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Wilkinson H, McDonald J, McCarthy HS, Perry J, Wright K, Hulme C, Cool P. Using nanopore sequencing to identify bacterial infection in joint replacements: a preliminary study. Brief Funct Genomics 2024:elae008. [PMID: 38555497 DOI: 10.1093/bfgp/elae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/02/2024] Open
Abstract
This project investigates if third-generation genomic sequencing can be used to identify the species of bacteria causing prosthetic joint infections (PJIs) at the time of revision surgery. Samples of prosthetic fluid were taken during revision surgery from patients with known PJIs. Samples from revision surgeries from non-infected patients acted as negative controls. Genomic sequencing was performed using the MinION device and the rapid sequencing kit from Oxford Nanopore Technologies. Bioinformatic analysis pipelines to identify bacteria included Basic Local Alignment Search Tool, Kraken2 and MinION Detection Software, and the results were compared with standard of care microbiological cultures. Furthermore, there was an attempt to predict antibiotic resistance using computational tools including ResFinder, AMRFinderPlus and Comprehensive Antibiotic Resistance Database. Bacteria identified using microbiological cultures were successfully identified using bioinformatic analysis pipelines. Nanopore sequencing and genomic classification could be completed in the time it takes to perform joint revision surgery (2-3 h). Genomic sequencing in this study was not able to predict antibiotic resistance in this time frame, this is thought to be due to a short-read length and low read depth. It can be concluded that genomic sequencing can be useful to identify bacterial species in infected joint replacements. However, further work is required to investigate if it can be used to predict antibiotic resistance within clinically relevant timeframes.
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Affiliation(s)
- Hollie Wilkinson
- Centre for Regenerative Medicine, School of Pharmacy and Bioengineering, Keele University, Keele, UK
- Oswestry Keele Orthopaedic Research Group (OsKOR), The Robert Jones and Agnes Hunt Orthopaedic Hospital Foundation Trust, Oswestry, UK
| | | | - Helen S McCarthy
- Centre for Regenerative Medicine, School of Pharmacy and Bioengineering, Keele University, Keele, UK
- Oswestry Keele Orthopaedic Research Group (OsKOR), The Robert Jones and Agnes Hunt Orthopaedic Hospital Foundation Trust, Oswestry, UK
| | - Jade Perry
- Centre for Regenerative Medicine, School of Pharmacy and Bioengineering, Keele University, Keele, UK
- Oswestry Keele Orthopaedic Research Group (OsKOR), The Robert Jones and Agnes Hunt Orthopaedic Hospital Foundation Trust, Oswestry, UK
| | - Karina Wright
- Centre for Regenerative Medicine, School of Pharmacy and Bioengineering, Keele University, Keele, UK
- Oswestry Keele Orthopaedic Research Group (OsKOR), The Robert Jones and Agnes Hunt Orthopaedic Hospital Foundation Trust, Oswestry, UK
| | - Charlotte Hulme
- Centre for Regenerative Medicine, School of Pharmacy and Bioengineering, Keele University, Keele, UK
- Oswestry Keele Orthopaedic Research Group (OsKOR), The Robert Jones and Agnes Hunt Orthopaedic Hospital Foundation Trust, Oswestry, UK
- School of Medicine, Keele University, Keele, UK
| | - Paul Cool
- Oswestry Keele Orthopaedic Research Group (OsKOR), The Robert Jones and Agnes Hunt Orthopaedic Hospital Foundation Trust, Oswestry, UK
- School of Medicine, Keele University, Keele, UK
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Satheeskaran M, Hussan A, Anto A, de Preux L. Cost-effectiveness analysis of antibiotic prophylaxis versus no antibiotic prophylaxis for acute cholecystectomy. BMJ Open Gastroenterol 2023; 10:e001162. [PMID: 37562856 PMCID: PMC10423775 DOI: 10.1136/bmjgast-2023-001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/22/2023] [Indexed: 08/12/2023] Open
Abstract
OBJECTIVE For acute cholecystitis, the treatment of choice is laparoscopic cholecystectomy. In mild-to-moderate cases, the use of antibiotic prophylaxis for the prevention of postoperative infectious complications (POICs) lacks evidence regarding its cost-effectiveness when compared with no prophylaxis. In the context of rising antimicrobial resistance, there is a clear rationale for a cost-effectiveness analysis (CEA) to determine the most efficient use of National Health Service resources and antibiotic routine usage. DESIGN 16 of 226 patients (7.1%) in the single-dose prophylaxis group and 29 of 231 (12.6%) in the non-prophylaxis group developed POICs. A CEA was carried out using health outcome data from thePerioperative antibiotic prophylaxis in the treatment of acute cholecystitis (PEANUTS II) multicentre, randomised, open-label, non-inferiority, clinical trial. Costs were measured in monetary units using pound sterling, and effectiveness expressed as POICs avoided within the first 30 days after cholecystectomy. RESULTS This CEA produced an incremental cost-effectiveness ratio of -£792.70. This suggests a modest cost-effectiveness of antibiotic prophylaxis being marginally less costly and more effective than no prophylaxis. Three sensitivity analyses were executed considering full adherence to the antibiotic, POICs with increased complexity and break-point analysis suggesting caution in the recommendation of systematic use of antibiotic prophylaxis for the prevention of POICs. CONCLUSION The results of this CEA point to greater consensus in UK-based guidelines surrounding the provision of antibiotic prophylaxis for mild-to-moderate cases of acute cholecystitis.
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Affiliation(s)
- Maya Satheeskaran
- Imperial College Business School, Imperial College London, London, UK
| | - Aminah Hussan
- Imperial College Business School, Imperial College London, London, UK
| | - Ailin Anto
- Imperial College Business School, Imperial College London, London, UK
| | - Laure de Preux
- Imperial College Business School, Imperial College London, London, UK
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Dunbar C, Santorelli JE, Marshall WA, Haines LN, Box K, Lee JG, Strait E, Costantini TW, Smith AM, Doucet JJ, Berndtson AE. Cross-Border Antibiotic Resistance Patterns in Burn Patients. Surg Infect (Larchmt) 2023; 24:327-334. [PMID: 37036781 DOI: 10.1089/sur.2022.313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023] Open
Abstract
Background: Antimicrobial resistance (AMR) is a growing problem worldwide, with differences in regional resistance patterns partially driven by local variance in antibiotic stewardship. Trauma patients transferring from Mexico have more AMR than those injured in the United States; we hypothesized a similar pattern would be present for burn patients. Patients and Methods: The registry of an American Burn Association (ABA)-verified burn center was queried for all admissions for burn injury January 2015 through December 2019 with hospital length-of-stay (LOS) longer than seven days. Patients were divided into two groups based upon burn location: United States (USA) or Mexico (MEX). All bacterial infections were analyzed. Results: A total of 73 MEX and 826 USA patients were included. Patients had a similar mean age (40.4 years MEX vs. 42.2 USA) and gender distribution (69.6% male vs. 64.4%). The MEX patients had larger median percent total body surface area burned (%TBSA; 11.1% vs. 4.3%; p ≤ 0.001) and longer hospital LOS (18.0 vs. 13.0 days; p = 0.028). The MEX patients more often had respiratory infections (16.4% vs. 7.4%; p = 0.046), whereas rates of other infections were similar. The MEX patients had higher rates of any resistant organism (47.2% of organisms MEX vs. 28.1% USA; p = 0.013), and were more likely to have resistant infections on univariable analysis; however, on multivariable analysis country of burn was no longer significant. Conclusions: Antimicrobial resistance is more common in burn patients initially burned in Mexico than those burned in the United States, but location was not a predictor of resistance compared to other traditional burn-related factors. Continuing to monitor for AMR regardless of country of burn remains critical.
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Affiliation(s)
- Chance Dunbar
- School of Medicine, UC San Diego, San Diego, California, USA
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - William A Marshall
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Laura N Haines
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Kevin Box
- Department of Pharmacology, UC San Diego, San Diego, California, USA
| | - Jeanne G Lee
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Eli Strait
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Alan M Smith
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, UC San Diego, San Diego, California, USA
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Forrester JD, Bekele A, Stefan AM, Tshokey T, Berndtson AE, Beyene RT, Chou J, Sawyer RG, Valenzuela JY, Rickard J. Components of Existing National Surgical Site Infection Surveillance Programs Based on a Case Series of Low- and Middle-Income Countries: Building Blocks for Success and Opportunities for Improvement. Surg Infect (Larchmt) 2023; 24:112-118. [PMID: 36629853 DOI: 10.1089/sur.2022.331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: Surgical site infection (SSI) surveillance programs are recommended to be included in national infection prevention and control (IPC) programs, yet few exist in low- or middle-income countries (LMICs). Our goal was to identify components of surveillance in existing programs that could be replicated elsewhere and note opportunities for improvement to build awareness for other countries in the process of developing their own national surgical site infection surveillance (nSSIS) programs. Methods: We administered a survey built upon the U.S. Centers for Disease Control and Prevention's framework for surveillance system evaluation to systematically deconstruct logistical infrastructure of existing nSSIS programs in LMICs. Qualitative analyses of survey responses by thematic elements were used to identify successful surveillance system components and recognize opportunities for improvement. Results: Three respondents representing countries in Europe and Central Asia, sub-Saharan Africa, and South Asia designated as upper middle-income, lower middle-income, and low-income responded. Notable strengths described by respondents included use of local paper documentation, staggered data entry, and limited data entry fields. Opportunities for improvement included outpatient data capture, broader coverage of healthcare centers within a nation, improved audit processes, defining the denominator of number of surgical procedures, and presence of an easily accessible, free SSI surveillance training program for healthcare workers. Conclusions: Outpatient post-surgery surveillance, national coverage of healthcare facilities, and training on how to take local SSI surveillance data and integrate it within a broader nSSIS program at the national level remain areas of opportunities for countries looking to implement a nSSIS program.
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Affiliation(s)
- Joseph D Forrester
- Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Abebe Bekele
- School of Medicine, University of Global Health Equity, Kigali, Rwanda
| | | | - Tshokey Tshokey
- Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Allison E Berndtson
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California, San Diego, San Diego, California, USA
| | - Robel T Beyene
- Division of Acute Care Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Jesse Chou
- Department of Plastic and Maxillofacial Surgery, University of Virginia, Charlottesville, Virgina, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Julie Y Valenzuela
- Department of Surgery, Jamaica Hospital Medical Center, New York, New York, USA
| | - Jennifer Rickard
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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Symeonidou E, Gkoutziotis I, Moulazimi A, Lagopoulos V, Kamparoudis A. Necrotizing Fasciitis of the Breast: A Case Series and Review of the Literature. Surg Infect (Larchmt) 2023; 24:19-26. [PMID: 36580649 DOI: 10.1089/sur.2022.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Abstract Background: Primary necrotizing fasciitis of the breast is a rare clinical condition and therefore a challenge for the clinical doctor. Its severity is associated with high morbidity and mortality. Patients and Methods: In the current article we present three cases that we treated in our surgical department with a combination of empirical antibiotic treatment, complete surgical debridement in stages, and negative pressure wound therapy. Conclusions: It appears that prompt diagnosis and surgical intervention are key for the successful management of these cases. The recognition of early clinical signs as well as risk factors are issues of great importance. A high index of suspicion is required for the early diagnosis and treatment, aiming to the best outcome for the patient.
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Affiliation(s)
- Elissavet Symeonidou
- 5th Department of Surgery, Ippokratio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Gkoutziotis
- 5th Department of Surgery, Ippokratio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasia Moulazimi
- 5th Department of Surgery, Ippokratio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasileios Lagopoulos
- 5th Department of Surgery, Ippokratio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Kamparoudis
- 5th Department of Surgery, Ippokratio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Devlin CA, Smeltzer SC, Yost J. Patient Smoking Status and Postoperative Outcomes: An Integrative Literature Review of Studies Using the ACS NSQIP Data Set. AORN J 2023; 117:109-120. [PMID: 36705450 DOI: 10.1002/aorn.13864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 05/07/2022] [Accepted: 06/27/2022] [Indexed: 01/28/2023]
Abstract
Tobacco use is associated with poor surgical outcomes and is the leading cause of preventable morbidity and mortality in the United States. Because of the risk for postoperative complications, researchers continue to examine the association between surgical patients' smoking status and adverse outcomes. This quantitative integrative review synthesizes evidence on the relationship between smoking status and postoperative outcomes according to information in the American College of Surgeons National Surgical Quality Improvement Program data set. The included studies involved 10 procedures and the evaluated outcomes comprise surgical complications (eg, surgical site infection), medical complications (eg, sepsis), and transitions in care (eg, discharge destination). The review results are mixed and are not generalizable because only two studies specified smoking status as a primary variable of interest. To develop policies for perioperative patient smoking cessation, perioperative nurses require additional research results on the relationships between smoking status and standardized variables.
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Terzian WTH, Nunn AM, Call EB, Bliss SE, Swinarska JT, Rigdon J, Avery MD, Hoth JJ, Miller PR. Duration of Antibiotic Therapy in Necrotizing Soft Tissue Infections: Shorter is Safe. Surg Infect (Larchmt) 2022; 23:430-435. [PMID: 35451883 DOI: 10.1089/sur.2022.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Early debridement improves outcome in necrotizing soft tissue infection (NSTI), but there is no consensus on duration of antimicrobial therapy. We recently changed practice to discontinue antibiotic agents early with a goal of 48 hours after adequate source control. We hypothesized that discontinuing antibiotic agents after a short course is safe in the treatment of NSTI. Patients and Methods: This was a prospective study of patients with NSTI comparing short duration of antibiotic agents to a control population after a change in practice. In 2018 we began discontinuing antibiotic agents within 48 hours of source control (absence of cellulitis and no evidence of active infection). Previously, antibiotic duration was at the discretion of the attending surgeon (generally 7-10 days). Patients were excluded from analysis if they were initially debrided at a referring facility, immune compromised, or died prior to source control. Patient characteristics and outcomes were evaluated. The primary outcome was treatment failure requiring antibiotic agents to be restarted with or without further debridement of infected tissue. Secondary outcomes included the duration of antibiotic therapy after source control. Results: We evaluated 151 patients; 119 admitted between January 1, 2011 and January 31, 2018 (PRE) and 32 admitted after January 31, 2018 (POST). Patients were not statistically different regarding characteristics, admission physiologic variables, and comorbidities. The median duration of antibiotic agents after source control in the PRE group was 180.3 hours (interquartile range [IQR], 100.7-318.8) versus 48 hours (IQR, 32.3-100.8) in the POST group (p < 0.01). Patients in each group were treated as described above, and treatment failure occurred in seven (5.9%) PRE patients and two (6.3%) POST (99.3% post hoc power at non-inferiority limit 20%, significance p < 0.05). Thirty-day all-cause mortality was not different between groups (6.7% vs. 6.3%; p = 0.94). Conclusions: Short-duration (48 hours) antibiotic agents after NSTI source control is as safe and effective as a longer course.
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Affiliation(s)
- W T Hillman Terzian
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andrew M Nunn
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Erika B Call
- Novant Health Acute Care Surgery, Winston-Salem, North Carolina, USA
| | - Sara E Bliss
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Joanna T Swinarska
- Department of Surgery, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Joseph Rigdon
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Martin D Avery
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - J Jason Hoth
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Preston R Miller
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Delaplain PT, Kaafarani HMA, Benedict LAO, Guidry CA, Kim D, Loor MM, Machado-Aranda D, Mele TS, Mendoza AE, Morris-Stiff G, Rattan R, Upperman JS, Barie PS, Schubl SD. Different Surgeon, Different Duration: Lack of Consensus on the Appropriate Duration of Antimicrobial Prophylaxis and Therapy in Surgical Practice. Surg Infect (Larchmt) 2022; 23:232-247. [PMID: 35196154 DOI: 10.1089/sur.2021.323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Background: The principles of antimicrobial stewardship promote the appropriate prescribing of agents with respect to efficacy, safety, duration, and cost. Antibiotic resistance often results from inappropriate use (e.g., indication, selection, duration). We evaluated practice variability in duration of antimicrobials in surgical infection treatment (Rx) or prophylaxis (Px). Hypothesis: There is lack of consensus regarding the duration of antibiotic Px and Rx for many common indications. Methods: A survey was distributed to the Surgical Infection Society (SIS) regarding the use of antimicrobial agents for a variety of scenarios. Standard descriptive statistics were used to compare survey responses. Heterogeneity among question responses were compared using the Shannon Index, expressed as natural units (nats). Results: Sixty-three SIS members responded, most of whom (67%) have held a leadership position within the SIS or contributed as an annual meeting moderator or discussant; 76% have been in practice for more than five years. Regarding peri-operative Px, more than 80% agreed that a single dose is adequate for most indications, with the exceptions of gangrenous cholecystitis (40% single dose, 38% pre-operative +24 hours) and inguinal hernia repair requiring a bowel resection (70% single dose). There was more variability regarding the use of antibiotic Px for various bedside procedures with respondents split between none needed (range, 27%-66%) versus a single dose (range, 31%-67%). Opinions regarding the duration of antimicrobial Rx for hospitalized patients who have undergone a source control operation or procedure varied widely based on indication. Only two of 20 indications achieved more than 60% consensus despite available class 1 evidence: seven days for ventilator-associated pneumonia (77%), and four plus one days for perforated appendicitis (62%). Conclusions: Except for peri-operative antibiotic Px, there is little consensus regarding antibiotic duration among surgical infection experts, despite class 1 evidence and several available guidelines. This highlights the need for further high-level research and better dissemination of guidelines.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, University of California-Irvine, Orange, California, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - L Andrew O Benedict
- Critical Care and Acute Care Surgery, St. Luke's Hospital, Kansas City, Missouri, USA
| | - Christopher A Guidry
- Trauma/Critical & Acute Care Surgery Division, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Dennis Kim
- Division of Trauma/Acute Care Surgery/Surgical Critical Care, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Michele M Loor
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David Machado-Aranda
- Department of Surgery, Michigan Medicine and Veteran's Affairs Healthcare System, Ann Arbor, Michigan, USA
| | - Tina S Mele
- Divisions of General Surgery and Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - April E Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gareth Morris-Stiff
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio. USA
| | - Rishi Rattan
- Department of Surgery, University of California-Irvine, Orange, California, USA
| | - Jeffrey S Upperman
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California-Irvine, Orange, California, USA
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Zucker I, Bouz A, Castro G, Rodriguez de la Vega P, Barengo NC. Smoking as a Risk Factor for Surgical Site Complications in Implant-Based Breast Surgery. Cureus 2021; 13:e18876. [PMID: 34804725 PMCID: PMC8599112 DOI: 10.7759/cureus.18876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 11/05/2022] Open
Abstract
Background Smoking is a cause of many postoperative complications, including delayed wound healing, tissue necrosis, and reconstructive flap loss. However, there is a paucity of evidence-based guidelines for smoking cessation in patients undergoing implant-based breast surgery. Objective The objective of this study was to determine if smoking is associated with wound dehiscence or superficial/deep surgical site infection (SSI) in women undergoing implant-based breast surgery. Methods Using theAmerican College of Surgeons National Surgical Quality Improvement Program, data was obtained of U.S. adult females (n=10,077) between the ages of 18 and 70 who underwent insertion of a breast prosthesis from 2014 to 2016. The patient's preoperative smoking status, demographics, and comorbidities were analyzed to determine association with wound dehiscence, superficial SSI, and deep SSI. Unadjusted and adjusted logistic regression analyses were used to calculate odds ratios (OR) and 95% confidence intervals (95% CI). Results Patients who smoked had a statistically significant higher proportion of wound complications (2.4%) compared to non-smokers (1.3%; p<0.01). Adjusted analysis demonstrated a significantly higher odds of wound complications in smoking patients compared to those who did not smoke (OR 2.0; 95% CI 1.3-3.2). Conclusions Our study suggests that smoking is an independent risk factor for postoperative complications in patients undergoing implant-based breast surgery. These results have significant clinical implications, as increased precautions can be taken in smokers undergoing breast surgery to minimize postoperative wound complications. Future studies may determine the optimal amount of time that patients should abstain from smoking prior to implant-based breast surgery.
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Affiliation(s)
- Isaac Zucker
- Department of Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Antoun Bouz
- Department of Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Grettel Castro
- Department of Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Pura Rodriguez de la Vega
- Department of Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Noel C Barengo
- Department of Public Health, University of Helsinki, Helsinki, FIN
- Department of Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
- Faculty of Medicine, Riga Stradins University, Riga, LVA
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10
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Delaplain PT, Kaafarani HMA, Benedict LAO, Guidry CA, Kim D, Loor MM, Machado-Aranda D, Mele TS, Mendoza AE, Morris-Stiff G, Rattan R, Upperman JS, Barie PS, Schubl SD. Surgical Infections and the Future of Research: Re-Defining the Research Agenda for the Surgical Infection Society. Surg Infect (Larchmt) 2021; 22:1014-1020. [PMID: 34357820 DOI: 10.1089/sur.2021.176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Infections represent a major component of surgical practice. Risk mitigation, seeking eradication and optimal patient outcomes, require a concerted, multifocal effort to understand disease and microbiology, prevent infections, and treat them. The present study was undertaken to re-define the Surgical Infection Society (SIS) research agenda for the next decade. Hypothesis: We utilized the expertise of the SIS membership to identify research questions regarding surgical infections, hypothesizing that consensus among participants could be used to re-define the future research agenda. Methods: Members of the SIS were surveyed using a modified Delphi. The three rounds of the survey were targeted at: question generation; question ranking; and reaching consensus. Each of the 15 questions to emerge was evaluated according to level of consensus, feasibility, and data availability. Results: One hundred twenty-four participants contributed. Initially, 226 questions were generated that were condensed to 35 unique questions for consideration in the subsequent two rounds. The 35 questions encompassed several research themes, with antibiotic prophylaxis (n = 8), prevention of surgical site infections (SSIs; n = 6), and improved diagnostics (n = 5) being most common. Standard deviation of importance scores was inversely proportional to the question rank, indicating greater consensus among higher ranking questions. All 15 questions had a feasibility score of greater than three (five-point Likert scale), and the majority (12/15) had a mean data availability score of less than three. In the final round of the survey, the top three topics for further research surrounded non-antimicrobial treatments, optimal treatment duration for bacteremia, and treatment duration for necrotizing soft tissue infections. Conclusions: Using a modified Delphi process, 15 research questions addressing surgical infections were identified. Such questions can assist the SIS and the SIS Foundation for Research and Education in prioritizing and enabling research efforts, and development of a strategic research plan for the next decade.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Haytham M A Kaafarani
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - L Andrew O Benedict
- Trauma, Critical Care and Acute Care Surgery, St. Luke's Hospital, Kansas City, Missouri, USA
| | - Christopher A Guidry
- Trauma/Critical & Acute Care Surgery Division, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Dennis Kim
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio, USA
| | - Michele M Loor
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David Machado-Aranda
- Department of Surgery, Michigan Medicine and Veteran's Administration Healthcare System, Ann Arbor, Michigan, USA
| | - Tina S Mele
- Divisions of General Surgery and Critical Care, Dept of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - April E Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gareth Morris-Stiff
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio, USA
| | - Rishi Rattan
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, Florida, USA
| | - Jeffrey S Upperman
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Department of Medicine, Weill Cornell Medicine, New York, New York, USA.,Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine, Orange, California, USA
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11
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Bowers JR, Monroy-Nieto J, Gade L, Travis J, Refojo N, Abrantes R, Santander J, French C, Dignani MC, Hevia AI, Roe CC, Lemmer D, Lockhart SR, Chiller T, Litvintseva AP, Clara L, Engelthaler DM. Rhizopus microsporus Infections Associated with Surgical Procedures, Argentina, 2006-2014. Emerg Infect Dis 2021; 26:937-944. [PMID: 32310081 PMCID: PMC7181922 DOI: 10.3201/eid2605.191045] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Rhizopus spp. fungi are ubiquitous in the environment and a rare but substantial cause of infection in immunosuppressed persons and surgery patients. During 2005–2017, an abnormally high number of Rhizopus infections in surgery patients, with no apparent epidemiologic links, were reported in Argentina. To determine the likelihood of a common source of the cluster, we performed whole-genome sequencing on samples collected during 2006–2014. Most isolates were separated by >60 single-nucleotide polymorphisms, and we found no evidence for recombination or nonneutral mutation accumulation; these findings do not support common source or patient-to-patient transmission. Assembled genomes of most isolates were ≈25 Mbp, and multiple isolates had substantially larger assembled genomes (43–51 Mbp), indicative of infections with strain types that underwent genome expansion. Whole-genome sequencing has become an essential tool for studying epidemiology of fungal infections. Less discriminatory techniques may miss true relationships, possibly resulting in inappropriate attribution of point source.
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12
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Gisnarian CJ, Fusco DS, Arciszewski M. A Novel Approach to Identifying How Equipment Disrupts the Airflow Patterns in the Operating Room. J Extra Corpor Technol 2021; 53:130-136. [PMID: 34194079 PMCID: PMC8220907 DOI: 10.1182/ject-2100019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/04/2021] [Indexed: 06/13/2023]
Abstract
A decrease in the infection rates in the operating room (OR) is attributable to advances in sterile technique; heating, ventilation, and air-conditioning (HVAC) filtration; and limiting the number of people entering and leaving the OR. However, some infection complications after open heart procedures have been linked to the discharge fans of surgical equipment, most notably from the LivaNova 3T. We believe that surgical infection within the OR may also be due to other devices with internal fans. The purpose of this study was to 1) identify surgical equipment with an internal fan and see how they affect the airflow in an OR, 2) use the equipment to positively affect airflow to possibly reduce the risk of surgical site infections, and 3) bring attention to the HVAC system ability to exchange air throughout the OR. By using a fog machine and multiple camera angles, we identified the devices that have an effect on the airflow. We saw that the direction of the intake vent of specific devices can change the direction of airflow and possibly help to remove air. Last, we showed how the current HVAC air exchange rate might not be enough to remove contaminated air within the OR. Understanding intake and discharge vents for all equipment is important because sterile contamination and wound infection may be minimized or mitigated completely by simply repositioning a few devices.
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Affiliation(s)
- Carl J Gisnarian
- Hartford Hospital, Heart and Vascular Institute, Hartford, Connecticut
| | - Daniel S Fusco
- Hartford Hospital, Heart and Vascular Institute, Hartford, Connecticut
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13
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Mora-Guzmán I, Rubio-Perez I, Domingo-Garcia D, Martin-Perez E. Risk Factors for Intra-Abdominal Infections Caused by Carbapenemase-Producing Enterobacteriaceae in a Surgical Setting. Surg Infect (Larchmt) 2021; 22:864-870. [PMID: 33857380 DOI: 10.1089/sur.2020.472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: The aim of this study was to identify risk factors for acquisition of intra-abdominal infections (IAI) caused by carbapenemase-producing Enterobacteriaceae (CPE) in surgical patients. Methods: A matched case-control study was performed. We included all cases with CPE-related IAI acquired during admission to a general surgery department from January 2013 to December 2018, and they were matched with control subjects with IAI caused by non-resistant bacteria (ratio 1:3). Independent risk factors were obtained by logistic regression. Results: Forty patients with IAI-CPE were matched with 120 control subjects. Independent risk factors for acquisition of IAI-CPE were previous hospitalization (odds ratio [OR] 2.56; 95% confidence interval [CI] l 1.01-6.49; p = 0.047), digestive endoscopy (OR 4.11; 95% CI 1.40-12.07; p = 0.010), carbapenem therapy (OR 9.54; 95% CI 3.33-27.30; p < 0.001), and aminoglycoside use (OR 45.41; 95% CI 7.90-261.06; p < 0.001). Conclusions: Four clinical factors can identify patients at high-risk of IAI-CPE.
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Affiliation(s)
- Ismael Mora-Guzmán
- Department of General Surgery. Hospital General La Mancha Centro, Alcázar de San Juan, Spain
| | - Inés Rubio-Perez
- Department of General Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Diego Domingo-Garcia
- Department of Clinical Microbiology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Elena Martin-Perez
- Department of General Surgery, Hospital Universitario de La Princesa, Madrid, Spain
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14
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Mele TS, Kaafarani HMA, Guidry CA, Loor MM, Machado-Aranda D, Mendoza AE, Morris-Stiff G, Rattan R, Schubl SD, Barie PS. Surgical Infection Society Research Priorities: A Narrative Review of Fourteen Years of Progress. Surg Infect (Larchmt) 2020; 22:568-582. [PMID: 33275862 DOI: 10.1089/sur.2020.309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: In 2006, the Surgical Infection Society (SIS) utilized a modified Delphi approach to define 15 specific priority research questions that remained unanswered in the field of surgical infections. The aim of the current study was to evaluate the scientific progress achieved during the ensuing period in answering each of the 15 research questions and to determine if additional research in these fields is warranted. Methods: For each of the questions, a literature search using the National Center for Biotechnology Information (NCBI) was performed by the Scientific Studies Committee of the SIS to identify studies that attempted to address each of the defined questions. This literature was analyzed and summarized. The data on each question were evaluated by a surgical infections expert to determine if the question was answered definitively or remains unanswered. Results: All 15 priority research questions were studied in the last 14 years; six questions (40%) were definitively answered and 9 questions (60%) remain unanswered in whole or in part, mainly because of the low quality of the studies available on this topic. Several of the 9 unanswered questions were deemed to remain research priorities in 2020 and warrant further investigation. These included, for example, the role of empiric antimicrobial agents in nosocomial infections, the use of inotropes/vasopressors versus volume loading to raise the mean arterial pressure, and the role of increased antimicrobial dosing and frequency in the obese patient. Conclusions: Several surgical infection-related research questions prioritized in 2006 remain unanswered. Further high-quality research is required to provide a definitive answer to many of these priority knowledge gaps. An updated research agenda by the SIS is warranted at this time to define research priorities for the future.
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Affiliation(s)
- Tina S Mele
- Divisions of General Surgery and Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher A Guidry
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michele M Loor
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David Machado-Aranda
- Division of Acute Care Surgery, Michigan Medicine and Ann Arbor Veterans' Affairs Health System, Ann Arbor, Michigan, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gareth Morris-Stiff
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio, USA
| | - Rishi Rattan
- Division of Trauma Surgery and Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine, California, USA
| | - Philip S Barie
- Division of Trauma Burns, Acute and Critical Care, Department of Surgery, and Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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15
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Nadareishvili L, Hoyle N, Nakaidze N, Nizharadze D, Kutateladze M, Balarjishvili N, Kutter E, Pruidze N. Bacteriophage Therapy as a Potential Management Option for Surgical Wound Infections. Phage (New Rochelle) 2020; 1:158-165. [PMID: 36147826 PMCID: PMC9041461 DOI: 10.1089/phage.2020.0010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
To investigate the potential role of bacteriophages in the treatment of surgical infections, we conducted a retrospective analysis of four surgical patients who have sought treatment at the Eliava Phage Therapy Center, Tbilisi, Georgia. Two patients had chronic osteomyelitis, one presented with a diabetic foot ulcer, and the fourth patient had developed a severe infectious complication after skin grafting surgery. Patients were treated with different combinations of bacteriophage preparations, based on the sensitivity of the isolated bacterial strain toward commercially available bacteriophages. The treatment lasted on average for 1 month, and positive results were obtained in all four cases: the wounds have healed, the general health status of the patients has improved. No allergic or adverse reactions have been observed throughout the treatment.
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Affiliation(s)
- L. Nadareishvili
- Eliava Phage Therapy Center, Eliava Foundation, Tbilisi, Georgia
| | - N. Hoyle
- Eliava Phage Therapy Center, Eliava Foundation, Tbilisi, Georgia
- PhageBiotics Research Foundation, The Evergreen State College, Olympia, Washington, USA
- Address correspondence to: N. Hoyle, Eliava Phage Therapy Center, 3 Gotua Street, Tbilisi 0160, Georgia
| | - N. Nakaidze
- PhageBiotics Research Foundation, The Evergreen State College, Olympia, Washington, USA
| | - D. Nizharadze
- Eliava Phage Therapy Center, Eliava Foundation, Tbilisi, Georgia
| | - M. Kutateladze
- G. Eliava Institute of Bacteriophages, Microbiology and Virology, Tbilisi, Georgia
| | - N. Balarjishvili
- G. Eliava Institute of Bacteriophages, Microbiology and Virology, Tbilisi, Georgia
| | - E. Kutter
- PhageBiotics Research Foundation, The Evergreen State College, Olympia, Washington, USA
| | - N. Pruidze
- Eliava Phage Therapy Center, Eliava Foundation, Tbilisi, Georgia
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16
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DeCesare L, Xu TQ, Saclarides C, Coughlin JM, Chivukula SV, Woodfin A, Chan E, Booker C, Jacobson R. Trends in Antibiotic Duration for Complicated Intra-Abdominal Infections : Adaptation to Current Guidelines. Am Surg 2020; 87:120-124. [PMID: 32845728 DOI: 10.1177/0003134820942186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The 2017 surgical infection society (SIS) guidelines recommend 4 days of antibiotic therapy after source control for complicated intra-abdominal infections (cIAIs). Inappropriate exposure to antibiotics has a negative impact on outcomes in individual patients and populations. The goal of this study was to evaluate our institution's practice patterns and adherence to current antibiotic guidelines. METHODS Medical records from 2010 to 2018 for cIAIs were examined. Complicated appendicitis and complicated diverticulitis cases were included. Exclusion criteria included other etiologies of IAIs, pediatric cases, and cancer operations. RESULTS Fifty-nine complicated appendicitis cases and 96 complicated diverticulitis cases were identified. For all cases, antibiotic duration prior to publication of the SIS guidelines was significantly longer than post-SIS duration (appendicitis: 12.6 ± 1.1 days pre-SIS [n = 37] vs 9.0 ± 1.1 days post-SIS [n = 22], P = .01; diverticulitis: 15.1 ± 0.8 days pre-SIS [n = 49] vs 11.2 ± 0.5 post-SIS [n = 47], P = .04). Surgical management (SM) was associated with shorter duration of postsource control antibiotic exposure compared with percutaneous drainage (PD) for both appendicitis (SM 10.0 ± 1.2 days vs PD 13.4 ± 1.0 days, P = .02) and diverticulitis (SM 12.8 ± 1.5 days vs PD 16.0 ± 1.5, P = .07). Patients with complicated appendicitis received shorter duration of antibiotics when managed by acute care surgeons compared to general surgeons (8.4 ± 1.1 vs 11.9 ± 0.8, P = .02). CONCLUSION Despite improvements after the SIS guidelines' publication, the antibiotic duration is still longer than recommended. Surgical intervention and management by acute care specialists were associated with a shorter duration of antibiotic exposure.
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Affiliation(s)
- Laura DeCesare
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Thomas Q Xu
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Julia M Coughlin
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Ashley Woodfin
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Edie Chan
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Connor Booker
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Richard Jacobson
- 2461Department of Surgery, Rush University Medical Center, Chicago, IL, USA
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17
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Sartelli M, C. Hardcastle T, Catena F, Chichom-Mefire A, Coccolini F, Dhingra S, Haque M, Hodonou A, Iskandar K, Labricciosa FM, Marmorale C, Sall I, Pagani L. Antibiotic Use in Low and Middle-Income Countries and the Challenges of Antimicrobial Resistance in Surgery. Antibiotics (Basel) 2020; 9:E497. [PMID: 32784880 PMCID: PMC7459633 DOI: 10.3390/antibiotics9080497] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 12/13/2022] Open
Abstract
Antimicrobial resistance (AMR) is a phenomenon resulting from the natural evolution of microbes. Nonetheless, human activities accelerate the pace at which microorganisms develop and spread resistance. AMR is a complex and multidimensional problem, threatening not only human and animal health, but also regional, national, and global security, and the economy. Inappropriate use of antibiotics, and poor infection prevention and control strategies are contributing to the emergence and dissemination of AMR. All healthcare providers play an important role in preventing the occurrence and spread of AMR. The organization of healthcare systems, availability of diagnostic testing and appropriate antibiotics, infection prevention and control practices, along with prescribing practices (such as over-the-counter availability of antibiotics) differs markedly between high-income countries and low and middle-income countries (LMICs). These differences may affect the implementation of antibiotic prescribing practices in these settings. The strategy to reduce the global burden of AMR includes, among other aspects, an in-depth modification of the use of existing and future antibiotics in all aspects of medical practice. The Global Alliance for Infections in Surgery has instituted an interdisciplinary working group including healthcare professionals from different countries with different backgrounds to assess the need for implementing education and increasing awareness about correct antibiotic prescribing practices across the surgical pathways. This article discusses aspects specific to LMICs, where pre-existing factors make surgeons' compliance with best practices even more important.
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Affiliation(s)
| | - Timothy C. Hardcastle
- Trauma Service, Inkosi Albert Luthuli Central Hospital and Department of Surgery, Nelson R. Mandela School of Clinical Medicine, Durban 4058, South Africa;
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, 43126 Parma, Italy;
| | - Alain Chichom-Mefire
- Department of Surgery and Obs/Gyn, Faculty of Health Sciences University of Buea, Buea P.O. Box 63, South West Province, Cameroon;
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Cisanello University Hospital, 56100 Pisa, Italy;
| | - Sameer Dhingra
- School of Pharmacy, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Eric Williams Medical Sciences Complex, Uriah Butler Highway, Champ Fleurs 33178, Trinidad and Tobago;
| | - Mainul Haque
- Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur 57000, Malaysia;
| | - Adrien Hodonou
- Department of General Surgery, Regional Hospital Borgou, Faculty of Medicine, University of Parakou, Parakou P.O. Box 123, Benin;
| | - Katia Iskandar
- Department of Pharmacy, Lebanese, International University, Beirut 1106, Lebanon;
| | | | - Cristina Marmorale
- Department of Surgery, Università Politecnica delle Marche, 60126 Ancona, Italy;
| | - Ibrahima Sall
- General Surgery Department, Military Teaching Hospital, Dakar 3006, Senegal;
| | - Leonardo Pagani
- Infectious Diseases Unit, Bolzano Central Hospital, 39100 Bolzano, Italy;
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18
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Mora-Guzmán I, Rubio-Perez I, Domingo-Garcia D, Martin-Perez E. Intra-Abdominal Infections by Carbapenemase-Producing Enterobacteriaceae in a Surgical Unit: Counting Mortality, Stay, and Costs. Surg Infect (Larchmt) 2020; 22:266-273. [PMID: 32598237 DOI: 10.1089/sur.2020.137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: Carbapenemase-producing Enterobacteriaceae (CPE)-related infections are a problem in public health at present, including intra-abdominal infections (IAI) and surgical populations. The aim of this study was to determine mortality and related risk factors, length of stay (LOS,) and costs for CPE-IAI in surgical patients. Patients and Methods: Review of CPE-related IAI acquired during admission in a general surgery department from January 2013 to December 2018. A mortality analysis was performed specifically in patients with CPE-IAI, and a global analysis of IAI including patients with CPE-IAI (cases) and matched patients with IAI by non-resistant bacteria (controls). Results: Forty patients with CPE-IAI were included, OXA-48-producing Klebsiella pneumoniae was present in 85%. Global mortality rate at 30 days for CPE-IAI was 17.5%; mortality-related factors were: solid tumor (p = 0.009), metastatic disease (p = 0.005), immunodeficiency (p = 0.039), blood transfusion (p = 0.009), and septic shock (p = 0.011). Predictors related to mortality for IAI in the global analysis included age (p = 0.046), Charlson index (p = 0.036), CPE isolation (p = 0.003), and septic shock (p < 0.001). Median global LOS was 43 days (IQR 27-64) in patients with CPE-IAI, and 27 days (IQR 18-35) in controls (p < 0.001). Median global cost of admission was $31,671 (IQR 14,006-55,745) for patients with CPE-IAI and $20,306 (IQR 11,974-27,947) for controls (p = 0.064). The most relevant locations of underlying disease for CPE-IAI were: colorectal (32.5%) with 57-day LOS (IQR 34-65) and cost of $42,877 (IQR 18,780-92,607), and pancreas (25%) with 60-day LOS (IQR 32-99) and cost of $56,371 (IQR 32,590-113,979). Conclusion: Carbapenemase-producing Enterobacteriaceae-related IAI is associated with substantial mortality, LOS, and costs. Factors related to CPE-IAI mortality are solid tumor, metastatic disease, immunodeficiency, blood transfusion, and septic shock. Carbapenemase-producing Enterobacteriaceae isolation in IAI implies higher risk of mortality.
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Affiliation(s)
- Ismael Mora-Guzmán
- Department of General Surgery, Hospital Santa Bárbara, Puertollano, Spain
| | - Inés Rubio-Perez
- Department of General Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Diego Domingo-Garcia
- Department of Clinical Microbiology, Hospital Universitario La Princesa, Madrid, Spain
| | - Elena Martin-Perez
- Department of General Surgery, Hospital Universitario La Princesa, Madrid, Spain
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19
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Delaplain PT, Dosch AR, Kaafarani HMA, Barie PS, Schubl SD. Revisiting the Surgical Infection Society Delphi Analysis of the Research Agenda in Surgical Infections: Advancements and Unanswered Questions. Surg Infect (Larchmt) 2020; 22:258-265. [PMID: 32589512 DOI: 10.1089/sur.2020.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background: In 2006, the Surgical Infection Society (SIS) used a modified Delphi process to enlist SIS member-experts to identify 15 research priorities in the field of surgical infectious diseases; it was intended to serve as a research road map for the next one to two decades. We sought to evaluate the progress made in each of these priority areas. Hypothesis: We examined the progress achieved with respect to the 15 research areas identified by the Delphi process at that time, hypothesizing that advances in knowledge would be achieved in most domains, if not all. Methods: Surgical Infection Society members were surveyed to determine whether each priority area question had been satisfactorily answered in the last 14 years; to assess the quality of evidence answering each question (1-3 scale); and to delineate whether there is a current unmet need for continued research in each area. Randomized controlled trials (RCTs) regarding these initiatives were also identified via literature search and their citations in the literature were tabulated. Results: Sixty-six members of the SIS responded to the survey. Thirteen of 15 research priority areas saw an increase in data perceived to be available as adjudged by experts, as well an increase in the number of RCTs addressing that topic. However, there were only six questions that were deemed by experts to be answered sufficiently, primarily regarding antibiotic duration for certain conditions and the impact of glycemic control on infection. The questions that remained unanswered related to nosocomial infections, sepsis/septic shock, prevention of SSI, and antimicrobial pharmacokinetics. For a majority of the questions that experts believed were not answered sufficiently (8/9), respondents opined that continued research into these areas was warranted. Conclusion: Whereas 40% (6/15) of the research questions prioritized by the SIS in 2006 were answered to the satisfaction of member-experts, there are many questions that remain unanswered despite an increase of available data. Revisiting these research priorities highlights advancements made in the field of surgical infections, but also helps identify the areas that would benefit from continued study. That a majority of questions remain unanswered underscores an opportunity for member-experts to collaborate on SIS-managed or -endorsed RCTs.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, University of California, Irvine Medical Center, Irvine, California, USA
| | - Austin R Dosch
- Department of Surgery, University of California, Irvine Medical Center, Irvine, California, USA
| | - Haytham M A Kaafarani
- Harvard Medical School & Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, and Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine Medical Center, Irvine, California, USA
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20
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Forrester JD, Berndtson AE, Santorelli J, Raschke E, Weiser TG, Coombs AV, Sawyer RG, Chou J, Knight HP, Valenzuela JY, Rickard J. Survey of National Surgical Site Infection Surveillance Programs in Low- and Middle-Income Countries. Surg Infect (Larchmt) 2020; 21:621-625. [PMID: 32397833 DOI: 10.1089/sur.2020.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Surgical site infection (SSI) surveillance programs are strongly recommended as a core component of effective national infection prevention and control (IPC) programs. Participation in national SSI surveillance (nSSIS) programs has been shown to decrease reported SSIs among high-income countries (HICs), and it is expected that the same is possible among low- and middle-income countries (LMICs). We sought to determine what, if any nSSIS programs exist among LMICs. Methods: A cross-sectional survey was performed to evaluate existence of nSSIS of World Bank-defined LMICs. A digital survey assessment for presence of national IPC and nSSIS programs was delivered to persons capable of identifying the presence of such a program. Statistical analysis was performed using STATA. Institutional Review Board approval was obtained for this study. Results: Of the 137 countries identified, 55 (40%) were upper middle income (UMI), 47 (34%) were lower middle income (LMI), and 34 (25%) were low income. Representatives from 39 (28%) LMICs completed the survey. Of these respondent countries, 13 (33%) reported the presence of a national IPC program. There was no difference between countries with IPC programs and those without with respect to country income designation, population size, World Health Organization region, or conflict status. Only five (13% of all respondents) reported presence of a nSSIS program. Conclusions: National surgical site infection surveillance programs are an integral component of a country's ability to provide safe surgical procedures. Presence of nSSIS was reported infrequently in LMICs. International governing bodies should be encouraged to guide LMIC leadership in establishing a nSSIS infrastructure that will help enable safe surgical procedures.
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Affiliation(s)
- Joseph D Forrester
- Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California, San Diego, La Jolla, California, USA
| | - Jarrett Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California, San Diego, La Jolla, California, USA
| | - Eric Raschke
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California, San Diego, La Jolla, California, USA
| | - Thomas G Weiser
- Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Andre V Coombs
- Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Jesse Chou
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Hunter P Knight
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Julie Y Valenzuela
- Division of Trauma Critical Care, Southside Hospital/Northwell Health, Glen Cove, New York, USA
| | - Jennifer Rickard
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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Kakembo N, Grabski DF, Fitzgerald TN, Muzira A, Cheung M, Kisa P, Sekabira J, Ozgediz D. Burden of Surgical Infections in a Tertiary-Care Pediatric Surgery Service in Uganda. Surg Infect (Larchmt) 2019; 21:130-135. [PMID: 31560249 DOI: 10.1089/sur.2019.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Delayed presentation of surgical disease often leads to infection in low- and middle-income countries (LMICs). In addition, many primary infections require surgical intervention. The burden of infection in children's surgery in LMICs is poorly defined and may tax the limited availability of surgical resources. Methods: A prospective surgical database was reviewed for all children presenting to a Ugandan tertiary referral hospital from January 2012 to August 2016. All patients presenting with infection were included and analyzed by operative intervention and survival. Results: Of the 3,494 children admitted over the time period, 712 (20.4%) presented with infection. A total of 455 patients (64%) with an infection underwent an operation, with an in-hospital mortality rate of 12.5%. Operations involving infections represented 20% of the volume of the children's surgery department. Common conditions were abscesses (n = 308; 43.4%), typhoid intestinal perforations (n = 85; 12.0%), appendicitis (n = 78; 11.0%) and perforated bowel caused by ileocolic intussusception (n = 37; 5.2%). Patients with esophageal atresia presenting with aspiration pneumonia had an in-hospital mortality rate of 78.6%, those with abdominal sepsis a 67% mortality rate, and neonatal infants with necrotizing enterocolitis a 50% mortality rate. Conclusion: There is a high volume of infection in children requiring surgery, contributing to a high mortality rate. Resource allocation for children's surgical care in LMIC should be directed toward timely diagnosis and surgical intervention of these conditions.
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Affiliation(s)
- Nasser Kakembo
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - David F Grabski
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Arlene Muzira
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Maija Cheung
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Phyllis Kisa
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - John Sekabira
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Doruk Ozgediz
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
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Buric J, Berjano P, Damilano M. Severe Spinal Surgery Infection and Local Ozone Therapy as Complementary Treatment: A Case Report. Int J Spine Surg 2019; 13:371-376. [PMID: 31534904 DOI: 10.14444/6050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background Infection is a serious surgical complication that significantly increases morbidity and mortality rates as well as health care expenses. Increased bacterial resistance to antibiotics makes the treatment of such events even more troublesome. Objective To report on a surgical infection case treated with ozone as a complementary therapy. Methods and Materials A female, 65 years old, submitted to a complex surgical procedure for adult kyphotic deformity correction that presented with early postsurgical infection. The patient was treated with revision surgery and antibiotics that improved the condition but were unable to delete the infection. Ozone, in its gaseous form, was injected subcutaneously and paravertebrally twice weekly for 3 weeks. Results After 3 weeks of treatment, the wound healed completely. Follow-up visits and laboratory exams for up to 1 year after surgery showed no recurrence of infection. Conclusions Although just a single case, topical ozone therapy for surgical infections showed promising potential in this specific case.
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Abstract
Surgical infections present a significant burden of disease globally. Management focuses on source control and appropriate antibiotic therapy. This remains a challenge in low- and middle-income settings, where access to surgical care and antibiotics is limited. This paper discusses the complex challenges facing the management of surgical infections in low- and middle-income countries.
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Affiliation(s)
- Jennifer Rickard
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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Affiliation(s)
- Evangelos P Misiakos
- 3rd Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Konstantinos George Tsalis
- 4th Surgical Department, Medical School, Aristotle University of Thessaloniki, General Hospital "G. Papanikolaou", Thessaloniki, Greece
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Rubio-Perez I, Martin-Perez E, Domingo-García D, Garcia-Olmo D. Specific Clinical Profile and Risk Factors for Mortality in General Surgery Patients with Infections by Multi-Drug-Resistant Gram-Negative Bacteria. Surg Infect (Larchmt) 2017; 18:625-633. [PMID: 28475416 DOI: 10.1089/sur.2016.255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The incidence of gram-negative multi-drug-resistant (MDR) infections is increasing worldwide. This study sought to determine the incidence, clinical profiles, risk factors, and mortality of these infections in general surgery patients. PATIENTS AND METHODS All general surgery patients with a clinical infection by gram-negative MDR bacteria were studied prospectively for a period of five years (2007-2011). Clinical, surgical, and microbiologic parameters were recorded, with a focus on the identification of risk factors for MDR infection and mortality. RESULTS Incidence of MDR infections increased (5.6% to 15.2%) during the study period; 106 patients were included, 69.8% presented nosocomial infections. Mean age was 65 ± 15 years, 61% male. Extended-spectrum β-lactamases (ESBL) Escherichia coli was the most frequent MDR bacteria. Surgical site infections and abscesses were the most common culture locations. The patients presented multiple pre-admission risk factors and invasive measures during hospitalization. Mortality was 15%, and related to older age (odds ratio [OR] 1.07), malnutrition (OR 13.5), chronic digestive conditions (OR 4.7), chronic obstructive pulmonary disease (OR 3.9), and surgical re-intervention (OR 9.2). CONCLUSION Multi-drug resistant infections in the surgical population are increasing. The most common clinical profile is a 65-year-old male, with previous comorbidities, who has undergone a surgical intervention, intensive care unit (ICU) admission, and invasive procedures and who has acquired the MDR infection in the nosocomial setting.
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Affiliation(s)
- Ines Rubio-Perez
- 1 General Surgery Department, Colorectal Surgery Unit, La Paz University Hospital , Madrid, Spain
| | - Elena Martin-Perez
- 2 General Surgery Department, Upper GI Unit, La Princesa University Hospital , Madrid, Spain
| | | | - Damian Garcia-Olmo
- 4 General Surgery Department, Fundacion Jimenez Diaz Hospital , Madrid, Spain
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26
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Jaworski R, Haponiuk I, Steffens M, Arlukowicz E, Irga-Jaworska N, Chojnicki M, Kwasniak E, Zielinski J. Colonization of multidrug resistant pathogens in a hybrid pediatric cardiac surgery center. Arch Med Sci 2016; 12:639-44. [PMID: 27279859 PMCID: PMC4889698 DOI: 10.5114/aoms.2016.59937] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 10/30/2014] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The incidence of multidrug resistant microorganisms worldwide is increasing. The aim of the study was to present institutional experience with the multidrug resistant microorganism colonization patterns observed in children with congenital heart diseases hospitalized in a hybrid pediatric cardiac surgery center. MATERIAL AND METHODS Microbiological samples were routinely collected in all children admitted to our department. All microbiological samples were analyzed with regard to multidrug resistant microorganisms: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Gram-negative rods producing extended-spectrum beta-lactamases (ESBL), multidrug resistant Gram-negative rods (MDR-GNRs), carbapenemase-producing Klebsiella pneumoniae (KPC), carbapenem-resistant Acinetobacter baumannii (CRAB) and Pseudomonas aeruginosa (CRPA). RESULTS In 30 (9%) swabs 'alert' pathogens from the above group of listed microorganisms were found. All positive swabs were isolated in 19 (16.1%) children. Multidrug resistant pathogen colonization was statistically significantly more often observed in children admitted from other medical facilities than in children admitted from home (38% vs. 10%, p = 0.0089). In the group of children younger than 6 months 'alert' pathogen were more often observed than in older children (34.1% vs. 5.4%, p < 0.001). CONCLUSIONS Preoperative multidrug resistant pathogen screening in children admitted and referred for congenital heart disease procedures may be of great importance since many of these patients are colonized with resistant bacteria. Knowledge of the patient's microbiome is important in local epidemiological control along with tailoring the most effective preoperative prophylactic antibiotic for each patient. The impact of preoperative screening on postoperative infections and other complications requires further analysis.
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Affiliation(s)
- Radoslaw Jaworski
- Department of Pediatric Cardiac Surgery, Copernicus Hospital, Gdansk, Poland
| | - Ireneusz Haponiuk
- Department of Pediatric Cardiac Surgery, Copernicus Hospital, Gdansk, Poland
- Chair of Physiotherapy, Gdansk University of Physical Education and Sport, Gdansk, Poland
| | - Mariusz Steffens
- Department of Pediatric Cardiac Surgery, Copernicus Hospital, Gdansk, Poland
| | | | - Ninela Irga-Jaworska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Maciej Chojnicki
- Department of Pediatric Cardiac Surgery, Copernicus Hospital, Gdansk, Poland
| | - Ewelina Kwasniak
- Department of Pediatric Cardiac Surgery, Copernicus Hospital, Gdansk, Poland
| | - Jacek Zielinski
- Department of Surgical Oncology, Medical University of Gdansk, Gdansk, Poland
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Abstract
Adverse publicity (the 'superbug') has demonstrated that the problem of MRSA (methicillin-resistant Staphylococcus aureus) is prevalent in many of the country's most prestigious hospitals. The results of the mandatory UK Department of Health (DH) surveillance for early surgical site infections in orthopaedic surgery (SSIS) have been published recently for the period April 2004 to March 2005 when 41,242 operations were studied ( 28 October 2005). Infection rates were generally and gratifyingly low but 48% of surgical site infections were caused by Staph. aureus and of those 68% were MRSA. The following article will discuss the aetiology and prevention of MRSA surgical site infection.
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Affiliation(s)
- Andrea Guyot
- Departments of Microbiology, Royal Surrey County HospitalGuildford, Surrey, UK
| | - Graham Layer
- Departments of General Surgery, Royal Surrey County HospitalGuildford, Surrey, UK
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