to describe the details of oral hygiene care.

METHODS

We searched seven databases. Eligibility criteria were based on perioperative oral hygiene care provided by healthcare professionals to patients aged ≥18 years who were surgically treated under general anesthesia and were evaluated for the incidence of PP and SSI. We reported risk ratios (RR) for dichotomous outcomes for PP and SSI using a fixed-effects model of meta-analysis.

RESULTS

The search resulted in 850 articles, among which two were randomized controlled trials (RCTs) and 21 were observational studies. Most studies indicated that dentists and medical care providers performed a combination of oral cleaning, and oral hygiene instructions. In RCTs, perioperative oral hygiene care significantly reduced the incidence of PP (RR, 0.86; p = .60), while in observational studies, perioperative oral hygiene care significantly reduced the incidence of PP (RR, 0.55; p < .001) and SSI (RR, 0.47; p < .001). The length of hospital stay was also significantly reduced (p < .05). However, the effectiveness of nursing intervention was not clear.

CONCLUSIONS

Perioperative oral hygiene care implemented by healthcare professionals prevented PP and SSI and reduced length of hospital stays for patients after cancer surgery. As daily perioperative oral hygiene care is performed by nurses, it is necessary to research the effects of oral hygiene by nurses in the future.

A nomogram combining prognostic nutritional index and platelet lymphocyte ratio predicts postoperative pulmonary infection following D2 radical gastrectomy for gastric cancer

Introduction

Introduction: the prognostic nutritional index (PNI) and platelet-lymphocyte ratio (PLR) have been found to correlate with outcomes following radical gastrectomy for gastric cancer (GC). Objectives: to construct a nomogram combining PNI and PLR for individually forecasting the risk of postoperative pulmonary infection (POI) following D2 radical gastrectomy for GC. Methods: retrospectively, clinical data was gathered from 404 patients treated with D2 radical gastrectomy for GC. The study used multivariate logistic regression analysis to screen independent risk factors for POI after surgery. Subsequently, a nomogram was developed based on the above factors to forecast the POI probability accurately. Results: the multivariate logistic regression analysis identified age, PNI, PLR, CA199 level, ASA score, and ICU treatment as independent risk variables for POI following D2 radical gastrectomy (p < 0.001 or 0.05). The nomogram's area under the receiver operating characteristic curve (AUC) for predicting the risk of POI was 0.736 (95 % confidence interval (CI) = 0.678-0.794). The nomogram was internally validated using the bootstrap approach, involving repeated sampling 1000 times. The result yielded a concordance index (c-index) of 0.707 (95 % CI = 0.705-0.709). The calibration curves demonstrated an excellent concordance between the predicted values of the nomogram and the observed values. The nomogram's clinical value was shown to be high using decision analysis curves. Conclusions: a nomogram combining PNI and PLR is a dependable tool for forecasting the probability of POI following D2 radical gastrectomy for GC.

Effect of incremental PEEP titration on postoperative pulmonary complications in patients undergoing emergency laparotomy: a randomized controlled trial

Postoperative pulmonary complications (PPC) has a significant negative impact and are associated with increased length of hospital stay and cost of care. Emergency surgery is a well-established risk factor for PPC. Previous studies reported that personalized positive end-expiratory pressure (PEEP) might reduce postoperative atelectasis and postoperative pulmonary complications. N = 168 adult patients undergoing major emergency laparotomy under general anesthesia were recruited in this study. A minimum driving pressure based incremental PEEP titration was compared to a fixed PEEP of 5 cmH2O. The primary outcome was PPC up to postoperative day 7. The mean (standard deviation) of the recruited patients was 41.7(16.1)y, and 48.8% (82 of 168 patients) were female. The risk of PPC at postoperative day 7 was similar in both the study groups [Relative risk (RR) (95% Confidence interval, CI) 0.81 (0.58, 1.13); p = 0.25]. In addition, the incidence of intraoperative hypotension [p = 0.75], oxygen-free days at day 28 [p = 0.27], duration of postoperative hospital stay [p = 0.50], length of postoperative intensive care unit stay [p = 0.28], and in-hospital mortality [p = 0.38] were similar in two groups. Incidence of PPC was not reduced with the use of an individualized PEEP strategy based on lowest driving pressure. However, the incidence of hypotension and bradycardia was also not increased with titrated PEEP.Trial Registration: www.ctri.nic.in ; CTRI/2020/12/029765.

Impact of the perioperative assessment of deglutition on postoperative respiratory complications in elderly patients undergoing gastrectomy for gastric cancer

PURPOSE

To investigate the association between perioperative deglutition screening and postoperative respiratory complications (PRCs) in elderly patients undergoing gastrectomy for gastric cancer.

METHODS

We analyzed data from 86 patients with gastric cancer (aged ≥ 70 years) who underwent gastrectomy between October, 2016 and November, 2018. Videofluoroscopic swallowing examinations (VFSEs) were performed before and after surgery. We examined the association of these results with postoperative respiratory complications, as well as the relationships between demographic, operative, and swallowing function assessment data.

RESULTS

PRCs were identified in 16 patients. The results of pre- and postoperative VFSE showed abnormalities in 28 and 32 patients, respectively. Multivariate analysis revealed that abnormalities in the postoperative VFSEs were strongly associated with the development of PRCs (P = 0.002). The findings of this analysis suggests that ventilatory impairment, a Charlson comorbidity index score ≥ 3, and an open surgical approach are independent risk factors for PRCs.

CONCLUSION

This is the first study to demonstrate the efficacy of perioperative assessment of swallowing function using VFSE for predicting PRCs in elderly patients undergoing gastrectomy for gastric cancer.

Association of Hyperlipidemia With Perioperative Complications in Posterior Cervical Spine Fusion: A Comparative Retrospective Study

STUDY DESIGN

A retrospective database study.

OBJECTIVES

The purpose of the current study was to investigate the impact of hyperlipidemia (HLD) on the incidence of perioperative complications associated with posterior cervical spine fusion (PCF).

BACKGROUND

HLD is a very common disease that leads to atherosclerosis. Therefore, it can cause fatal diseases as well as lifestyle-related diseases. The possible impact of HLD on outcomes after PCF has not yet been investigated.

METHODS

Patients with cervical degeneration underwent initial PCF from 2010 through the third quarter of 2020 using the MSpine subset of the PearlDiver Patient Record Database. The incidence of perioperative complications was queried using relevant ICD-9, 10, and CPT codes. χ 2 analysis was performed in age-, sex-, and Charlson Comorbidity Index (CCI)-matched populations to compare between non-HLD and HLD patients in each single-level and multilevel PCF.

RESULTS

Through propensity score matching, 1600 patients each in the HLD and non-HLD groups were analyzed in the single-level PCF, 6855 patients were analyzed in the multilevel PCF were analyzed. The comorbidity of HLD significantly decreased the incidence of respiratory failure in single-level PCF (OR=0.58, P <0.01). In the multilevel PCF, the presence of HLD increased the incidence of cervicalgia (OR=1.26, P =0.030). On the contrary, the incident of spinal cord injury (OR=0.72, P <0.01), dysphagia (OR=0.81, P =0.023), respiratory failure (OR=0.85, P =0.030), pneumonia (OR=0.70, P =0.045), neurological bladder (OR=0.84, P =0.041), and urinary tract infection (OR=0.85, P =0.021) in the HLD group were significantly lower than those in non-HLD group.

CONCLUSIONS

In the current study, the presence of HLD significantly increased the incidence of postoperative cervicalgia in multilevel PCF. On the other hand, the incidence of some complications was significantly decreased with HLD. Further studies are needed taking into account other factors such as the treatment of HLD, its efficacy, and intraoperative events.

LEVEL OF EVIDENCE

Level III.

Impact of Enhanced in-Hospital Infection Prevention During the COVID-19 Pandemic on Postoperative Pneumonia in Older Surgical Patients

Purpose

We aimed to investigate the impact of enhanced in-hospital infection prevention during the coronavirus disease 2019 (COVID-19) pandemic on postoperative pneumonia in older surgical patients.

Patients and Methods

We retrospectively reviewed the electronic medical records of consecutive patients ≥70 years who underwent elective surgery between 2017 and 2021 at our institution. All perioperative variables were retrieved from the electronic medical records. The primary outcome was new-onset postoperative pneumonia during the hospitalization period. Since February 2020, our institution implemented a series of policies to enhance infection prevention, hence patients were divided into groups according to whether they underwent surgery before or during the COVID-19 pandemic. An interrupted time series analysis was performed to evaluate the difference between pre- and post-intervention slopes of the primary outcome.

Results

Among the 29,387 patients included in the study, 10,547 patients underwent surgery during the COVID-19 pandemic. Although there was a decreasing trend of the monthly incidence rate of postoperative pneumonia compared to before the COVID-19 pandemic, there was no statistical significance in the trend (slope before COVID-19 period: β-coefficient, -0.007; 95% CI, -0.022 to 0.007).

Conclusion

Our study revealed that enhanced in-hospital infection prevention implemented to manage the COVID-19 pandemic did not significantly affect the decreasing trend of postoperative pneumonia at our institution.

Effect of preoperative inspiratory muscle training on postoperative outcomes in patients undergoing cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Cardiovascular disease is the most prevalent disease worldwide and places a great burden on the health and economic welfare of patients. Cardiac surgery is an important way to treat cardiovascular disease, but it can prolong mechanical ventilation time, intensive care unit (ICU) stay, and postoperative hospitalization for patients. Previous studies have demonstrated that preoperative inspiratory muscle training could decrease the incidence of postoperative pulmonary complications.

AIM

To explore the effect of preoperative inspiratory muscle training on mechanical ventilation time, length of ICU stay, and duration of postoperative hospitalization after cardiac surgery.

METHODS

A literature search of PubMed, Web of Science, Cochrane Library, EMBASE, China National Knowledge Infrastructure, WanFang, and the China Science and Technology journal VIP database was performed on April 13, 2022. The data was independently extracted by two authors. The inclusion criteria were: (1) Randomized controlled trial; (2) Accessible as a full paper; (3) Patients who received cardiac surgery; (4) Preoperative inspiratory muscle training was implemented in these patients; (5) The study reported at least one of the following: Mechanical ventilation time, length of ICU stay, and/or duration of postoperative hospitalization; and (6) In English language.

RESULTS

We analyzed six randomized controlled trials with a total of 925 participants. The pooled mean difference of mechanical ventilation time was -0.45 h [95% confidence interval (CI): -1.59-0.69], which was not statistically significant between the intervention group and the control group. The pooled mean difference of length of ICU stay was 0.44 h (95%CI: -0.58-1.45). The pooled mean difference of postoperative hospitalization was -1.77 d in the intervention group vs the control group [95%CI: -2.41-(-1.12)].

CONCLUSION

Preoperative inspiratory muscle training may decrease the duration of postoperative hospitalization for patients undergoing cardiac surgery. More high-quality studies are needed to confirm our conclusion.

Analysis of Bacterial Pathogens Causing Complicating HAP in Patients with Secondary Peritonitis

Background: Diffuse peritonitis is an acute abdominal condition characterized by high mortality. The main treatment modality is surgery, requiring a subsequent prolonged hospital stay. These patients are, among other things, at risk of developing hospital-acquired pneumonia (HAP), which considerably worsens their treatment outcomes. This study aimed to extend the existing knowledge by providing more detailed microbiological characteristics of complicating HAP in patients with secondary peritonitis, including the identification of isolated bacterial pathogens and their potential sources. Methods: The 2015–2019 retrospective study comprised all patients with an intraoperatively confirmed diagnosis of secondary diffuse peritonitis who were classified in accordance with the quick Sepsis Related Organ Failure Assessment scoring system. Results: HAP developed in 15% of patients. The 90-day mortality rates were 53% and 24% in patients with and without HAP; respectively. The most frequent pathogens responsible for HAP were Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Enterobacter cloacae complex and Enterococcus faecalis. Multidrug resistance to antibiotics was found in 38% of bacterial pathogens. Clonal spread of these bacterial pathogens among patients was not detected. Rather, the endogenous characteristic of HAP was confirmed. Conclusions: The initial antibiotic therapy of complicating HAP in patients with secondary peritonitis must be effective mainly against enterobacteria, including strains with the production of ESBL and AmpC beta-lactamases, Pseudomonas aeruginosa and Enterococcus faecalis. The study further highlighted the importance of monitoring the respiratory tract bacterial microflora in patients with secondary peritonitis. The results should be used for initial antibiotic treatment of complicating HAP instances.

Postoperative Respiratory Failure and Advanced Ventilator Settings

Postoperative respiratory failure has a multifactorial etiology, of which atelectasis is the most common mechanism. Its injurious effects are magnified by surgical inflammation, high driving pressures, and postoperative pain. Chest physiotherapy and noninvasive ventilation are good options to prevent progression of respiratory failure. Acute respiratory disease syndrome is a late and severe finding, which is associated with high morbidity and mortality. If present, proning is a safe, effective, and underutilized therapy. Extracorporeal membrane oxygenation is an option only when traditional supportive measures have failed.

An assessment of burden of hospital-acquired pneumonia among abdominal surgical patients in tertiary university hospital in Serbia: A matched nested case-control study

Background

In the population of abdominal surgical patients hospital-acquired pneumonia (HAP) significantly increases morbidity and mortality.

Patients and methods

Through regular hospital surveillance of patients who received abdominal operations, we identified postoperative HAP from 2007 to 2019. In an initial nested case-control study, every surgical patient with HAP was compared with three control patients without HAP. Control patients were matched to the cases by age, gender, the American Society of Anesthesiologists score, and type of surgical operation. Also, the patients with HAP, who died were compared with those who survived.

Results

Multivariate logistic regression analysis (MLRA) revealed that other postoperative infections, length of intensive care unit stay, use of H2RA, use of PPI/ H2RA, multiple transfusion, and use of vancomycin in surgical prophylaxis were independent RFs for occurrence of HAP. Also, MLRA identified that age, lenght of hospital stay, use of mechanical ventilation and ceftriaxone in HAP therapy were indepedenttly associated with poor outcome of HAP. All Acinetobacter baumannii isolates were resistant to aminoglycoside antimicrobial agents and showed carbapenem resistance. The most frequently used antibiotics in patients with HAP and without HAP were vancomycin and metronidazole, respectively.

Conclusion

Our study provided an insight into the burden of HAP in abdominal surgical patients, and highlighted several priority areas and targets for quality improvement.

The association between non-ventilator associated hospital acquired pneumonia and patient outcomes among U.S. Veterans

BACKGROUND

Non-ventilator associated hospital acquired pneumonia (NV-HAP) affects approximately 1 in 100 hospitalized patients yet risk-adjusted outcomes associated with developing NV-HAP are unknown.

METHODS

Retrospective cohort study with propensity score matched populations (NV-HAP vs no NV-HAP), using ICD-10 codes for bacterial pneumonia not present on admission. Outcomes included the patient level probability of NV-HAP developing among acute care non-transfer admissions in 133 Veterans Affairs hospitals and subsequent mortality, length of stay, inpatient sepsis, and 12-month costs.

RESULTS

NV-HAP occurred in 0.6% of Veteran admissions. Among admissions that developed NV-HAP, the mean length of stay of 26.3 days (6.72 days among non-NV-HAP), 30-day mortality was 18.4% (4.5% among non-NV-HAP), 1-year mortality was 47.8% (21.4% among non-NV-HAP), and total median 12-month direct medical costs were $138,136.32 ($64,357.21 among non-NV-HAP). Inpatient sepsis occurred in approximately 20% of NV-HAP admissions (0.7% among non-NV-HAP). Data available at admission was insufficient to identify high and low risk patient groups.

CONCLUSIONS

NV-HAP is associated with severely worse patient outcomes and increased costs of care up to 12 months post-episode. Since population risk stratification is not feasible, prevention efforts should be directed at the full population of hospitalized Veterans.

Effects of lymphocyte and neutrophil counts and their time courses on mortality in patients with postoperative pneumonia

The prognostic significance of absolute lymphocyte count (ALC) and absolute neutrophil count (ANC) remains unclear in patients with postoperative pneumonia (POP). The study objectives were to investigate the prognostic effects of ALC and ANC in POP patients, and to evaluate the time courses of ALC and ANC during hospitalization. This post-hoc analysis of a single-center prospective observational study evaluated consecutive POP patients, and comparatively analyzed community-acquired pneumonia (CAP) patients to highlight features of POP. In total, 228 POP patients and 1027 CAP patients were assessed. Severe lymphopenia (ALC < 500 cells/μL) at diagnosis was associated with worse 90-day survival in both types of pneumonia. In POP patients, neutrophilia (ANC > 7500 cells/μL) was associated with better survival, whereas CAP patients with neutrophilia tended to have a lower survival rate. Prolonged lymphopenia and delayed increase in neutrophils were characteristic time-course changes of non-survivors in POP. The time courses of ALC and ANC between survivors and non-survivors in POP trended differently from those in CAP. Our study showed that ALC and ANC at pneumonia diagnosis can serve as prognostic factors in POP patients. Differences in time-course changes of ALC and ANC between survivors and non-survivors may provide important information for future immunological research in pneumonia.

Prognostic Nutritional Index and Postoperative Pulmonary Complications in Patients With Major Burns

INTRODUCTION

Burns can cause multiple organ systemic derangements, particularly in respiratory systems. The prognostic nutritional index (PNI) can predict postoperative outcomes. We evaluated the incidence and risk factors, including PNI, for postoperative pulmonary complications (PPCs) in patients with major burns.

METHODS

PNI was calculated as 10 × (serum albumin level) + 0.005 × (total lymphocyte count). Major burn patients admitted to the ICU without burn-induced lung injuries were retrospectively included. The incidence of PPCs was measured within 1 wk of burn surgery. A multivariable logistic regression analysis was performed to evaluate the risk factors for PPCs. Receiver operating characteristic curve analysis and propensity-score matched analysis were conducted to estimate the influence of PNI on PPCs. Outcomes after burn surgery were also assessed.

RESULTS

Of 444 major burn patients, 138 (31.1%) showed PPCs. Risk factors for PPCs were PNI, gender, total body surface area burned, interval between burn and surgery, and red blood cell transfusion rate. The area under the curve of PNI for predicting PPCs was 0.709 (cutoff value = 31.5). The incidence of PPCs was significantly higher in the PNI ≤ 31.5 group than in the PNI > 31.5 group (55.7% versus 22.8%, P < 0.001) after propensity-score matching. The intensive care unit stay duration was longer and 90-d mortality was higher in patients who developed PPCs (19 [9-27] d versus 8 [4-17] d, P < 0.001; 11.6% versus 0.3%, P < 0.001).

CONCLUSIONS

The prevalence of PPCs in patients with major burns was 31.1% and preoperative PNI was a predictor of PPCs in these patients. PNI ≤ 31.5 was significantly related to a higher incidence of PPCs.

Intensive physical therapy after emergency laparotomy: Pilot phase of the Incidence of Complications following Emergency Abdominal surgery Get Exercising randomized controlled trial

BACKGROUND

Postoperative pneumonia and delayed physical recovery are significant problems after emergency laparotomy. No randomized controlled trial has assessed the feasibility, safety, or effectiveness of intensive postoperative physical therapy in this high-risk acute population.

METHODS

The internal pilot phase of the Incidence of Complications after Emergency Abdominal Surgery: Get Exercising (ICEAGE) trial was a prospective, randomized controlled trial that evaluated the feasibility, safety, and clinical trial processes of providing intensive physical therapy immediately following emergency laparotomy. Fifty consecutive patients were recruited at the principal participating hospital and randomly assigned to standard-care or intensive physical therapy of twice daily coached breathing exercises for 2 days and 30 minutes of daily supervised rehabilitation over the first 5 postoperative days.

RESULTS

Interventions were provided exactly as per protocol in 35% (78 of 221 patients) of planned treatment sessions. Main barriers to protocol delivery were physical therapist unavailability on weekends (59 of 221 patients [27%]), awaiting patient consent (18 of 99 patients [18%]), and patient fatigue (26 of 221 patients [12%]). Despite inhibitors to treatment delivery, the intervention group still received twice as many breathing exercise sessions and four times the amount of physical therapy over the first 5 postoperative days (23 minutes [interquartile range, 12-29 minutes] vs. 86 minutes [interquartile range, 53-121 minutes]; p < 0.001). One adverse event was reported from 78 rehabilitation sessions (1.3%), which resolved fully on cessation of activity without escalation of medical care.

CONCLUSION

Intensive postoperative physical therapy can be delivered safely and successfully to patients in the first week after emergency laparotomy. The ICEAGE trial protocol resulted in intervention group participants receiving more coached breathing exercises and spending significantly more time physically active over the first 5 days after surgery compared with standard care. It was therefore recommended to progress into the multicenter phase of ICEAGE to definitively test the effect of intensive physical therapy to prevent pneumonia and improve physical recovery after emergency laparotomy.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level II.

Implementation of perioperative breathing exercises and its effect on postoperative pulmonary complications and long-term prognosis in elderly patients undergoing laparoscopic colorectal surgery: A randomized controlled trial

OBJECTIVE

This study was to investigate the impact of breathing exercises on recovery in elderly patients receiving laparoscopic colorectal surgery.

DESIGN

A prospective randomized controlled trial.

SETTING

University hospital.

SUBJECT

A total of 264 elder patients undergoing laparoscopic colorectal surgery participated in this study.

INTERVENTION

Patients in intervention group received respiratory-related exercises based on standardized enhanced recovery after surgery strategies from admission to 90 days after surgery. The control group received perioperative standardized enhanced recovery after surgery strategies without formatted breathing exercises.

MAIN MEASURES

The primary outcome was the incidence of postoperative pulmonary complications. The secondary outcomes included 6-minute walking distance, surgery-related complications, length of stay, mortality postoperatively, and hospitalization costs.

RESULTS

Completion rate of breathing exercise in intervention group was over 80% till 90 days postoperatively. The incidence of postoperative pulmonary complications was lower in breathing exercises group (17/132 [12.9%] vs. 43/132 [32.6%], p < 0.001). The mean value of 6-minute walking distance increased more in intervention group compared with baseline values preoperatively (44.2 ± 4.3 vs. 3.2 ± 0.2, p < 0.001). On 90 days postoperatively, the mean value of 6-minute walking distance in breathing exercises group increased by 18.8 m compared with its baseline (557.0 ± 133.5 vs. 538.2 ± 112.7, p = 0.022), while that of control group decreased by 53.2 m from baseline (481.9 ± 102.5 vs. 535.1 ± 123.4, p < 0.001). Patients who received breathing exercises had shorter length of stay and lower hospitalization costs (p < 0.050).

CONCLUSIONS

Perioperative breathing exercises helped prevent postoperative pulmonary complications and improve long-term prognosis in elderly patients undergoing laparoscopic colorectal surgery.

Effect of Electrical Impedance Tomography-Guided Early Mobilization in Patients After Major Upper Abdominal Surgery: Protocol for a Prospective Cohort Study

Background: Pulmonary complications are common in patients after upper abdominal surgery, resulting in poor clinical outcomes and increased costs of hospitalization. Enhanced Recovery After Surgery Guidelines strongly recommend early mobilization post-operatively; however, the quality of the evidence is poor, and indicators for quantifying the effectiveness of early mobilization are lacking. This study will evaluate the effectiveness of early mobilization in patients undergoing an upper abdominal surgery using electrical impedance tomography (EIT). Specifically, we will use EIT to assess and compare the lung ventilation distribution among various regions of interest (ROI) before and after mobilization in this patient population. Additionally, we will assess the temporal differences in the distribution of ventilation in various ROI during mobilization in an effort to develop personalized activity programs for this patient population.

Methods: In this prospective, single-center cohort study, we aim to recruit 50 patients after upper abdominal surgery between July 1, 2021 and June 30, 2022. This study will use EIT to quantify the ventilation distribution among different ROI. On post-operative day 1, the nurses will assist the patient to sit on the chair beside the bed. Patient's heart rate, blood pressure, oxygen saturation, respiratory rate, and ROI 1-4 will be recorded before the mobilization as baseline. These data will be recorded again at 15, 30, 60, 90, and 120 min after mobilization, and the changes in vital signs and ROI 1-4 values at each time point before and after mobilization will be compared.

Ethics and Dissemination: The study protocol has been approved by the Institutional Review Board of Liaocheng Cardiac Hospital (2020036). The trial is registered at chictr.org.cn with identifier ChiCTR2100042877, registered on January 31, 2021. The results of the study will be presented at relevant national and international conferences and submitted to international peer-reviewed journals. There are no plans to communicate results specifically to participants. Important protocol modifications, such as changes to eligibility criteria, outcomes, or analyses, will be communicated to all relevant parties (including investigators, Institutional Review Board, trial participants, trial registries, journals, and regulators) as needed via email or in-person communication.

Postoperative complications and open gastrectomy affect non-cancer-related death and shorten life expectancy in elderly patients with gastric cancer

Postoperative complications contribute to recurrences and poor long-term outcomes for gastric cancer patients, especially among the elderly. However, the prognostic effect of postoperative complications on non-cancer-related death in elderly patients with gastric cancer has not been reported. Two hundred and twenty elderly (> 75 years of age) patients with stage I gastric cancer were retrospectively identified from consecutive admissions between 1995 and 2020. Non-cancer-related death following gastrectomy occurred in 13.6% (30/220) of patients. Non-cancer-related death was associated with respiratory disease in 46.7% (14/30) of cases. Although there was no association with any preoperative comorbidities, postoperative complications [P < 0.001, HR 4.16 (95% CI: 1.91-9.02)] and open gastrectomy [P=0.002, HR 3.87 (95% CI: 1.54-9.66)] were independently associated with a poorer prognosis for non-cancer-related death. Poor nutritional status [P=0.028, OR 4.25 (95% CI: 1.17-15.4)] was an independent risk factor for postoperative complications. Postoperative complications shortened life expectancy from 8.8 years to 6.1 years. Specifically, postoperative complications shortened life expectancy from 6.7 years to 3.9 years in elderly patients over 80 years of age. Postoperative complications and open gastrectomy affected the incidence of non-cancer-related death among elderly patients with gastric cancer, primarily attributed to respiratory disease. Efforts should be made to perform minimally invasive surgery, improve preoperative nutrition, and avoid postoperative complications.

Effect of the postural transition in minimally invasive esophagectomy: a propensity score matching analysis

BACKGROUND

The advantages of prone position in minimally invasive esophagectomy have not been well studied. This study aimed to investigate the safety and feasibility of a transition from the left lateral decubitus position to the prone position for thoracic procedures in minimally invasive esophagectomy.

METHODS

We retrospectively analyzed patients with thoracic esophageal carcinomas who underwent thoracoscopic esophagectomy and laparoscopic gastric mobilization between January 2015 and December 2019. The left decubitus and prone positions were analyzed using propensity score-matched pairs for the baseline characteristics, morbidity, and survival.

RESULTS

A total of 114 consecutive patients were included in this study; 90 (78.9%) were male and the median age was 67.2 years old. Of these patients, 39 and 75 underwent left decubitus and prone esophagectomy, respectively. Prone esophagectomy was associated with a lower incidence of pneumonia than that performed in the decubitus position (12.5% vs. 37.5%, p = 0.0187). With respect to the long-term outcomes, there were no significant differences between the 2 groups. The 4-year overall and relapse-free survival rates for prone and decubitus esophagectomy were 73.8% and 73.2%, and 84.4% and 71.8%, respectively (p = 0.9899 and 0.6751, respectively). Prone esophagectomy yielded a shorter operative time (total: 528 [485-579] min vs. 581 [555-610] min, p < 0.0022; thoracic section: 243 [229-271] min vs. 292 [274-309] min, p < 0.0001), less bleeding in the thoracic procedures (0 [0-10] mL vs. 70 [20-138] mL, p < 0.0001), a shorter length of postoperative hospital stay (19 [15-23] vs. 30 [21-46] days, p = 0.0002), and a lower total hospital charge (30,046 [28,175-32,660] US dollars vs. 36,396 [31,533-41,180] US dollars, p < 0.0001).

CONCLUSIONS

Transition into the prone position in minimally invasive esophagectomy is feasible with adequate postoperative and oncological safety and economical in esophageal cancer surgery.

Preoperative risk factors for postoperative pneumonia following primary Total Hip and Knee Arthroplasty

BACKGROUND

The purpose of this study is to evaluate risk factors for pneumonia following THA and TKA.

METHODS

Patients were identified from the American College of Surgeons National Quality Improvement Database (NSQIP) who experienced postoperative pneumonia after undergoing primary THA and TKA.

RESULTS

Many characteristics including old age, anemia, diabetes, cardiac comorbidities, dialysis, and smoking were independent risk factors for postoperative pneumonia after THA or TKA.

CONCLUSION

This analysis offers new evidence on risk factors associated with the development of pneumonia after THA and TKA. These risk factors can help guide clinicians in preventing postoperative pneumonia after THA and TKA.

Impact of the 'weekend effect' on hospital-acquired pneumonia after aneurysmal subarachnoid hemorrhage

OBJECTIVES

Weekend admission has been reported to be associated with poor clinical outcomes of various diseases. This study aimed to determine whether weekend admission increases the incidence of hospital-acquired pneumonia (HAP) in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

We retrospectively analyzed aSAH patients admitted to our hospital between 2014 and 2020. These patients were divided into weekend and weekday groups. We compared the incidence of HAP and other clinical outcomes between the two groups. Risk factors for HAP were identified by logistic regression analysis.

RESULTS

Of 653 included aSAH patients, 145 (22%) were admitted on weekends and 508 (78%) were admitted on weekdays. The incidence of HAP in the weekend group was significantly higher than that in the weekday group (25% vs 16%, P = 0.01). The weekend group showed worse clinical outcomes, including worse neurological outcome (74% vs 65%, P = 0.03), higher risk of intensive care unit (ICU) admission (21% vs 13%, P = 0.01) and longer length of stay (21.3 vs 16.4 days, P < 0.01). Age ≥ 60 years (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.3-3.0, P < 0.01), modified Fisher score (MFS) ≥ 3 (OR = 1.7, 95% CI = 1.1-2.6, P = 0.02), weekend admission (OR = 1.8, 95% CI = 1.1-2.8, P = 0.02) and operative treatment (OR = 2.3, 95% CI = 1.2-4.5, P = 0.02) were risk factors for HAP following aSAH.

CONCLUSION

Weekend admission was associated with a higher incidence of HAP in aSAH patients. This study suggested that medical administrators may need to optimize healthcare services on weekends.

Preliminary model assessing the cost-effectiveness of preoperative chlorhexidine mouthwash at reducing postoperative pneumonia among abdominal surgery patients in South Africa

Background

Pneumonia is a common and severe complication of abdominal surgery, it is associated with increased length of hospital stay, healthcare costs, and mortality. Further, pulmonary complication rates have risen during the SARS-CoV-2 pandemic. This study explored the potential cost-effectiveness of administering preoperative chlorhexidine mouthwash versus no-mouthwash at reducing postoperative pneumonia among abdominal surgery patients.

Methods

A decision analytic model taking the South African healthcare provider perspective was constructed to compare costs and benefits of mouthwash versus no-mouthwash-surgery at 30 days after abdominal surgery. We assumed two scenarios: (i) the absence of COVID-19; (ii) the presence of COVID-19. Input parameters were collected from published literature including prospective cohort studies and expert opinion. Effectiveness was measured as proportion of pneumonia patients. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainties. The results of the probabilistic sensitivity analysis were presented using cost-effectiveness planes and cost-effectiveness acceptability curves.

Results

In the absence of COVID-19, mouthwash had lower average costs compared to no-mouthwash-surgery, $3,675 (R 63,770) versus $3,958 (R 68,683), and lower proportion of pneumonia patients, 0.029 versus 0.042 (dominance of mouthwash intervention). In the presence of COVID-19, the increase in pneumonia rate due to COVID-19, made mouthwash more dominant as it was more beneficial to reduce pneumonia patients through administering mouthwash. The cost-effectiveness acceptability curves shown that mouthwash surgery is likely to be cost-effective between $0 (R0) and $15,000 (R 260,220) willingness to pay thresholds.

Conclusions

Both the absence and presence of SARS-CoV-2, mouthwash is likely to be cost saving intervention for reducing pneumonia after abdominal surgery. However, the available evidence for the effectiveness of mouthwash was extrapolated from cardiac surgery; there is now an urgent need for a robust clinical trial on the intervention on non-cardiac surgery.

Preoperative Pulmonary Risk Assessment

Postoperative pulmonary complications have a significant impact on perioperative morbidity and mortality and contribute substantially to health care costs. Surgical stress and anesthesia lead to changes in respiratory physiology, altering lung volumes, respiratory drive, and muscle function that can cumulatively increase the risk of postoperative pulmonary complications. Preoperative medical evaluation requires a structured approach to identify patient-, procedure-, and anesthesia-related risk factors for postoperative pulmonary complications. Validated risk prediction models can be used for risk stratification and to help tailor the preoperative investigation. Optimization of pulmonary comorbidities, smoking cessation, and correction of anemia are risk-mitigation strategies. Lung-protective ventilation, moderate PEEP application, and conservative use of neuromuscular blocking drugs are intra-operative preventive strategies. Postoperative early mobilization, chest physiotherapy, oral care, and appropriate analgesia speed up recovery. High-risk patients should receive inspiratory muscle training prior to surgery, and there should be a focus to minimize surgery time.

Association between perioperative chlorhexidine oral care and postoperative pneumonia in non-cardiac surgical patients: A systematic review and meta-analysis

BACKGROUND

Postoperative pneumonia is the third most common complication after surgery, and its occurrence is associated with a poor prognosis in patients. Perioperative chlorhexidine oral care has been reported to reduce the incidence of postoperative pneumonia in patients undergoing cardiac surgery. However, whether perioperative chlorhexidine oral care can reduce the incidence of postoperative pneumonia in noncardiac surgical patients is still unknown. The aim of this systematic review and meta-analysis was to determine the association between perioperative chlorhexidine oral care and postoperative pneumonia in noncardiac surgical patients.

METHODS

A comprehensive systematic search of PubMed, Ovid Embase, Web of Science, the Cochrane Library, Wanfang Database, and the China National Knowledge Infrastructure was conducted to include studies from the inception of each database through March 2021. The reference lists of all included studies were also searched by hand. Eligible studies were published and unpublished randomized controlled trials and observational studies evaluating the effect of perioperative chlorhexidine oral care on the reported incidence of postoperative pneumonia. Relative risks or odds ratio with their 95% confidence intervals were calculated and risk of bias was assessed for eligible studies.

RESULTS

Seven randomized controlled trials with a total of 1,773 patients and 3 observational studies with a total of 12,528 noncardiac surgical patients were included. A total of 621 and 5,904 patients received perioperative chlorhexidine oral care in randomized controlled trials and observational studies, respectively. Six (85%) randomized controlled trials had a high risk of bias, and 2 (67%) observational studies had a high quality. Perioperative chlorhexidine oral care significantly reduced the incidence of postoperative pneumonia in randomized controlled trials (relative risk, 0.60; 95% confidence interval, 0.44-0.80; P < .001) and observational studies (odds ratio, 0.26; 95% confidence interval, 0.08-0.90; P = .03).

CONCLUSION

Perioperative chlorhexidine oral care led by a nurse significantly decreases the incidence of postoperative pneumonia in noncardiac surgical patients and may be more convenient and economical compared with dental professional-led perioperative oral care.

Superinfection associated with prolonged antibiotic use in non-ventilator associated hospital-acquired pneumonia

Background Non-ventilator associated hospital-acquired pneumonia accounts for significant antibiotic use and is associated with a high rate of resistance emergence. However, the optimal duration of antibiotic treatment is uncertain, especially in cases of non-fermenting gram-negative bacilli. Objective To compare a short course (5-7 days) to a prolonged course (10-14 days) of antibiotics for non-ventilator associated hospital-acquired pneumonia. Methods Data collected retrospectively on patients completed treatment in a Malaysian tertiary hospital from January 2017 till December 2018. Regression analysis determined variables independently associated with clinical outcome. Main outcome measures Clinical resolution, superinfection, 30-day and 90-day all-cause mortality between short and prolonged courses. Results Of the 167 patients included, 112 patients were treated with a short course antibiotic, whereas 55 patients received a prolonged course of therapy. Neither short nor prolonged course group has a significantly higher rate of clinical resolution. Short course group had significantly higher mean ± SD antibiotic-free days (21.9 ± 3.5 versus 15.1 ± 6.2 days, p < 0.001). Higher rate of superinfection was observed in prolonged course group compared to short course group (6.3% versus 18.2%, p = 0.027). For non-ventilator associated hospital-acquired pneumonia caused by non-fermenting gram-negative bacilli, the superinfection rate was higher in prolonged course group (35.7% versus 15.4%, p = 0.385) while 30-day mortality rate was higher in the short course group (38.5% versus 14.3%, p = 0.209). Non-fermenting gram-negative bacilli cause higher rate of superinfection (p = 0.010). Conclusion We found no clinical benefit as defined by clinical resolution and reduction in all-cause mortality in prolonging antimicrobial therapy. Superinfections emerge more frequently in prolonged course of antibiotic therapy and more likely to develop in non-fermenting gram-negative bacilli.

Association of Breast Implants with Nonspecific Symptoms, Connective Tissue Diseases, and Allergic Reactions: A Retrospective Cohort Analysis

BACKGROUND

Given the rising media attention regarding various adverse conditions attributed to breast implants, the authors examined the association between breast implantation and the risk of being diagnosed with connective tissue diseases, allergic reactions, and nonspecific constitutional complaints in a cohort study with longitudinal follow-up.

METHODS

Women enrolled in a regional military health care system between 2003 and 2012 were evaluated in this retrospective cohort study. A propensity score was generated to match women who underwent breast implantation with women who did not undergo breast implantation. The propensity score included age, social history, health care use, comorbidities, and medication use. Outcomes assessed included International Classification of Diseases, Ninth Revision, diagnoses codes for (1) nonspecific constitutional symptoms, (2) nonspecific cardiac conditions, (3) rheumatoid arthritis and systemic lupus erythematosus, (4) other connective tissue diseases, and (5) allergic reactions.

RESULTS

Of 22,063 women included in the study (513 breast implants and 21,550 controls), we propensity score-matched 452 breast implant recipients with 452 nonrecipients. Odds ratios and 95 percent confidence intervals in breast implant recipients compared to nonrecipients were similar, including nonspecific constitutional symptoms (OR, 0.77; 95 percent CI, 0.53 to 1.13), nonspecific cardiac conditions (OR, 0.97; 95 percent CI, 0.69 to 1.37), rheumatoid arthritis and systemic lupus erythematosus (OR, 0.66; 95 percent CI, 0.33 to 1.31), other connective tissue diseases (OR, 1.02; 95 percent CI, 0.78 to 1.32), and allergic reactions (OR, 1.18; 95 percent CI, 0.84 to 1.66).

CONCLUSIONS

Women with breast implants did not have an increased likelihood of being diagnosed with nonspecific constitutional symptoms, connective tissue disorders, and/or allergic reaction conditions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Respiratory complications after surgery in Vietnam: National estimates of the economic burden

Background

Estimating the cost of postoperative respiratory complications is crucial in developing appropriate strategies to mitigate the global and national economic burden. However, systematic analysis of the economic burden in low- and middle-income countries is lacking.

Methods

We used the nationwide database of the Vietnam Social Insurance agency and extracted data from January 2017 to September 2018. The data contain 1 241 893 surgical patients undergoing one of seven types of surgery. Propensity score matching method was used to match cases with and without complications. We used generalized gamma regressions to estimate the direct medical costs; logistic regressions to evaluate the impact of postoperative respiratory complications on re-hospitalization and outpatient visits.

Findings

Postoperative respiratory complications increased the odds of re-hospitalization and outpatient visits by 3·49 times (95% CI: 3·35–3·64) and 1·39 times (95% CI: 1·34–1·45) among surgical patients, respectively. The mean incremental cost associated with postoperative respiratory complications occurring within 30 days of the index admission was 1053·3 USD (95% CI: 940·7–1165·8) per procedure, which was equivalent to 41% of the GDP per capita of Vietnam in 2018. We estimated the national annual incremental cost due to respiratory complications occurring within 30 days after surgery was 13·87 million USD. Pneumonia contributed the greatest part of the annual cost burden of postoperative respiratory complications.

Interpretation

The economic burden of postoperative respiratory complications is substantial at both individual and national levels. Postoperative respiratory complications also increase the odds of re-hospitalization and outpatient visits and increase the length of hospital stay among surgical patients.

Funding

The authors did not receive any funds for conducting this study

Decreased Long-Term Respiratory Infection Risk After Bariatric Surgery: a Comprehensive National Cohort Study

PURPOSE

This study aims to determine whether bariatric surgery (BS) decreases the risk of respiratory tract infections (RTIs) in obese patients.

MATERIALS AND METHODS

This retrospective, population-based, matched cohort study utilized data from the Taiwan National Health Insurance Research Database. All patients 18 to 55 years of age with obesity diagnosed between 2005 and 2010 were enrolled. Patients were separated into two groups based on whether they underwent BS. Two groups were selected using 1:1 propensity score matching according to age, sex, and comorbidities. The general population was also enrolled for comparison. The primary endpoint was the incidence of RTIs, including pneumonia, influenza, and bronchitis. All patients were followed up until the end of 2013, the primary endpoint, or death.

RESULTS

Compared to the non-surgery group, the BS group was at significantly lower risk for RTIs (aHR 0.432, 95% CI 0.340-0.549, p < 0.001) with shorter length of hospital stay (LOH) and lower cost. Regardless of the RTI-related mortality, pneumonia, influenza, and bronchitis rates, BS did have significant protective effects on the non-surgery group. Compared to the general population, the BS group was at higher risk for RTIs (aHR 3.601, 95% CI 2.742-4.728, p < 0.001) with similar LOH and lower cost.

CONCLUSION

Patients with obesity who underwent BS were at significantly lower risk for RTIs than obese patients who did not undergo BS but were at higher risk for RTIs than the general population. BS may result in a long-term reduction of the RTI risk.

Is Statin Use Associated With Risk of Thyroid Diseases? Results of a Retrospective Cohort Study

BACKGROUND

Given the ubiquity of statin use and prevalence of thyroid diseases, such as thyroid cancer, hyperthyroidism, and thyroiditis, understanding their association deserves further attention.

OBJECTIVE

To examine the association between statin use and thyroid cancer, thyrotoxicosis, goiter, and thyroiditis.

METHODS

Using Tricare data, 2 propensity score (PS)-matched cohorts of statin users and nonusers were formed: (1) a PS-matched general cohort (all patients aged 30-85 years) and (2) a PS-matched healthy cohort (excluded patients with cardiovascular diseases or severe comorbidities). Outcomes were thyroid cancer, thyrotoxicosis, goiter, and thyroiditis. Odds ratios (ORs) and 95% CIs of outcomes were estimated using conditional regression analysis.

RESULTS

Of 43 438 patients, the PS-matched general cohort matched 6342 statin users to 6342 nonusers. The OR of thyroid cancer was 0.62 (95% CI = 0.39-0.996). There was no significant difference between statin users and nonusers in risk of thyrotoxicosis (OR = 0.88; 95% CI = 0.71-1.09), goiter (OR = 0.9; 95% CI = 0.77-1.03), or thyroiditis (OR = 0.78; 95% CI = 0.53-1.15). In the PS-matched healthy cohort (3351 statin users to 3351 nonusers), there was no difference between statin users and nonusers in any outcome. Limitations of the study include its retrospective observational design and use of administrative codes in outcomes ascertainment.

CONCLUSION AND RELEVANCE

This study did not demonstrate any association of statins with harmful effects on thyroid diseases, which offers assurance to clinicians and patients. Furthermore, statin use appears to be associated with a decreased risk of thyroid cancer, but more studies are needed.

Disturbance in the oropharyngeal microbiota in relation to antibiotic and proton pump inhibitor medication and length of hospital stay

The aim of this study was to investigate the appearance of a disturbed oropharyngeal microbiota during hospitalization and explore the patient characteristics that maybe associated with such a disturbance. Oropharyngeal swabs were collected from 134 patients at hospital admission and every 3-4 days thereafter. The samples were cultivated to determine the presence of a disturbed microbiota, which, in turn, was subcategorized into respiratory tract pathogens, gut microbiota and yeast species. Demographics, medical history data and hospitalization events were compared. The percentage of disturbed oropharyngeal microbiota increased significantly with length of stay (LOS). Receiving antibiotic treatment during the hospitalization tended to be associated with a disturbed microbiota (OR 2.75 [0.99-7.60]). Proton pump inhibitor (PPI) medication and receiving antibiotics before hospitalization were associated with the development of a disturbed oropharyngeal microbiota with colonization of gut pathogens (OR 3.49 [1.19-10.2] and OR 4.52 [1.13-18.1], respectively), while acute hospital admission was associated with a lower risk of colonization of gut pathogens (OR: 0.23 [0.074-0.72]). The risk of developing a disturbed oropharyngeal microbiota increased with LOS in hospitalized patients. PPI medication and receiving antibiotics before hospitalization were independent risk factors for developing oropharyngeal colonization of gut pathogens.

Perioperative breathing training to prevent postoperative pulmonary complications in patients undergoing laparoscopic colorectal surgery: A randomized controlled trial

OBJECTIVE

The aim of this study was to determine whether perioperative breathing training reduces the incidence of postoperative pulmonary complications in patients undergoing laparoscopic colorectal surgery.

DESIGN

A randomized controlled trial.

SETTING

University hospital.

SUBJECTS

A total of 240 patients undergoing laparoscopic colorectal surgery participated in this study.

INTERVENTION

The enrolled patients were randomized into an intervention or control group. Patients in the intervention group received perioperative breathing training, including deep breathing and coughing exercise, balloon-blowing exercise, and pursed lip breathing exercise. The control group received standard perioperative care without any breathing training.

MAIN MEASURES

The primary endpoint was the incidence of postoperative pulmonary complications. The secondary objectives were to evaluate the effect of perioperative breathing training on arterial oxygenation, incidence of other postoperative complications, patient satisfaction, length of stay, and hospital charges.

RESULTS

The incidence of postoperative pulmonary complications in the breathing training group was lower than that in the control group (5/120 [4%] vs 14/120 [12%]; RR 0.357, 95%CI 0.133-0.960; P = 0.031). In addition, PaO₂ and arterial oxygenation index on the first and fourth days after surgery were significantly higher in the breathing training group than in the control group (P < 0.001). In addition, patients with breathing training had shorter length of stay (6d [IQR 5-7] vs 8d [IQR 7-9]), lower hospital charges (7761 ± 1679 vs 8212 ± 1326), and higher patient satisfaction (9.46 ± 0.65 vs 9.21 ± 0.47) than those without.

CONCLUSION

Perioperative breathing training may reduce the incidence of postoperative pulmonary complications and preserve of arterial oxygenation after laparoscopic colorectal surgery.

Timing of nasogastric tube insertion and the risk of postoperative pneumonia: an international, prospective cohort study

AIM

Aspiration is a common cause of pneumonia in patients with postoperative ileus. Insertion of a nasogastric tube (NGT) is often performed, but this can be distressing. The aim of this study was to determine whether the timing of NGT insertion after surgery (before versus after vomiting) was associated with reduced rates of pneumonia in patients undergoing elective colorectal surgery.

METHOD

This was a preplanned secondary analysis of a multicentre, prospective cohort study. Patients undergoing elective colorectal surgery between January 2018 and April 2018 were eligible. Those receiving a NGT were divided into three groups, based on the timing of the insertion: routine NGT (inserted at the time of surgery), prophylactic NGT (inserted after surgery but before vomiting) and reactive NGT (inserted after surgery and after vomiting). The primary outcome was the development of pneumonia within 30 days of surgery, which was compared between the prophylactic and reactive NGT groups using multivariable regression analysis.

RESULTS

A total of 4715 patients were included in the analysis and 1536 (32.6%) received a NGT. These were classified as routine in 926 (60.3%), reactive in 461 (30.0%) and prophylactic in 149 (9.7%). Two hundred patients (4.2%) developed pneumonia (no NGT 2.7%; routine NGT 5.2%; reactive NGT 10.6%; prophylactic NGT 11.4%). After adjustment for confounding factors, no significant difference in pneumonia rates was detected between the prophylactic and reactive NGT groups (odds ratio 1.03, 95% CI 0.56-1.87, P = 0.932).

CONCLUSION

In patients who required the insertion of a NGT after surgery, prophylactic insertion was not associated with fewer cases of pneumonia within 30 days of surgery compared with reactive insertion.

Carbapenem Antibiotics for the Empiric Treatment of Nosocomial Pneumonia: A Systematic Review and Meta-analysis

BACKGROUND

Previous meta-analyses suggested that treating hospital-acquired pneumonia (HAP), including ventilator-associated pneumonia (VAP), with empiric carbapenems was associated with lower mortality rates but higher rates of clinical failure for pseudomonal pneumonia. This study was an updated meta-analysis with sensitivity analyses and meta-regression to better understand the impact of carbapenem use in HAP/VAP.

RESEARCH QUESTION

What is the efficacy of carbapenems for empiric treatment of nosocomial pneumonia?

STUDY DESIGN AND METHODS

Databases were searched for randomized controlled studies evaluating empiric treatment for HAP and/or VAP, and studies were included comparing carbapenem- vs non-carbapenem-containing regimens. The primary outcome was all-cause mortality. Secondary outcomes included subgroup stratification and resistance development.

RESULTS

Of 9,140 references, 20 trials enrolling 5,489 patients met inclusion criteria. For mortality, carbapenem use had a risk ratio (RR) of 0.84 (95% CI, 0.74-0.96; P = .01). Stratified according to VAP proportion (< 33%, 33%-66%, and > 66%), RRs were 0.95 (95% CI, 0.77-1.17; P = .66), 0.78 (95% CI, 0.57-1.07; P = .13), and 0.81 (95% CI, 0.65-0.99; P = .04), respectively. Stratified according to severity, only groups with Acute Physiology and Chronic Health Evaluation II scores < 14 and between 14 and 17 showed mortality benefit (RRs of 0.64 [95% CI, 0.45-0.92; P = .01] and 0.77 [95% CI, 0.61-0.97; P = .03]). Meta-regression did not show an association between Pseudomonas prevalence and mortality (P = .44). Carbapenem use showed a trend toward developing resistance (RR, 1.40; 95% CI, 0.95-2.06; P = .09) and a 96% probability of resistance emergence.

INTERPRETATION

Carbapenem-based empiric regimens were associated with lower mortality rates compared with non-carbapenems, largely driven by trials of VAP. The mortality effect was not observed in trials with high disease severity and was not associated with Pseudomonas. The mortality difference was observed mainly in studies that used ceftazidime as control. There was a trend toward increasing resistance associated with carbapenems.

TRIAL REGISTRY

International Prospective Register of Systematic Reviews; No. CRD42018093602; URL: https://www.crd.york.ac.uk/prospero/.

Multicenter Evaluation of the BioFire FilmArray Pneumonia/Pneumonia Plus Panel for Detection and Quantification of Agents of Lower Respiratory Tract Infection

The ability to provide timely identification of the causative agents of lower respiratory tract infections can promote better patient outcomes and support antimicrobial stewardship efforts. Current diagnostic testing options include culture, molecular testing, and antigen detection. These methods may require collection of various specimens, involve extensive sample treatment, and can suffer from low sensitivity and long turnaround times. This study assessed the performance of the BioFire FilmArray Pneumonia Panel (PN panel) and Pneumonia Plus Panel (PNplus panel), an FDA-cleared sample-to-answer assay that enables the detection of viruses, atypical bacteria, bacteria, and antimicrobial resistance marker genes from lower respiratory tract specimens (sputum and bronchoalveolar lavage [BAL] fluid). Semiquantitative results are also provided for the bacterial targets. This paper describes selected analytical and clinical studies that were conducted to evaluate performance of the panel for regulatory clearance. Prospectively collected respiratory specimens (846 BAL and 836 sputum specimens) evaluated with the PN panel were also tested by quantitative reference culture and molecular methods for comparison. The PN panel showed a sensitivity of 100% for 15/22 etiologic targets using BAL specimens and for 10/24 using sputum specimens. All other targets had sensitivities of ≥75% or were unable to be calculated due to low prevalence in the study population. Specificity for all targets was ≥87.2%, with many false-positive results compared to culture that were confirmed by alternative molecular methods. Appropriate adoption of this test could provide actionable diagnostic information that is anticipated to impact patient care and antimicrobial stewardship decisions.

Predictors of prolonged length of hospital stay and in-hospital mortality among adult patients admitted at the surgical ward of Jimma University medical center, Ethiopia: prospective observational study

Background

Data regarding prolonged length of hospital stay (PLOS) and in-hospital mortality are paramount to evaluate efficiency and quality of surgical care as well as for rational resource utilization, allocation, and administration. Thus, PLOS and in-hospital mortality have been used as a surrogate indicator of satisfactory treatment outcome and efficient utilization of resources for a given health institution. However, there was a scarcity of data regarding these issues in Ethiopia. Therefore, this study aimed to assess treatment outcome, length of hospital stay, in-hospital mortality, and their determinants.

Methods

Health facility-based prospective observational study was used for three consecutive months among adult patients hospitalized for the surgical case. Socio-demographic, clinical history, medication history, in-hospital complications, and overall treatment outcomes were collected from the medical charts' of the patients, using a checklist from the day of admission to discharge. PLOS is defined as hospital stay > 75th percentile (≥33 days for the current study). To identify predictor variables for both PLOS and in-hospital mortality, multivariate logistic regression was performed at p-value < 0.05 using SPSS version 20. Written informed consent was sought and secured.

Results

Of 269 study participants, 91.8% were improved and discharged. PLOS was recorded in 25.3%; at least 33 days of hospital stay. Overall in-hospital mortality was 4.8%; which is equal to an incidence rate of 0.00193 per person-days, 5.2% in-hospital sepsis, and 2.6% of Hospital-acquired pneumonia (HAP), during their hospital stay. After adjusting for other factors; female gender (p = 0.003), emergency admission (p = 0.015), presence of Poly-pharmacy (p = 0.017), and presence of sepsis (p = 0.006) were found to be independent predictors for in-hospital mortality. On top of this, female gender (p = 0.026), patients who was paid by government (p = 0.007), burn-related surgery (p = 0.049), presence of cancer (p = 0.027), > 2 antibiotic exposure (p < 0.0001), and waiting for surgery for > 7 days (p < 0.0001) were independent predictors for PLOS.

Conclusion

In-hospital mortality rate was almost comparable to reports from developing countries, though it was higher than the developed countries. However, the length of hospital stay was extremely higher than that of reports from other parts of the world. Besides, different socio-demographic, health facility's and patients' clinical conditions (baseline and in-hospital complications) were identified as independent predictors for both in-hospital mortality and PLOS. Therefore, the clinician and stakeholders have to emphasize to avoid the modifiable factors to reduce in-hospital mortality and PLOS in the study area; to improve the quality of surgical care.

The Evaluation of Clinical Classifications Software Using the National Inpatient Sample Database

The Clinical Classifications Software (CCS), by grouping International Classification of Diseases (ICD), provides the capacity to better account for clinical conditions for payers, policy makers, and researchers to analyze outcomes, costs, and utilization. There is a critical need for additional research on application of CCS categories to validate the clinical condition representation and to prevent gaps in research. This study compared the event frequency and ICD codes of CCS categories with significant changes from the first three quarters of 2015 to 2016 using National Inpatient Sample data. A total of 63 of the 285 diagnostics CCS were identified with greater than 20% change, of which 32 had increased and 31 decreased over time. Due to the complexity associated with the transition from ICD-9 to ICD-10, more studies are needed to identify the reason for the changes to improve CCS use for ICD-10 and its comparability with ICD-9 based data.

Sepsis in the Context of Nonventilator Hospital-Acquired Pneumonia

BACKGROUND

Sepsis is a leading cause of mortality among hospitalized patients and is the most expensive condition affecting the US health care system. Pneumonia is associated with about half of sepsis cases, yet limited research has described the incidence of sepsis in the context of nonventilator hospital-acquired pneumonia (NV-HAP). Persons with NV-HAP who are at risk for sepsis must be identified so that interventions to reduce the burden of NV-HAP and improve outcomes among patients with sepsis can be designed.

OBJECTIVE

To determine the proportion of persons with NV-HAP in whom sepsis develops and to describe the demographic and clinical characteristics of persons with NV-HAP in whom sepsis develops.

METHODS

In this retrospective, population-based study, data were extracted from the National Inpatient Sample from the 2012 Healthcare Cost and Utilization Project dataset. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify adult patients at least 18 years of age who had a stay of at least 48 hours, had no documented diagnosis of ventilator-associated pneumonia, and had secondary diagnoses of both NV-HAP and sepsis, neither of which was present on admission.

RESULTS

In the 2012 calendar year, 119 075 adults had NV-HAP develop; sepsis developed in 36.3% of these cases. Male and black patients were overrepresented in the sample, and patients had a mean of 7 comorbid conditions (SD, 3.3).

CONCLUSIONS

Sepsis in the context of NV-HAP is a key concern. Additional research is needed to identify factors associated with the development of sepsis among patients with NV-HAP.

Development and validation of a prognostic nomogram for predicting post-operative pulmonary infection in gastric cancer patients following radical gastrectomy

The aim of this retrospective study was to develop and validate a nomogram for predicting the risk of post-operative pulmonary infection (POI) in gastric cancer (GC) patients following radical gastrectomy. 2469 GC patients who underwent radical gastrectomy were enrolled, and randomly divided into the development and validation groups. The nomogram was constructed based on prognostic factors using logistic regression analysis, and was internally and crossly validated by bootstrap resampling and the validation dataset, respectively. Concordance index (C-index) value and calibration curve were used for estimating the predictive accuracy and discriminatory capability. Sixty-five (2.63%) patients developed POI within 30 days following surgery, with higher rates of requiring intensive care and longer post-operative hospital stays. The nomogram showed that open operation, chronic obstructive pulmonary disease (COPD), intra-operative blood transfusion, tumor located at upper and/or middle third and longer operation time (≥4 h) in a descending order were significant contributors to POI risk. The C-index value for the model was 0.756 (95% CI: 0.675−0.837), and calibration curves showed good agreement between nomogram predictions and actual observations. In conclusion, a nomogram based on these factors could accurately and simply provide a picture tool to predict the incidence of POI in GC patients undergoing radical gastrectomy.

Sustaining Quality Improvement: Long-Term Reduction of Nonventilator Hospital-Acquired Pneumonia

BACKGROUND

Hospital-acquired pneumonia is now the number one hospital-acquired infection. Hospitals have addressed ventilator-associated pneumonia; however, patients not on a ventilator acquire more pneumonia with significant associated mortality rates.

LOCAL PROBLEM

In our hospital, non-ventilator-associated pneumonia was occurring on all types of units.

METHODS

The Influencer Model was used to reduce nonventilator hospital-acquired pneumonia rates. Statistical process control R and X-bar-charts were monitored monthly.

INTERVENTIONS

After a gap analysis, an interdisciplinary team implemented enhanced oral care before surgery and on the units, changed tube management, and monitored stress ulcer medication.

RESULTS

We achieved a statistically significantly reduction (P = .01) in pneumonia rates that have been sustained over 4 years.

CONCLUSIONS

Sustaining change requires (a) a continued team-based, collaborative approach, (b) ongoing stakeholder and executive leadership engagement, (c) monitoring that easy-to-use protocols and required equipment remain in place, and (d) embedded analytics to monitor results over a prolonged period.

Risk calculator for predicting postoperative pneumonia after gastroenterological surgery based on a national Japanese database

BACKGROUND

The aim of the present study was to develop a risk calculator predictive of postoperative pneumonia in patients undergoing gastroenterological surgery.

METHODS

We analyzed data from 382 124 patients undergoing eight main gastroenterological surgeries between 2011 and 2013 using the National Clinical Database in Japan. A risk model was developed using multivariate logistic regression analysis with patient data from 2011 to 2012 (n = 247 604) and validated using data from 2013 (n = 134 520).

RESULTS

Pneumonia was observed in 11 105 patients (2.9%). After the input of significant primary disease and surgical procedures, 18 patient characteristics including gender, chronic obstructive pulmonary disease, sepsis, and need for any assistance in the activities of daily living, six laboratory parameters, and two intraoperative factors were used for risk calculation. Area under the receiver-operating characteristic curve was 0.822 (95% confidence interval, 0.817-0.826) in the derivation group and 0.826 (0.819-0.832) in the validation group.

CONCLUSION

The risk calculator accurately predicted the occurrence of pneumonia following gastroenterological surgery.

Time in Collars and Collar-Related Complications in Older Patients

BACKGROUND

Cervical spine immobilization, including cervical collars, has been recommended in most trauma guidelines. However, cervical spine immobilization can be associated with harm, and an increasing body of evidence has demonstrated associated complications. We hypothesized that older trauma patients placed in cervical collars for >24 hours were at greater risk of developing collar-related complications compared with those placed in cervical collars for ≤24 hours.

METHODS

We conducted a retrospective cohort study of injured patients without a fracture of the cervical vertebrae, aged ≥65 years, who had been placed in a cervical collar during the period from January 1, 2015 to December 31, 2015. The primary outcome was the composite of the in-hospital development of nosocomial pneumonia and collar-related pressure ulcers.

RESULTS

A total of 1154 patients had been treated with cervical collars during the study period, and 61 (5.1%) had developed collar-related complications. Male sex, a lower initial Glasgow Coma Scale score, a history of congestive heart failure, a history of chronic obstructive pulmonary disease or asthma, operative management, and longer hospital and intensive care unit lengths of stay demonstrated a univariable association with collar-related complications (P < 0.10), in addition to a duration in the collar for >24 hours. An independent association was found between collar duration >24 hours and the outcome of interest (adjusted odds ratio, 2.50; 95% confidence interval, 1.16-5.39; P = 0.02).

CONCLUSIONS

Among older patients without a cervical vertebral fracture, duration of cervical collar use for >24 hours was associated with the development of collar-related complications. We recommend attention to early collar clearance for older trauma patients.

Development and validation of a nomogram predicting postoperative pneumonia after major abdominal surgery

PURPOSE

Postoperative pneumonia (POP) is a common complication that can adversely affect the outcomes after surgery. This study aimed to devise and validate a model for stratifying the probability of POP in patients undergoing abdominal surgery.

METHODS

We included 1050 patients who underwent major abdominal surgery between 2012 and 2013. A nomogram was devised by evaluating the predictive factors for POP.

RESULTS

Of the 1050 patients, 56 (5.3%) developed POP. Multivariable logistic regression analysis revealed that the independent predictive factors for POP were age, male sex, history of cerebrovascular disease, Brinkman Index (BI) ≥ 900, and upper midline incision. A nomogram was devised by employing these five significant predictive factors. The prediction model showed a relatively good discrimination performance, with a concordance index of 0.77.

CONCLUSIONS

A nomogram based on age, male sex, history of cerebrovascular disease, BI ≥ 900, and upper midline incision may be useful for identifying patients with a high probability of developing POP after major abdominal surgery.

Processing of Electronic Medical Records for Health Services Research in an Academic Medical Center: Methods and Validation

Background

Electronic medical records (EMRs) contain a wealth of information that can support data-driven decision making in health care policy design and service planning. Although research using EMRs has become increasingly prevalent, challenges such as coding inconsistency, data validity, and lack of suitable measures in important domains still hinder the progress.

Objective

The objective of this study was to design a structured way to process records in administrative EMR systems for health services research and assess validity in selected areas.

Methods

On the basis of a local hospital EMR system in Singapore, we developed a structured framework for EMR data processing, including standardization and phenotyping of diagnosis codes, construction of cohort with multilevel views, and generation of variables and proxy measures to supplement primary data. Disease complexity was estimated by Charlson Comorbidity Index (CCI) and Polypharmacy Score (PPS), whereas socioeconomic status (SES) was estimated by housing type. Validity of modified diagnosis codes and derived measures were investigated.

Results

Visit-level (N=7,778,761) and patient-level records (n=549,109) were generated. The International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) codes were standardized to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) with a mapping rate of 87.1%. In all, 97.4% of the ICD-9-CM codes were phenotyped successfully using Clinical Classification Software by Agency for Healthcare Research and Quality. Diagnosis codes that underwent modification (truncation or zero addition) in standardization and phenotyping procedures had the modification validated by physicians, with validity rates of more than 90%. Disease complexity measures (CCI and PPS) and SES were found to be valid and robust after a correlation analysis and a multivariate regression analysis. CCI and PPS were correlated with each other and positively correlated with health care utilization measures. Larger housing type was associated with lower government subsidies received, suggesting association with higher SES. Profile of constructed cohorts showed differences in disease prevalence, disease complexity, and health care utilization in those aged above 65 years and those aged 65 years or younger.

Conclusions

The framework proposed in this study would be useful for other researchers working with EMR data for health services research. Further analyses would be needed to better understand differences observed in the cohorts.

ICEAGE (Incidence of Complications following Emergency Abdominal surgery: Get Exercising): study protocol of a pragmatic, multicentre, randomised controlled trial testing physiotherapy for the prevention of complications and improved physical recovery after emergency abdominal surgery

Background

Postoperative complications and delayed physical recovery are significant problems following emergency abdominal surgery. Physiotherapy aims to aid recovery and prevent complications in the acute phase after surgery and is commonplace in most first-world hospitals. Despite ubiquitous service provision, no well-designed, adequately powered, parallel-group, randomised controlled trial has investigated the effect of physiotherapy on the incidence of respiratory complications, paralytic ileus, rate of physical recovery, ongoing need for formal sub-acute rehabilitation, hospital length of stay, health-related quality of life, and mortality following emergency abdominal surgery. We hypothesise that an enhanced physiotherapy care package of additional education, breathing exercises, and early rehabilitation prevents postoperative complications and improves physical recovery following emergency abdominal surgery compared to standard care alone.

Methods

The Incidence of Complications following Emergency Abdominal surgery: Get Exercising (ICEAGE) trial is a pragmatic, investigator-initiated, multicentre, patient- and assessor-blinded, parallel-group, active-placebo controlled randomised trial, powered for superiority. ICEAGE will compare standard care physiotherapy to an enhanced physiotherapy care package in 288 participants admitted for emergency abdominal surgery at three Australian hospitals. Participants will be randomised using concealed allocation to receive either standard care physiotherapy (education, single session of coached breathing exercises, and daily early ambulation for 15 min) or an enhanced physiotherapy care package (education, twice daily coached breathing exercises for a minimum 2 days, and 30 min of daily supervised early rehabilitation for minimum five postoperative days). The primary outcome is a respiratory complication within the first 14 postoperative hospital days assessed daily with standardised diagnostic criteria. Secondary outcomes include referral for sub-acute rehabilitation services, discharge destination, paralytic ileus, hospital length of stay and costs, intensive care unit utilisation, 90-day patient-reported complications and health-related quality of life and physical capacity, and mortality at 30 days and at 1 year following surgery.

Discussion

The morbidity, mortality, and fiscal burdens following emergency abdominal surgery are some of the worst within surgery. Physiotherapy may be an effective, low-cost, minimal harm intervention to improve outcomes and reduce hospital utilisation following this surgery type. ICEAGE will test the benefits of this commonly provided intervention within a methodologically robust, multicentre, double-blinded, active-placebo controlled randomised trial.

Trial registration

ACTRN 12615000318583. Registered 8 April 2015

Electronic supplementary material

The online version of this article (10.1186/s13017-018-0189-y) contains supplementary material, which is available to authorized users.

The risk of hospitalization for respiratory tract infection (RTI) in children who are treated with high-dose IVIG in Kawasaki Disease: a nationwide population-based matched cohort study

Background

Kawasaki disease (KD) is an immune-mediated systemic vasculitis, and infection plays an important role in the pathophysiology of KD. The susceptibility to infectious disease in patients with KD remains largely unclear. This study aimed to investigate the risk of respiratory tract infection (RTI)-related hospitalizations in children with KD.

Methods

Data from the Taiwanese National Health Insurance Research Database was analyzed. We excluded patients with history of congenital abnormality, allergic diseases, or hospitalization history. Children with KD were selected as KD group and age- and sex-matched non-KD patients were selected as control group with 1:4 ratio. Both cohorts were tracked for one year to investigate the incidences of RTI-related hospitalizations. Cox regression hazard model was used to adjust for confounding factors and calculate the adjusted hazard ratio (aHR).

Results

Between January 1996 and December 2012, 4,973 patients with KD were identified as the KD group and 19,683 patients were enrolled as the control group. An obviously reduced risk of RTI-related hospitalizations was observed in KD patients (aHR: 0.75, 95% CI [0.66-0.85]). The decreased risk persisted through the first six-months follow-up period with a peak protection in 3-6 months (aHR: 0.49, 95% CI [0.37-0.64]).

Conclusions

KD patients had approximately half reduction of risk for RTI-related hospitalizations. The protective effects persisted for at least six months. Further studies are warranted to elucidate the entire mechanism and investigate the influences of intravenous immunoglobulin.

The epidemiology of nonventilator hospital-acquired pneumonia in the United States

BACKGROUND

Nonventilator hospital-acquired pneumonia (NV-HAP) is among the most common hospital-acquired infections. The purpose of our study was to quantify the incidence and influence of NV-HAP in the United States using a national dataset.

METHODS

The 2012 US National Inpatient Sample dataset was used to compare an NV-HAP group to 4 additional group cohorts: pneumonia on admission, general hospital admissions, matched on mortality and disease severity, and ventilator-associated pneumonia (VAP). The main outcome was NV-HAP incidence. The secondary outcome was to compare hospital length of stay, total hospital charges, and mortality between the NV-HAP group and the 4 additional group cohorts.

RESULTS

The overall incidence of NV-HAP was 1.6%, which represents a rate of 3.63 per 1,000 patient-days. NV-HAP was associated with increased total hospital charges, a longer hospital length of stay, and greater likelihood of death in comparison to all groups except patients with VAP.

CONCLUSION

NV-HAP is an underappreciated and serious patient safety issue, resulting in significant increases in cost, length of stay, and mortality. Efforts toward prevention of NV-HAP should be raised to the same level of concern as VAP prevention.

Oropharyngeal Microbiota in Frail Older Patients Unaffected by Time in Hospital

Respiratory tract infections are the commonest nosocomial infections, and occur predominantly in frailer, older patients with multiple comorbidities. The oropharyngeal microbiota is the major reservoir of infection. This study explored the relative contributions of time in hospital and patient demographics to the community structure of the oropharyngeal microbiota in older patients with lower limb fracture. We collected 167 throat swabs from 53 patients (mean age 83) over 14 days after hospitalization, and analyzed these using 16S rRNA gene sequencing. We calculated frailty/comorbidity indices, undertook dental examinations and collected data on respiratory tract infections. We analyzed microbial community composition using correspondence (CA) and canonical correspondence analysis. Ten patients were treated for respiratory tract infection. Microbial community structure was related to frailty, number of teeth and comorbidity on admission, with comorbidity exerting the largest effect. Time in hospital neither significantly changed alpha (t = −0.910, p = 0.365) nor beta diversity (CA1 t = 0.022, p = 0.982; CA2 t = −0.513, p = 0.609) of microbial communities in patient samples. Incidence of respiratory pathogens were not associated with time in hospital (t = −0.207, p = 0.837), nor with alpha diversity of the oral microbiota (t = −1.599, p = 0.113). Patient characteristics at admission, rather than time in hospital, influenced the community structure of the oral microbiota.