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May AK. Host Microbiome Threats in the Intensive Care Unit. Surg Infect (Larchmt) 2023; 24:276-283. [PMID: 37010970 DOI: 10.1089/sur.2023.029] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023] Open
Abstract
Human microbiota demonstrate diversity and balance that is adaptive for the host and supports maintaining homeostasis. Although acute illness or injury may derange microbiota diversity and the proportion of potentially pathogenic microbes, that derangement may be further exacerbated by commonly deployed intensive care unit (ICU) therapeutic and practices. These include antibiotic administration, delayed luminal nutrition, acid suppression, and vasopressor infusion. Furthermore, the local ICU microbial ecology, regardless of disinfection practices, shapes the patient's microbiota, especially with the acquisition of multi-drug-resistant pathogens. Current approaches to protect a normal microbiome, or restore a deranged one, are part of a multifaceted approach that may include antibiotic stewardship and infection control practices as microbiome-directed therapeutics emerge.
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Affiliation(s)
- Addison K May
- Carolinas Medical Center and Atrium Health, Wake Forest School of Medicine, Charlotte, North Carolina, USA
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2
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Cohen NS, Bock JM, May AK. Sepsis and postoperative surgical site infections. Surgery 2023:S0039-6060(23)00006-5. [PMID: 36775759 DOI: 10.1016/j.surg.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 12/21/2022] [Accepted: 01/06/2023] [Indexed: 02/12/2023]
Abstract
Surgical site infections remain a significant cause of morbidity and mortality. High-quality evidence supports several measures to prevent surgical site infections that should be applied with high compliance, although effective application remains suboptimal. Recognizing high-risk patients and avoiding potential pitfalls in the diagnosis of surgical site infections is paramount in preventing progression to sepsis, particularly in emergency surgical patients with physiologic derangement. A high index of suspicion postoperatively is critical to identify patients with surgical site infections and to prevent failure to rescue.
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Affiliation(s)
- Nina S Cohen
- Division of Acute Care Surgery, Atrium Health - Carolinas Medical Center, Charlotte, NC
| | - Jiselle M Bock
- Department of Surgery, Atrium Health - Cleveland, Shelby, NC. http://www.twitter.com/jisellebockmd
| | - Addison K May
- Acute Care Surgery, Department of Surgery, Atrium Health, Wake Forest School of Medicine, Charlotte, NC.
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Ross SW, McCartt JC, Cunningham KW, Reinke CE, Thompson KJ, Green JM, Thomas BW, Jacobs DG, May AK, Christmas AB, Sing RF. Emergencies do not shut down during a pandemic: COVID pandemic impact on Acute Care Surgery volume and mortality at a level I trauma center. Am J Surg 2022; 224:1409-1416. [PMID: 36372581 PMCID: PMC9575313 DOI: 10.1016/j.amjsurg.2022.10.030] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 09/23/2022] [Accepted: 10/13/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of the COVID-19 pandemic on volume and outcomes of Acute Care Surgery patients, and we hypothesized that inpatient mortality would increase due to COVID+ and resource constraints. METHODS An American College of Surgeons verified Level I Trauma Center's trauma and operative emergency general surgery (EGS) registries were queried for all patients from Jan. 2019 to Dec. 2020. April 1st, 2020, was the demarcation date for pre- and during COVID pandemic. Primary outcome was inpatient mortality. RESULTS There were 14,460 trauma and 3091 EGS patients, and month-over-month volumes of both remained similar (p > 0.05). Blunt trauma decreased by 7.4% and penetrating increased by 31%, with a concomitant 25% increase in initial operative management (p < 0.001). Despite this, trauma (3.7%) and EGS (2.9-3.0%) mortality rates remained stable which was confirmed on multivariate analysis; p > 0.05. COVID + mortality was 8.8% and 3.7% in trauma and EGS patients, respectively. CONCLUSION Acute Care Surgeons provided high quality care to trauma and EGS patients during the pandemic without allowing excess mortality despite many hardships and resource constraints.
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Affiliation(s)
- Samuel W. Ross
- Corresponding author. Atrium Health Carolinas Medical Center, Charlotte NC, 1000 Blythe Blvd, Suite 601 MEB, Charlotte, NC, 28203, USA
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4
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Guidry CA, Medvecz AJ, Adams RC, Dennis BM, Eastham SC, Guillamondegui OD, Gunter OL, Peetz AB, Thompson CM, Gondek SP, Nunez TC, Sawyer RG, May AK, Patel MB. Prior Antibiotic Exposure Is Associated With Reoperation After Elective Non-colorectal Surgery. Am Surg 2022; 88:2752-2759. [PMID: 35722722 DOI: 10.1177/00031348221109812] [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: 11/16/2022]
Abstract
BACKGROUND Recent antibiotic exposure has previously been associated with poor outcomes following elective surgery. The purpose of this study is to evaluate the impact of prior recent antibiotic exposure in a multicenter cohort of Veterans Affairs patients undergoing elective non-colorectal surgery. METHODS This is a retrospective cohort study of the Veterans Affairs Surgical Quality Improvement Program, including elective, non-cardiovascular, non-colorectal surgery from 2013 to 2017. Outpatient antibiotic exposure within 90 days prior to surgery was identified from the Veterans Affairs outpatient pharmacy database and matched with each case. Primary outcomes included serious complication, any complication, any infection, or surgical site infection. Secondary outcomes included 30-day mortality, length of stay, and Clostridioides difficile infection. RESULTS Of 21,112 eligible patients, 2885 (13.7%) were exposed to antibiotics within 90 days prior to surgery with a duration of 7 (IQR: 5-10) days and prescribed 42 (IQR: 21-64) days prior to surgical intervention. Compared to non-exposed patients, exposed patients had higher unadjusted complication rates, increased length of stay, and rates of return to the operating. Exposure was independently associated with return to the operating room (OR: 1.39; 99% CI: 1.05-1.84). CONCLUSIONS Among Veterans, recent antibiotic exposure within 90 days of elective surgery was associated with a 39% increase in the odds of return to the operating room. Further work is needed to evaluate the effects of antibiotic exposure and dysbiosis on surgical outcomes.
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Affiliation(s)
- Christopher A Guidry
- Division of Trauma, Acute Care Surgery and Critical Care; Department of Surgery, 21638The University of Kansas Medical Center, Kansas City, KS, USA
| | - Andrew J Medvecz
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Raeanna C Adams
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bradley M Dennis
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shannon C Eastham
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oscar D Guillamondegui
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oliver L Gunter
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Allan B Peetz
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Surgical Services, Nashville Veterans Affairs Medical Center; Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Callie M Thompson
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephen P Gondek
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy C Nunez
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Surgical Services, Nashville Veterans Affairs Medical Center; Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Robert G Sawyer
- Department of Surgery, 51374Western Michigan University Homer Stryker School of Medicine, Kalamazoo, MI, USA
| | - Addison K May
- Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Mayur B Patel
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care; Department of Surgery, Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Surgical Services, Nashville Veterans Affairs Medical Center; Tennessee Valley Healthcare System, Nashville, TN, USA
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5
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Donohue SJ, Reinke CE, Evans SL, Jordan MM, Warren YE, Hetherington T, Kowalkowski M, May AK, Matthews BD, Ross SW. Laparoscopy is associated with decreased all-cause mortality in patients undergoing emergency general surgery procedures in a regional health system. Surg Endosc 2022; 36:3822-3832. [PMID: 34477959 DOI: 10.1007/s00464-021-08699-1] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/24/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the use of laparoscopic surgery for common emergency general surgery (EGS) procedures within an integrated Acute Care Surgery (ACS) network. We hypothesized that laparoscopy would be associated with improved outcomes. METHODS Our integrated health care system's EGS registry created from AAST EGS ICD-9 codes was queried from January 2013 to October 2015. Procedures were grouped as laparoscopic or open. Standard descriptive and univariate tests were performed, and a multivariable logistic regression controlling for open status, age, BMI, Charlson Comorbidity Index (CCI), trauma tier, and resuscitation diagnosis was performed. Laparoscopic procedures converted to open were identified and analyzed using concurrent procedure billing codes across episodes of care. RESULTS Of 60,604 EGS patients identified over the 33-month period, 7280 (12.0%) had an operation and 6914 (11.4%) included AAST-defined EGS procedures. There were 4813 (69.6%) surgeries performed laparoscopically. Patients undergoing a laparoscopic procedure tended to be younger (45.7 ± 18.0 years vs. 57.2 ± 17.6, p < 0.001) with similar BMI (29.7 ± 9.0 kg/m2 vs. 28.8 ± 8.3, p < 0.001). Patients in the laparoscopic group had lower mean CCI score (1.6 ± 2.3 vs. 3.4 ± 3.2, p ≤ 0.0001). On multivariable analysis, open surgery had the highest association with inpatient mortality (OR 8.67, 4.23-17.75, p < 0.0001) and at all time points (30-, 90-day, 1-, 3-year). At all time points, conversion to open was found to be a statistically significant protective factor. CONCLUSION Use of laparoscopy in EGS is common and associated with a decreased risk of all-cause mortality at all time points compared to open procedures. Conversion to open was protective at all time points compared to open procedures.
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Affiliation(s)
- Sean J Donohue
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Susan L Evans
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Mary M Jordan
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Yancey E Warren
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Timothy Hetherington
- Carolinas Medical Center, Center for Outcomes Research and Evaluation, Charlotte, NC, USA
| | - Marc Kowalkowski
- Carolinas Medical Center, Center for Outcomes Research and Evaluation, Charlotte, NC, USA
| | - Addison K May
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Brent D Matthews
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Samuel W Ross
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
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Pouliot JD, Dortch MJ, Givens G, Tidwell W, Hamblin SE, May AK. Factors Associated With Prolonged Antibiotic Use in the Setting of Suspected Pneumonia and Negative Bronchoalveolar Lavage Cultures. Hosp Pharm 2021; 56:444-450. [PMID: 34720144 DOI: 10.1177/0018578720918548] [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: 11/17/2022]
Abstract
Background: Diagnostic criterion for pneumonia includes clinical data and bronchoalveolar lavage cultures (BALCx) to identify pathogens. Although ~60% of BALCx are negative, there may be reluctance to discontinue antibiotics, leading to prolonged antibiotic use (PAU). Objective: The purpose of this study is to compare outcomes of subjects with negative BALCx with PAU versus without prolonged antibiotic use (nPAU). Methods: A retrospective cohort study was conducted including subjects admitted to the intensive care unit (ICU), with suspected pneumonia, and negative BALCx. Data were compared based on length of exposure to antibiotics, PAU (antibiotics >4 days) versus nPAU (antibiotics <4 days). Results: A total of 128 subjects were included, 57 in the PAU group and 71 in the nPAU group. Baseline demographics were similar between groups. Severity of illness measured by multiple organ dysfunction scores at time of bronchoalveolar lavage (BAL) collection to final result showed a statistically significant decrease in the PAU group but not in the nPAU group. No differences were found in ICU days, ventilator-free days, or mortality; however, length of stay was longer for PAU (23 vs. 17, p = .04). In the PAU group, there were fewer BALCx results of "no growth" (23% vs. 45%, p = .04), more positive gram stains (83% vs. 60%, p = .01) and more positive non-BALCx (40% vs. 14%, p = .01). In a multivariate analysis, factors associated with PAU were positive BAL gram stains (adjusted odds ratio [aOR] 3.1, p = .037) and positive non-BALCx (aOR 4.7, p = .002). Conclusion: For subjects with suspected pneumonia and negative BALCx, positive non-BALCx and positive BALCx gram stain influenced the length of exposure of antibiotics.
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Affiliation(s)
- Jonathon D Pouliot
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
| | | | - Gabrielle Givens
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
| | - William Tidwell
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan E Hamblin
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
| | - Addison K May
- Atrium Health, Charlotte, NC, USA.,University of North Carolina School of Medicine, Charlotte, USA
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7
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Ayuso SA, Elhage SA, Cunningham KW, Britton Christmas A, Sing RF, Thomas BW, May AK, Reinke CE, Ross SW. Emergency General Surgery Regionalization: Retrospective Cohort Study of Emergency General Surgery Patients at a Tertiary Care Center. Am Surg 2021:31348211038577. [PMID: 34397281 DOI: 10.1177/00031348211038577] [Citation(s) in RCA: 2] [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: 11/15/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) patients presenting at tertiary care hospitals may bypass local hospitals with adequate resources. However, many tertiary care hospitals frequently operate at capacity. We hypothesized that understanding patient geographic origin could identify opportunities for enhanced system triage and optimization and be an important first step for EGS regionalization and care coordination that could potentially lead to improved utilization of resources. METHODS We analyzed patient zip code and categorized EGS patients who were cared for at our tertiary care hospital as potentially divertible if the southern region hospital was geographically closer to their home, regional hospital admission (RHA) patients, or local admission (LA) patients if the tertiary care facility was closer. Baseline characteristics and outcomes were compared for RHA and LA patients. RESULTS Of 14 714 EGS patients presenting to the tertiary care hospital, 30.2% were categorized as RHA patients. Overall, 1526 (10.4%) patients required an operation including 527 (34.5%) patients who were potentially divertible. Appendectomy and cholecystectomy comprised 66% of the operations for potentially divertible patients. Length of stay was not significantly different (P = .06) for RHA patients, but they did have lower measured short-term and long-term mortality when compared to their LA counterparts (P < .05). CONCLUSIONS EGS diagnoses and patient geocode analysis can identify opportunities to optimize regional operating room and bed utilization. Understanding where EGS patients are cared for and factors that influenced care facility will be critical for next steps in developing EGS regionalization within our system.
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Affiliation(s)
- Sullivan A Ayuso
- Department of Surgery, 22442Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Sharbel A Elhage
- Department of Surgery, 22442Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Kyle W Cunningham
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - A Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Ronald F Sing
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Bradley W Thomas
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Addison K May
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Caroline E Reinke
- Division of Gastrointestinal and Minimally Invasive Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
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8
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Brakenridge SC, Wilfret DA, Maislin G, Andrade KE, Walker V, May AK, Dankner WM, Bulger EM. Resolution of organ dysfunction as a predictor of long-term survival in necrotizing soft tissue infections: Analysis of the AB103 Clinical Composite Endpoint Study in Necrotizing Soft Tissue Infections trial and a retrospective claims database-linked chart study. J Trauma Acute Care Surg 2021; 91:384-392. [PMID: 33797490 DOI: 10.1097/ta.0000000000003183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) are an acute surgical condition with high morbidity and mortality. Timely identification, resuscitation, and aggressive surgical management have significantly decreased inpatient mortality. However, reduced inpatient mortality has shifted the burden of disease to long-term mortality associated with persistent organ dysfunction. METHODS We performed a combined analysis of NSTI patients from the AB103 Clinical Composite Endpoint Study in Necrotizing Soft Tissue Infections randomized-controlled interventional trial (ATB-202) and comprehensive administrative database (ATB-204) to determine the association of persistent organ dysfunction on inpatient and long-term outcomes. Persistent organ dysfunction was defined as a modified Sequential Organ Failure Assessment (mSOFA) score of 2 or greater at Day 14 (D14) after NSTI diagnosis, and resolution of organ dysfunction defined as mSOFA score of 1 or less. RESULTS The analysis included 506 hospitalized NSTI patients requiring surgical debridement, including 247 from ATB-202, and 259 from ATB-204. In both study cohorts, age and comorbidity burden were higher in the D14 mSOFA ≥2 group. Patients with D14 mSOFA score of 1 or less had significantly lower 90-day mortality than those with mSOFA score of 2 or higher in both ATB-202 (2.4% vs. 21.5%; p < 0.001) and ATB-204 (6% vs. 16%: p = 0.008) studies. In addition, in an adjusted covariate analysis of the combined study data sets D14 mSOFA score of 1 or lesss was an independent predictor of lower 90-day mortality (odds ratio, 0.26; 95% confidence interval, 0.13-0.53; p = 0.001). In both studies, D14 mSOFA score of 1 or less was associated with more favorable discharge status and decreased resource utilization. CONCLUSION For patients with NSTI undergoing surgical management, persistent organ dysfunction at 14 days, strongly predicts higher resource utilization, poor discharge disposition, and higher long-term mortality. Promoting the resolution of acute organ dysfunction after NSTI should be considered as a target for investigational therapies to improve long-term outcomes after NSTI. LEVEL OF EVIDENCE Prognostic/epidemiology study, level III.
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Affiliation(s)
- Scott C Brakenridge
- From the Department of Surgery (S.C.B.), University of Florida College of Medicine, Gainesville, Florida; Atox Bio, Ltd (D.A.W., W.M.D.), Durham, North Carolina; Biomedical Statistical Consulting (G.M.), Wynnewood, Pennsylvania; Health Economics and Outcomes Research, Optum (K.E.A., V.W.), Eden Prairie, Minnesota; Division of Acute Care Surgery (A.K.M.), Atrium Health, Charlotte, North Carolina; Department of Surgery (E.M.B.) University of Washington, Harborview Medical Center, Seattle, Washington
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9
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Maloney SR, Reinke CE, Nimeri AA, Ayuso SA, Christmas AB, Hetherington T, Kowalkowski M, Sing RF, May AK, Ross SW. The Obesity Paradox in Emergency General Surgery Patients. Am Surg 2021; 88:852-858. [PMID: 33530738 DOI: 10.1177/0003134820968524] [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: 11/15/2022]
Abstract
Operative management of emergency general surgery (EGS) diagnoses involves a range of procedures which can carry high morbidity and mortality. Little is known about the impact of obesity on patient outcomes. The aim of this study was to examine the association between body mass index (BMI) >30 kg/m2 and mortality for EGS patients. We hypothesized that obese patients would have increased mortality rates. A regional integrated health system EGS registry derived from The American Association for the Surgery of Trauma EGS ICD-9 codes was analyzed from January 2013 to October 2015. Patients were stratified into BMI categories based on WHO classifications. The primary outcome was 30-day mortality. Longer-term mortality with linkage to the Social Security Death Index was also examined. Univariate and multivariable analyses were performed. A total of 60 604 encounters were identified and 7183 (11.9%) underwent operative intervention. Patient characteristics include 53% women, mean age 58.2 ± 18.7 years, 64.2% >BMI 30 kg/m2, 30.2% with chronic obstructive pulmonary disease, 19% with congestive heart failure, and 31.1% with diabetes. The most common procedure was laparoscopic cholecystectomy (36.4%). Overall, 90-day mortality was 10.9%. In multivariable analysis, all classes of obesity were protective against mortality compared to normal BMI. Underweight patients had increased risk of inpatient (OR = 1.9, CI = 1.7-2.3), 30-day (OR = 1.9, CI = 1.7-2.1), 90-day (OR = 1.8, CI 1.6-2.0), 1-year (OR = 1.8, CI = 1.7-2.0), and 3-year mortality (OR = 1.7, CI = 1.6-1.9). When stratified by BMI, underweight EGS patients have the highest odds of death. Paradoxically, obesity appears protective against death, even when controlling for potentially confounding factors. Increased rates of nonoperative management in the obese population may impact these findings.
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Affiliation(s)
- Sean R Maloney
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | | | | | - Sullivan A Ayuso
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | | | | | - Marc Kowalkowski
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Ronald F Sing
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Addison K May
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Samuel Wade Ross
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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10
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Rossi IR, Ross SW, May AK, Reinke CE. Readmission After Emergency General Surgery: NSQIP Review of Risk, Cause and Ideal Follow-Up. J Surg Res 2020; 260:359-368. [PMID: 33387679 DOI: 10.1016/j.jss.2020.11.035] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 10/15/2020] [Accepted: 11/01/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The Emergency General Surgery (EGS) population is particularly at high risk for readmission. Currently, no system exists to predict which EGS patients are most at risk. We hypothesized that a subset of EGS patients could be identified with increased 30-day unplanned readmission. We also hypothesized that a majority of readmissions occur sooner than the conventional 2-week follow-up period. METHODS National Surgical Quality Improvement Program (NSQIP) nonelective general surgery patients were analyzed. Multivariable logistic regression identified factors with increased odds of unplanned readmission. AAST EGS Diagnosis Categories were used to categorize postop ICD-9 codes, and the top 10 CPT codes in each group were analyzed. Readmission rate, the reason for unplanned readmission, and time to readmission were analyzed. RESULTS A total of 383,726 patients were identified with a readmission rate of 8.1% within 30 d of their primary procedure. The top 50 CPT codes accounted for 84% of EGS readmissions. Increased readmission risk was demonstrated for underweight patients (OR = 1.15, P < 0.05). High-risk hospital characteristics were LOS >2 d, any inpatient pulmonary complications, and discharge to any facility or rehab (all P < 0.05). Surgical site infections cause nearly 25% of readmissions. Intestinal procedures are most frequently readmitted (22% of EGS readmissions), with colorectal procedures having the higher odds of readmission. Most readmissions occur <10 d after discharge. CONCLUSIONS A high-risk subpopulation exists within EGS, and most readmissions occur sooner than a typical 2-week follow-up. Early interventions for high-risk EGS subpopulations may allow for early intervention and reduction of unnecessary healthcare utilization.
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Affiliation(s)
- Isolina R Rossi
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina.
| | - Samuel W Ross
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Addison K May
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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11
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Betzold RD, Dennis BM, Bellister SA, Guidry CA, Guillamondegui OD, Drake W, May AK. Antibiotic Exposure Is Not Associated With Clearance of Bronchoalveolar Growth: Results From a Prospective Ventilator-Associated Pneumonia Study. Am Surg 2020; 87:1347-1351. [PMID: 33345582 DOI: 10.1177/0003134820966281] [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: 11/15/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia is poorly understood in trauma. Ventilated trauma patients can develop bacterial burden without symptoms; the factors that influence this are unknown. METHODS Injured adults ventilated for > 2 days were enrolled. Mini-bronchoalveolar lavage was performed for 14 days or until extubation. Semi-quantitative cultures were blinded from clinicians. All cultures with > 104 colony forming units (CFU) were assessed for antibiotic exposure (ABXE) and spectrum of coverage. mBAL CFU was assessed daily. RESULTS 60 patients were ventilated for 9 days (median). There were 75 with > 104 CFU. 46 had > 104 CFU and no ABXE on the sample day. 74% had clearance or a decrease (CoD) in CFU without ABXE. 29 had > 104 CFU and ABXE on the sample day. 19 had ABXE with pathogen coverage. 84% had CoD in CFU. 10 had ABXE with no spectrum of coverage. 1/10 had increased CFU and the remaining 9/10 CoD in CFU. The three groups were not statistically different on chi-squared analysis. CONCLUSION Clearance of pathogens on surveillance cultures was unaffected by ABXE.
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Affiliation(s)
- Richard D Betzold
- 137889R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Bradley M Dennis
- Division of Trauma and Acute Care Surgery, Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Seth A Bellister
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Christopher A Guidry
- Division of Trauma and Acute Care Surgery, Department of Surgery, 21638University of Kansas Medical Center, Kansas City, KS, USA
| | - Oscar D Guillamondegui
- Division of Trauma and Acute Care Surgery, Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wonder Drake
- Division of Trauma and Acute Care Surgery, Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Addison K May
- Division of Trauma and Acute Care Surgery, 2351Carolinas Medical Center/Atrium Health, Charlotte, NC, USA
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12
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Kao AM, Maloney SR, Prasad T, Reinke CE, May AK, Heniford BT, Ross SW. The CELIOtomy Risk Score: An effort to minimize futile surgery with analysis of early postoperative mortality after emergency laparotomy. Surgery 2020; 168:676-683. [DOI: 10.1016/j.surg.2020.05.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 10/23/2022]
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13
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May AK, Talisa VB, Wilfret DA, Bulger E, Dankner W, Bernard A, Yende S. Estimating the Impact of Necrotizing Soft Tissue Infections in the United States: Incidence and Re-Admissions. Surg Infect (Larchmt) 2020; 22:509-515. [PMID: 32833599 DOI: 10.1089/sur.2020.099] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 12/17/2022] Open
Abstract
Background: Previous estimates of the incidence of necrotizing soft tissue infections (NSTI) in the United States have substantial limitations and underestimate its occurrence. Improvements in hospital mortality after NSTI have increased the number of survivors at risk for long-term sequelae. This study estimates the incidence of NSTI and the burden of re-admission and associated healthcare spending in patients who survived admission for NSTI. Methods: Index admissions for NSTI were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes combined with either Current Procedural Technology (CPT) or diagnosis-related group codes to increase specificity. Two separate datasets were used to provide primary and secondary estimates of the annual incidence of NSTIs in the United States: the National Inpatient Sample (NIS) for the years 2012-2016 and the Watson Health dataset for 2009-2013, respectively, and extrapolated to estimate the incidence for 2018. The Nationwide Readmissions Database (NRD) from 2013-2015 was used to estimate of the risk for re-admission, cost of re-admissions, and to compare 90-day re-admission rates for NSTI to common medical conditions. Results: National Inpatient Sample and Watson Health datasets demonstrated an increasing annual incidence and estimated 33,600 and 28,500 cases in 2018, respectively. The estimated annual incidences in the United States in 2018 were 10.3 and 8.7 per 100,000 persons, respectively. Risk of 90-day re-admission ranged from 24%-29% over the 3 years, 89% of which were unplanned. Of those re-admitted, 90% had one or more comorbidities, the most common diagnoses associated with re-admission were infection in 65%, acute kidney injury in 22%, and shock in 10%. The median re-admission length of stay was seven days (interquartile range [IQR]: 4-13 days) with a median cost of re-admission of $13,590 (IQR: $7186-$27440). Conclusion: The incidence of NSTI is more common than generally reported. Re-admission within 90 days is common, occurring in more than one in four survivors resulting in high healthcare costs.
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Affiliation(s)
- Addison K May
- Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Victor B Talisa
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center and Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania, USA
| | | | - Eileen Bulger
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Andrew Bernard
- Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Sachin Yende
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center and Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania, USA
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14
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Ho VP, Truong EI, Nisar S, May AK, Beilman GJ, Fry DE, Barie PS, Huston JM, Shupp JW, Pieracci FM. Pro-Con Perspectives on Ethics in Surgical Research: Update from the 39th Annual Surgical Infection Society Meeting. Surg Infect (Larchmt) 2020; 21:332-343. [PMID: 32364879 PMCID: PMC7232654 DOI: 10.1089/sur.2020.098] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Surgical research is potentially invasive, high-risk, and costly. Research that advances medical dogma must justify both its ends and its means. Although ethical questions do not always have simple answers, it is critically important for the clinician, researcher, and patient to approach these dilemmas and surgical research in a thoughtful, conscientious manner. Methods: We present four ethical issues in surgical research and discuss the opposing viewpoints. These topics were presented and discussed at the 39th Annual Meeting of the Surgical Infection Society as pro-con debates. The presenters of each opinion developed a succinct summary of their respective reviews for this publication. Results: The key subjects for these pro-con debates were: (1) Should patients be enrolled for time-sensitive surgical infection research using an opt-out or an opt-in strategy? (2) Should patients who are being enrolled in a randomized controlled trial (RCT) comparing surgery with a non-operative intervention pay the costs of their treatment arm? (3) Should the scientific community embrace open access journals as the future of scientific publishing? (4) Should the majority of funding go to clinical or basic science research? Important points were illustrated in each of the pro-con presentations and illustrated the difficulties that are facing the performance and payment of infection research in the future. Conclusions: Surgical research is ethically complex, with conflicting demands between individual patients, society, and healthcare economics. At present, there are no clear answers to these and the many other ethical issues facing research in the future. Answers will only come from continued robust dialogue among all stakeholders in surgical research.
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Affiliation(s)
- Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Quantitative and Population Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Evelyn I. Truong
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Saira Nisar
- The Burn Center, Medstar Washington Hospital Center, Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Addison K. May
- Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Gregory J. Beilman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Donald E. Fry
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - Philip S. Barie
- Departments of Surgery and Public Health, Weill Cornell Medical College, New York, New York, USA
| | - Jared M. Huston
- Departments of Surgery and Science Education, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Jeffrey W. Shupp
- The Burn Center, Medstar Washington Hospital Center, Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Fredric M. Pieracci
- Department of Surgery, Denver Health Medical Center/University of Colorado School of Medicine, Denver, Colorado, USA
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15
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Heffernan DS, Evans HL, Huston JM, Claridge JA, Blake DP, May AK, Beilman GS, Barie PS, Kaplan LJ. Surgical Infection Society Guidance for Operative and Peri-Operative Care of Adult Patients Infected by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). Surg Infect (Larchmt) 2020; 21:301-308. [DOI: 10.1089/sur.2020.101] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Daithi S. Heffernan
- Department of Surgery, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- Division of Trauma and Surgical Critical Care, Department of Surgery, Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Heather L. Evans
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jared M. Huston
- Departments of Surgery and Science Education, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Jeffrey A. Claridge
- Division of Trauma, Critical Care, Burns & Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - David P. Blake
- Department of Surgery, Division of Trauma/Surgical Critical Care, Inova Medical Group, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Department of Surgery, Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine, Bethesda, Maryland, USA
| | - Addison K. May
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Greg S. Beilman
- Division of General Surgery/Critical Care Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Philip S. Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York, USA
- Division of Medical Ethics, Weill Cornell Medicine, New York, New York, USA
| | - Lewis J. Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Society of Critical Care Medicine, Mount Prospect, Illinois, USA
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16
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Ross SW, Lauer CW, Miles WS, Green JM, Christmas AB, May AK, Matthews BD. Maximizing the Calm before the Storm: Tiered Surgical Response Plan for Novel Coronavirus (COVID-19). J Am Coll Surg 2020; 230:1080-1091.e3. [PMID: 32240770 PMCID: PMC7128345 DOI: 10.1016/j.jamcollsurg.2020.03.019] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 03/19/2020] [Indexed: 01/16/2023]
Abstract
The novel coronavirus (COVID-19) was first diagnosed in Wuhan, China in December 2019 and has now spread throughout the world, being verified by the World Health Organization as a pandemic on March 11. This had led to the calling of a national emergency on March 13 in the US. Many hospitals, healthcare networks, and specifically, departments of surgery, are asking the same questions about how to cope and plan for surge capacity, personnel attrition, novel infrastructure utilization, and resource exhaustion. Herein, we present a tiered plan for surgical department planning based on incident command levels. This includes acute care surgeon deployment (given their critical care training and vertically integrated position in the hospital), recommended infrastructure and transfer utilization, triage principles, and faculty, resident, and advanced care practitioner deployment.
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Affiliation(s)
- Samuel Wade Ross
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC.
| | - Cynthia W Lauer
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
| | - William S Miles
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
| | - John M Green
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
| | - A Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
| | - Addison K May
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
| | - Brent D Matthews
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
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17
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Rogers AJ, Solus JF, Hunninghake GM, Baron RM, Meyer NJ, Janz DR, Schwartz DA, May AK, Lawson WE, Blackwell TS, Ware LB. MUC5B Promoter Polymorphism and Development of Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2019; 198:1342-1345. [PMID: 30025215 DOI: 10.1164/rccm.201801-0140le] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | | | - Nuala J Meyer
- 4 University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania
| | - David R Janz
- 5 Louisiana State University School of Medicine New Orleans, Louisiana
| | | | | | - William E Lawson
- 2 Vanderbilt University Nashville, Tennessee.,7 Department of Veterans Affairs Medical Center Nashville, Tennessee
| | - Timothy S Blackwell
- 2 Vanderbilt University Nashville, Tennessee.,7 Department of Veterans Affairs Medical Center Nashville, Tennessee
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18
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Wischmeyer PE, Mintz-Cole RA, Baird CH, Easley KA, May AK, Sax HC, Kudsk KA, Hao L, Tran PH, Jones DP, Blumberg HM, Ziegler TR. Role of heat shock protein and cytokine expression as markers of clinical outcomes with glutamine-supplemented parenteral nutrition in surgical ICU patients. Clin Nutr 2019; 39:563-573. [PMID: 30981628 DOI: 10.1016/j.clnu.2019.02.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/26/2019] [Accepted: 02/26/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Nutrients, such as glutamine (GLN), have been shown to effect levels of a family of protective proteins termed heat shock proteins (HSPs) in experimental and clinical critical illness. HSPs are believed to serve as extracellular inflammatory messengers and intracellular cytoprotective molecules. Extracellular HSP70 (eHSP70) has been termed a chaperokine due to ability to modulate the immune response. Altered levels of eHSP70 are associated with various disease states. Larger clinical trial data on GLN effect on eHSP expression and eHSP70's association with inflammatory mediators and clinical outcomes in critical illness are limited. OBJECTIVE Explore effect of longitudinal change in serum eHSP70, eHSP27 and inflammatory cytokine levels on clinical outcomes such as pneumonia and mortality in adult surgical intensive care unit (SICU) patients. Further, evaluate effect of parenteral nutrition (PN) supplemented with GLN (GLN-PN) versus GLN-free, standard PN (STD-PN) on serum eHSP70 and eHSP27 concentrations. METHODS Secondary observational analysis of a multicenter clinical trial in 150 adults after cardiac, vascular, or gastrointestinal surgery requiring PN support and SICU care conducted at five academic medical centers. Patients received isocaloric, isonitrogenous PN, with or without GLN dipeptide. Serum eHSP70 and eHSP27, interleukin-6 (IL-6), and 8 (IL-8) concentrations were analyzed in patient serum at baseline (prior to study PN) and over 28 days of follow up. RESULTS eHSP70 declined over time in survivors during 28 days follow-up, but non-survivors had significantly higher eHSP70 concentrations compared to survivors. In patients developing pneumonia, eHSP70, eHSP27, IL-8, and IL-6 were significantly elevated. Adjusted relative risk for hospital mortality was reduced 75% (RR = 0.25, p = 0.001) for SICU patients with a faster decline in eHSP70. The area under the receiver operating characteristic curve was 0.85 (95% CI: 0.76 to 0.94) for the final model suggesting excellent discrimination between SICU survivors and non-survivors. GLN-PN did not alter eHSP70 or eHSP27 serum concentrations over time compared to STD-PN. CONCLUSION Our results suggest that serum HSP70 concentration may be an important marker for severity of illness and likelihood of recovery in the SICU. GLN-supplemented-PN did not increase eHSP70.
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Affiliation(s)
- Paul E Wischmeyer
- Duke University Hospital, Department of Anesthesiology and Duke Clinical Research Institute, 2301 Erwin Rd, Durham, NC 27710, USA.
| | - Rachael A Mintz-Cole
- Duke University Hospital, Department of Anesthesiology and Duke Clinical Research Institute, 2301 Erwin Rd, Durham, NC 27710, USA.
| | - Christine H Baird
- University of Colorado Denver Anschutz Medical Campus, Anesthesiology, 12700 E. 19th Avenue Box 8602, Aurora, CO 80045, USA.
| | - Kirk A Easley
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
| | - Addison K May
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37240, USA.
| | - Harry C Sax
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA.
| | - Kenneth A Kudsk
- Department of Surgery, University of Wisconsin, Schools of Medicine and Public Health, Madison, Madison, WI 53792, USA.
| | - Li Hao
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Phong H Tran
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Dean P Jones
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA; Center for Clinical and Molecular Nutrition, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
| | - Thomas R Ziegler
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA; Center for Clinical and Molecular Nutrition, Emory University School of Medicine, Atlanta, GA 30322, USA; Atlanta Veterans Affairs Medical Center, Decatur, GA 30033, USA.
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19
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Itani KMF, May AK. Surgical Infection Society: We Endorse Antimicrobial Stewardship We Stand by Our International Colleagues and Societies in the Fight for Proper Antimicrobial Therapy. Surg Infect (Larchmt) 2018; 18:843-845. [PMID: 29120282 DOI: 10.1089/sur.2017.218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Kamal M F Itani
- 1 VA Boston Health Care System, Boston University and Harvard Medical School , Boston, Massachusetts
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20
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Sartelli M, Kluger Y, Ansaloni L, Coccolini F, Baiocchi GL, Hardcastle TC, Moore EE, May AK, Itani KMF, Fry DE, Boermeester MA, Guirao X, Napolitano L, Sawyer RG, Rasa K, Abu-Zidan FM, Adesunkanmi AK, Atanasov B, Augustin G, Bala M, Cainzos MA, Chichom-Mefire A, Cortese F, Damaskos D, Delibegovic S, Demetrashvili Z, De Simone B, Duane TM, Ghnnam W, Gkiokas G, Gomes CA, Hecker A, Karamarkovic A, Kenig J, Khokha V, Kong V, Isik A, Leppäniemi A, Litvin A, Lostoridis E, Machain GM, Marwah S, McFarlane M, Mesina C, Negoi I, Olaoye I, Pintar T, Pupelis G, Rems M, Rubio-Perez I, Sakakushev B, Segovia-Lohse H, Siribumrungwong B, Talving P, Ulrych J, Vereczkei AG, Labricciosa FM, Catena F. Knowledge, awareness, and attitude towards infection prevention and management among surgeons: identifying the surgeon champion. World J Emerg Surg 2018; 13:37. [PMID: 30140304 PMCID: PMC6098571 DOI: 10.1186/s13017-018-0198-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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] [Received: 05/29/2018] [Accepted: 08/08/2018] [Indexed: 02/08/2023] Open
Abstract
Despite evidence supporting the effectiveness of best practices of infection prevention and management, many surgeons worldwide fail to implement them. Evidence-based practices tend to be underused in routine practice. Surgeons with knowledge in surgical infections should provide feedback to prescribers and integrate best practices among surgeons and implement changes within their team. Identifying a local opinion leader to serve as a champion within the surgical department may be important. The “surgeon champion” can integrate best clinical practices of infection prevention and management, drive behavior change in their colleagues, and interact with both infection control teams in promoting antimicrobial stewardship.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia, 62100 Macerata, Italy
| | - Yoram Kluger
- 2Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Luca Ansaloni
- General Surgery Department, "M. Bufalini" Cesena Hospital, Cesena, Italy
| | - Federico Coccolini
- General Surgery Department, "M. Bufalini" Cesena Hospital, Cesena, Italy
| | - Gian Luca Baiocchi
- 4Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Timothy C Hardcastle
- Department of Surgery, Trauma Service, Inkosi Albert Luthuli Central Hospital, Nelson R Mandela School of Clinical Medicine, Durban, South Africa
| | - Ernest E Moore
- 6Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, CO USA
| | - Addison K May
- 7Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN USA
| | - Kamal M F Itani
- Department of Surgery, VA Boston Health Care System, Boston University, Harvard Medical School, Boston, MA USA
| | - Donald E Fry
- 9Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL USA.,10University of New Mexico School of Medicine, Albuquerque, NM USA
| | | | - Xavier Guirao
- Unit of Endocrine, Head, and Neck Surgery and Unit of Surgical Infections Support, Department of General Surgery, ParcTaulí, Hospital University, Sabadell, Spain
| | - Lena Napolitano
- 13Department of Surgery, University of Michigan, Ann Arbor, MI USA
| | - Robert G Sawyer
- 14Department of Surgery, Western Michigan University School of Medicine, Kalamazoo, MI USA
| | - Kemal Rasa
- Department of Surgery, Anadolu Medical Center, Kocaali, Turkey
| | - Fikri M Abu-Zidan
- 16Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Boyko Atanasov
- 18Department of General Surgery, Medical University of Plovdiv, UMHAT Eurohospital, Plovdiv, Bulgaria
| | - Goran Augustin
- 19Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Miklosh Bala
- 20Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Miguel A Cainzos
- 21Department of Surgery, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | | | - Dimitris Damaskos
- 24Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Samir Delibegovic
- 25Department of Surgery, University Clinical Center of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Zaza Demetrashvili
- Department General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
| | | | - Therese M Duane
- Department of Surgery, John Peter Smith Health Network, Fort Worth, TX USA
| | - Wagih Ghnnam
- 29Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - George Gkiokas
- 30Second Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Carlos A Gomes
- Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Department of Surgery, Hospital Universitário Terezinha de Jesus, Juiz de Fora, Brazil
| | - Andreas Hecker
- 32Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | | | - Jakub Kenig
- 34Third Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Victor Kong
- 36Department of Surgery, Edendale Hospital, Pietermaritzburg, South Africa
| | - Arda Isik
- 37General Surgery Department, Magee Womens Hospital, UPMC, Pittsburgh, USA
| | - Ari Leppäniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Andrey Litvin
- 39Surgical Disciplines, Immanuel Kant Baltic Federal University/Regional Clinical Hospital, Kaliningrad, Russian Federation
| | | | - Gustavo M Machain
- 41Department of Surgery, II Cátedra de Clínica Quirúrgica, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Sanjay Marwah
- 42Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | - Michael McFarlane
- 43Department of Surgery, Radiology, University Hospital of the West Indies, Kingston, Jamaica
| | - Cristian Mesina
- Second Surgical Clinic, Emergency Hospital of Craiova, Craiova, Romania
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Iyiade Olaoye
- 46Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Tadeja Pintar
- 47Department of Surgery, UMC Ljubljana, Ljubljana, Slovenia
| | - Guntars Pupelis
- 48Department of General and Emergency Surgery, Riga East University Hospital "Gailezers", Riga, Latvia
| | - Miran Rems
- Department of General Surgery, Jesenice General Hospital, Jesenice, Slovenia
| | - Ines Rubio-Perez
- 50Colorectal Surgery Unit, General Surgery Department, La Paz University Hospital, Madrid, Spain
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Helmut Segovia-Lohse
- 41Department of Surgery, II Cátedra de Clínica Quirúrgica, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Boonying Siribumrungwong
- 52Faculty of Medicine, Department of Surgery, Thammasat University Hospital, Thammasat University, Amphoe Khlong Luang, Pathum Thani Thailand
| | - Peep Talving
- Department of Surgery, North Estonia Medical Center, Tallinn, Estonia
| | - Jan Ulrych
- 54First Department of Surgery-Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Prague, Czech Republic
| | - András G Vereczkei
- 55Department of Surgery, Medical School University of Pécs, Pécs, Hungary
| | | | - Fausto Catena
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
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21
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May AK. The 38th Surgical Infection Society Presidential Address: Just Advance the Needle! Surg Infect (Larchmt) 2018; 19:573-581. [PMID: 30044181 DOI: 10.1089/sur.2018.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Addison K May
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
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22
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Dennis BM, Betzold RD, Patton D, Hopper HA, Jenkins J, Fonnesbeck C, Drake W, May AK. Bacterial Burden in Critically Injured Ventilated Patients Does Not Correlate with Progression to Pneumonia. Surg Infect (Larchmt) 2018; 19:369-375. [PMID: 29652241 DOI: 10.1089/sur.2017.199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is common in critically injured patients. The pathogenesis of VAP is not completely understood. We hypothesized that mechanically ventilated trauma patients who develop pneumonia have a progressive increase in pathogen burden over the course of ventilation until a threshold for symptomatic pneumonia is reached, leading to clinical suspicion of VAP. METHODS Critically injured adults ventilated for more than two successive days were enrolled. Patients underwent daily surveillance mini-bronchoscopic alveolar lavage (mBAL) while ventilated for 14 days or until extubation. Standard semi-quantitative cultures were performed, and the investigators were blinded to the results. Standard patient management was performed by the clinical team. Patients suspected of having VAP by the clinical team underwent bronchoscopic bronchoalveolar lavage (bBAL) and semi-quantitative culture, with VAP defined as clinical symptoms plus >104 colony-forming units (CFU) of bacteria. Standard statistical analysis for non-parametric data was performed. RESULTS The 37 patients enrolled were ventilated for a median of nine days. While ventilated, 23 patients met the criteria for a clinical suspicion of VAP, of which two were too ill for bronchoscopy. Thus, 21 patients underwent bBALs because of a suspicion of VAP, and 13 (35%) were positive, with >104 CFU of one or more pathogens, and were treated for pneumonia. The bacterial burden on mBAL remained <104 CFU during ventilation for 32% of patients. None developed clinical symptoms of VAP. Two-thirds (67%) had an mBAL bacterial burden of >104 CFU without clinical suspicion of VAP. Half (56%) of positive surveillance cultures were followed by clinical VAP, confirmed by bBAL, all of which had identical pathogens on mBAL and bBAL. Almost half (44%) of the patients with positive surveillance mBALs never developed clinical VAP. CONCLUSION A significant percentage of critically injured, ventilated adults develop high bacterial burdens in the lungs early in their course, and many clear these bacteria without developing VAP. Further study is needed to identify the factors causing progression to VAP.
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Affiliation(s)
- Bradley M Dennis
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Richard D Betzold
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Daryl Patton
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Herbert A Hopper
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Judith Jenkins
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Chris Fonnesbeck
- 2 Department of Biostatistics, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Wonder Drake
- 3 Division of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Addison K May
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
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Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, Stollings JL, Kumar AB, Hughes CG, Hernandez A, Guillamondegui OD, May AK, Weavind L, Casey JD, Siew ED, Shaw AD, Bernard GR, Rice TW. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med 2018; 378:829-839. [PMID: 29485925 PMCID: PMC5846085 DOI: 10.1056/nejmoa1711584] [Citation(s) in RCA: 755] [Impact Index Per Article: 125.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomes. METHODS In a pragmatic, cluster-randomized, multiple-crossover trial conducted in five intensive care units at an academic center, we assigned 15,802 adults to receive saline (0.9% sodium chloride) or balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) according to the randomization of the unit to which they were admitted. The primary outcome was a major adverse kidney event within 30 days - a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) - all censored at hospital discharge or 30 days, whichever occurred first. RESULTS Among the 7942 patients in the balanced-crystalloids group, 1139 (14.3%) had a major adverse kidney event, as compared with 1211 of 7860 patients (15.4%) in the saline group (marginal odds ratio, 0.91; 95% confidence interval [CI], 0.84 to 0.99; conditional odds ratio, 0.90; 95% CI, 0.82 to 0.99; P=0.04). In-hospital mortality at 30 days was 10.3% in the balanced-crystalloids group and 11.1% in the saline group (P=0.06). The incidence of new renal-replacement therapy was 2.5% and 2.9%, respectively (P=0.08), and the incidence of persistent renal dysfunction was 6.4% and 6.6%, respectively (P=0.60). CONCLUSIONS Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline. (Funded by the Vanderbilt Institute for Clinical and Translational Research and others; SMART-MED and SMART-SURG ClinicalTrials.gov numbers, NCT02444988 and NCT02547779 .).
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Affiliation(s)
- Matthew W Semler
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Wesley H Self
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Jonathan P Wanderer
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Jesse M Ehrenfeld
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Li Wang
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Daniel W Byrne
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Joanna L Stollings
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Avinash B Kumar
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Christopher G Hughes
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Antonio Hernandez
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Oscar D Guillamondegui
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Addison K May
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Liza Weavind
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Jonathan D Casey
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Edward D Siew
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Andrew D Shaw
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Gordon R Bernard
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
| | - Todd W Rice
- From the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., G.R.B., T.W.R.), the Departments of Emergency Medicine (W.H.S.), Anesthesiology (J.P.W., J.M.E., A.B.K., C.G.H., A.H., L. Weavind, A.D.S.), Biomedical Informatics (J.P.W., J.M.E.), Surgery (J.M.E., O.D.G., A.K.M.), Health Policy (J.M.E.), Biostatistics (L. Wang, D.W.B.), and Pharmaceutical Services (J.L.S.), and the Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Disease (E.D.S.) - all at Vanderbilt University Medical Center, Nashville
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Sartelli M, Kluger Y, Ansaloni L, Carlet J, Brink A, Hardcastle TC, Khanna A, Chicom-Mefire A, Rodríguez-Baño J, Nathwani D, Mendelson M, Watkins RR, Pulcini C, Beović B, May AK, Itani KMF, Mazuski JE, Fry DE, Coccolini F, Raşa K, Montravers P, Eckmann C, Abbo LM, Abubakar S, Abu-Zidan FM, Adesunkanmi AK, Al-Hasan MN, Althani AA, Ticas JEA, Ansari S, Ansumana R, da Silva ARA, Augustin G, Bala M, Balogh ZJ, Baraket O, Bassett,i M, Bellanova G, Beltran MA, Ben-Ishay O, Biffl WL, Boermeester MA, Brecher SM, Bueno J, Cainzos MA, Cairns K, Camacho-Ortiz A, Ceresoli M, Chandy SJ, Cherry-Bukowiec JR, Cirocchi R, Colak E, Corcione A, Cornely OA, Cortese F, Cui Y, Curcio D, Damaskos D, Daş K, Delibegovic S, Demetrashvili Z, De Simone B, de Souza HP, De Waele J, Dhingra S, Diaz JJ, Di Carlo I, Di Marzo F, Di Saverio S, Dogjani A, Dorj G, Dortet L, Duane TM, Dupont H, Egiev VN, Eid HO, Elmangory M, Marei HES, Enani MA, Escandón-Vargas K, Faro Junior MP, Ferrada P, Foghetti D, Foianini E, Fraga GP, Frattima S, Gandhi C, Gattuso G, Giamarellou E, Ghnnam W, Gkiokas G, Girardis M, Goff DA, Gomes CA, Gomi H, Gronerth RIG, Guirao X, Guzman-Blanco M, Haque M, Hecker A, Hell M, Herzog T, Hicks L, Kafka-Ritsch R, Kao LS, Kanj SS, Kaplan LJ, Kapoor G, Karamarkovic A, Kashuk J, Kenig J, Khamis F, Khokha V, Kiguba R, Kirkpatrick AW, Kørner H, Koike K, Kok KYY, Kon K, Kong V, Inaba K, Ioannidis O, Isik A, Iskandar K, Labbate M, Labricciosa FM, Lagrou K, Lagunes L, Latifi R, Lasithiotakis K, Laxminarayan R, Lee JG, Leone M, Leppäniemi A, Li Y, Liang SY, Liau KH, Litvin A, Loho T, Lowman W, Machain GM, Maier RV, Manzano-Nunez R, Marinis A, Marmorale C, Martin-Loeches I, Marwah S, Maseda E, McFarlane M, de Melo RB, Melotti MR, Memish Z, Mertz D, Mesina C, Menichetti F, Mishra SK, Montori G, Moore EE, Moore FA, Naidoo N, Napolitano L, Negoi I, Nicolau DP, Nikolopoulos I, Nord CE, Ofori-Asenso R, Olaoye I, Omari AH, Ordoñez CA, Ouadii M, Ouedraogo AS, Pagani L, Paiva JA, Parreira JG, Pata F, Pereira J, Pereira NR, Petrosillo N, Picetti E, Pintar T, Ponce-de-Leon A, Popovski Z, Poulakou G, Preller J, Guerrero AP, Pupelis G, Quiodettis M, Rawson TM, Reichert M, Reinhart K, Rems M, Rello J, Rizoli S, Roberts J, Rubio-Perez I, Ruppé E, Sakakushev B, Sall I, Kafil HS, Sanders J, Sato N, Sawyer RG, Scalea T, Scibé R, Scudeller L, Lohse HS, Sganga G, Shafiq N, Shah JN, Spigaglia P, Suroowan S, Tsioutis C, Sifri CD, Siribumrungwong B, Sugrue M, Talving P, Tan BK, Tarasconi A, Tascini C, Tilsed J, Timsit JF, Tumbarello M, Trung NT, Ulrych J, Uranues S, Velmahos G, Vereczkei AG, Viale P, Estape JV, Viscoli C, Wagenlehner F, Wright BJ, Xiao Y, Yuan KC, Zachariah SK, Zahar JR, Mergulhão P, Catena F. A Global Declaration on Appropriate Use of Antimicrobial Agents across the Surgical Pathway. Surg Infect (Larchmt) 2017; 18:846-853. [PMID: 29173054 DOI: 10.1089/sur.2017.219] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
This declaration, signed by an interdisciplinary task force of 234 experts from 83 different countries with different backgrounds, highlights the threat posed by antimicrobial resistance and the need for appropriate use of antibiotic agents and antifungal agents in hospitals worldwide especially focusing on surgical infections. As such, it is our intent to raise awareness among healthcare workers and improve antimicrobial prescribing. To facilitate its dissemination, the declaration was translated in different languages.
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Smith SE, Rumbaugh KA, May AK. Evaluation of a Short Course of Antimicrobial Therapy for Complicated Intra-Abdominal Infections in Critically Ill Surgical Patients. Surg Infect (Larchmt) 2017; 18:742-750. [PMID: 28832270 DOI: 10.1089/sur.2017.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 12/31/2022] Open
Abstract
BACKGROUND The optimal duration of antimicrobial therapy for treatment of complicated intra-abdominal infections (cIAI) in critically ill surgical patients is unknown. Recent evidence suggests that a short (four-day) course of therapy may be effective, however data in severely critically ill patients are limited. PATIENTS AND METHODS A single-center, retrospective, cohort study was conducted at a tertiary academic medical center. Adult patients admitted to the surgical intensive care unit (SICU) with cIAI between December 2011 and July 2015 were enrolled. Patients undergoing transplantation and those with less than 24 h in the SICU were excluded. Patients were divided into two groups, short (≤ 7 d) and long (> 7 d) antimicrobial therapy. The primary outcome was treatment failure, which was defined as a composite of recurrent cIAI, secondary extra-abdominal infection, and/or in-hospital mortality from any cause. Categorical and continuous data were analyzed with χ2 and Mann-Whitney U tests, respectively. Binary logistic regression was performed to determine factors associated with treatment failure and mortality. RESULTS Of 1,679 patients screened, 240 were included, 103 in the short and 137 in the long group. Patients in the short and long groups received a median of 5 and 14 d of therapy, respectively (p < 0.001). Treatment failure occurred less frequently with a short duration of therapy (39% versus 63%, p < 0.001) and it occurred two days sooner after source control in patients receiving the shorter courses of antimicrobial therapy (short, median 6 d, interquartile range [IQR] 3-9; long, 8 d, IQR 6-14; p < 0.001). Logistic regression demonstrated that a long duration of therapy was associated with treatment failure (odds ratio [OR] 2.186, 95% confidence interval [CI] 1.251-3.820, p = 0.006), but not with mortality (OR 0.738, 95% CI 0.329-1.655, p = 0.461). CONCLUSIONS In critically ill surgical patients with cIAI, a short duration of antimicrobial therapy after source control resulted in similar outcomes to previously published studies, providing support for the safety of this approach in critically ill patients.
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Affiliation(s)
- Susan E Smith
- 1 Department of Pharmaceutical Services, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Kelli A Rumbaugh
- 1 Department of Pharmaceutical Services, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Addison K May
- 2 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
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Murphy LS, Wickersham N, McNeil JB, Shaver CM, May AK, Bastarache JA, Ware LB. Endothelial glycocalyx degradation is more severe in patients with non-pulmonary sepsis compared to pulmonary sepsis and associates with risk of ARDS and other organ dysfunction. Ann Intensive Care 2017; 7:102. [PMID: 28986821 PMCID: PMC5630541 DOI: 10.1186/s13613-017-0325-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [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: 04/17/2017] [Accepted: 09/23/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Disruption of the endothelial glycocalyx contributes to acute lung injury in experimental sepsis but has not been well studied in humans. To study glycocalyx degradation in sepsis-induced ARDS, we measured plasma levels of syndecan-1, a marker for glycocalyx degradation. METHODS The present study is a retrospective observational study of 262 ventilated medical ICU patients at risk of ARDS due to severe sepsis and APACHE II ≥ 25. Plasma syndecan-1 was measured at study enrollment. Primary analysis focused on the association between syndecan-1 levels and the development of ARDS, other organ dysfunction (Brussels criteria), or in-hospital mortality. RESULTS Overall, 135 (52%) patients developed ARDS. In patients with non-pulmonary sepsis, syndecan-1 levels were associated with ARDS (p = 0.05). Regardless of etiology of sepsis, higher syndecan-1 levels were associated with hepatic (p < 0.001), renal (p = 0.003), coagulation (p = 0.001), and circulatory (p = 0.02) failure as well as in-hospital mortality (p = 0.001), and there was a significant association between syndecan-1 levels and the number of vasopressors required in the first 24 h (p < 0.001). In addition, elevated syndecan levels were independently predictive of mortality in multivariable logistic regression adjusted for age and APACHE II score (odds ratio 1.85 per log increase in syndecan-1, 95% CI 1.056-3.241, p = 0.03). CONCLUSION The extent of endothelial glycocalyx degradation is associated with non-pulmonary organ dysfunction in subjects with sepsis and is associated with ARDS but only in the subgroup with non-pulmonary sepsis. Measurement of syndecan-1 levels in sepsis patients might be useful for identifying patients at high risk of organ dysfunction and mortality as well as those who could benefit from therapies targeted at protecting or restoring the glycocalyx.
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Affiliation(s)
- Laura S. Murphy
- 0000 0001 2264 7217grid.152326.1Vanderbilt University School of Medicine, Nashville, TN USA
| | - Nancy Wickersham
- 0000 0001 2264 7217grid.152326.1Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, T1218 Medical Center North, 1161 21st Avenue S, Nashville, TN 37232-2650 USA
| | - J. Brennan McNeil
- 0000 0001 2264 7217grid.152326.1Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, T1218 Medical Center North, 1161 21st Avenue S, Nashville, TN 37232-2650 USA
| | - Ciara M. Shaver
- 0000 0001 2264 7217grid.152326.1Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, T1218 Medical Center North, 1161 21st Avenue S, Nashville, TN 37232-2650 USA
| | - Addison K. May
- 0000 0004 1936 9916grid.412807.8Department of Surgery, Vanderbilt University Medical Center, Nashville, TN USA
| | - Julie A. Bastarache
- 0000 0001 2264 7217grid.152326.1Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, T1218 Medical Center North, 1161 21st Avenue S, Nashville, TN 37232-2650 USA
| | - Lorraine B. Ware
- 0000 0001 2264 7217grid.152326.1Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, T1218 Medical Center North, 1161 21st Avenue S, Nashville, TN 37232-2650 USA ,0000 0001 2264 7217grid.152326.1Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN USA
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Abstract
Three therapeutic principles most substantially improve organ dysfunction and survival in sepsis: early, appropriate antimicrobial therapy; restoration of adequate cellular perfusion; timely source control. The new definitions of sepsis and septic shock reflect the inadequate sensitivity, specify, and lack of prognostication of systemic inflammatory response syndrome criteria. Sequential (sepsis-related) organ failure assessment more effectively prognosticates in sepsis and critical illness. Inadequate cellular perfusion accelerates injury and reestablishing perfusion limits injury. Multiple organ systems are affected by sepsis and septic shock and an evidence-based multipronged approach to systems-based therapy in critical illness results in improve outcomes.
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Affiliation(s)
- Bracken A Armstrong
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S Medical Arts Building 404, Nashville, TN 37212, USA.
| | - Richard D Betzold
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S Medical Arts Building 404, Nashville, TN 37212, USA
| | - Addison K May
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S Medical Arts Building 404, Nashville, TN 37212, USA
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Merchant AI, Walters CB, Valenzuela J, McQueen KA, May AK. Creating a Global Acute Care Surgery Fellowship to Meet International Need. J Surg Educ 2017; 74:780-786. [PMID: 28427944 DOI: 10.1016/j.jsurg.2017.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 01/04/2017] [Accepted: 01/30/2017] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Existing Acute Care Surgery (ACS) fellowships are positioned to develop well-trained surgeons with specific skills to facilitate improvements in care delivery in Global ACS. Many resident and fellowship programs offer clinical electives that expose trainees to operative experiences, exposing trainees to the needs in resource-challenged settings. However, most lack a focus on long-term development and research designed to enhance the country's local skills, capability, and capacity. The Global Acute Care Surgery (Global ACS) fellowship produces a surgeon who focuses on capacity building and systems development across the world. METHODS At Vanderbilt University, the current American Association for the Surgery of Trauma-Acute Care Surgery (AAST-ACS) fellowship was adapted to create an academic Global Acute Care Surgery (Global ACS) fellowship. This fellowship specifically enhances fellowship trainee's skills in needs assessment and performing research to facilitate the development and implementation of trauma and acute care surgery systems in low- and middle income countries. This research will foster context-appropriate data, collected and based in low- and middle-income countries, to guide practice and policy. RESULTS AND CONCLUSION Two fellows have completed the Global ACS fellowship at Vanderbilt University. The fellowship requirements, clinical skills, project development and overall goals are outlined within the article. Challenges, funding, and mentorship must also be addressed to develop a comprehensive fellowship. A sample two-year timeline is provided to complete the fellowship track and meet the defined goals. A structured global acute care surgery fellowship enables fellows to reduce the surgical burden of disease and contribute to surgical systems development at both local and international levels by creating meaningful research and developing sustainable change in LMIC countries.
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Affiliation(s)
- Amina I Merchant
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Camila B Walters
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Julie Valenzuela
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly A McQueen
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Addison K May
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
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Ware LB, Zhao Z, Koyama T, Brown RM, Semler MW, Janz DR, May AK, Fremont RD, Matthay MA, Cohen MJ, Calfee CS. Derivation and validation of a two-biomarker panel for diagnosis of ARDS in patients with severe traumatic injuries. Trauma Surg Acute Care Open 2017; 2:e000121. [PMID: 29766112 PMCID: PMC5887582 DOI: 10.1136/tsaco-2017-000121] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 07/12/2017] [Indexed: 01/11/2023] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is common after severe traumatic injuries but is underdiagnosed and undertreated. We hypothesized that a panel of plasma biomarkers could be used to diagnose ARDS in severe trauma. To test this hypothesis, we derived and validated a biomarker panel in three independent cohorts and compared the diagnostic performance to clinician recognition of ARDS. Methods Eleven plasma biomarkers of inflammation, lung epithelial and endothelial injury were measured in a derivation cohort of 439 severe trauma patients. ARDS status was analyzed by two-investigator consensus, and cases were required to meet Berlin criteria on intensive care unit (ICU) day 1. Controls were subjects without ARDS during the first 4 days of study enrollment. A multivariable logistic regression model was used to generate probabilities for ARDS. A reduced model with the top two performing markers was then tested in two independent validation cohorts. To assess clinical diagnosis of ARDS, medical records in the derivation cohort were systematically searched for documentation of ARDS diagnosis made by a clinical provider. Results Among 11 biomarkers, the combination of the endothelial injury marker angiopoietin-2 (Ang-2) and the lung epithelial injury marker receptor for advanced glycation endproducts (RAGE) provided good discrimination for ARDS in the derivation cohort (area under the curve (AUC)=0.74 (95% CI 0.67 to 0.80). In the validation cohorts, the AUCs for this model were 0.70 (0.61 to 0.77) and 0.78 (0.71 to 0.84). In contrast, provider assessment demonstrated poor diagnostic accuracy for ARDS, with AUC of 0.55 (0.51 to 0.60). Discussion A two-biomarker panel consisting of Ang-2 and RAGE performed well across multiple patient cohorts and outperformed clinical providers for diagnosing ARDS in severe trauma. Clinical application of this model could improve both diagnosis and treatment of ARDS in patients with severe trauma. Level of evidence Diagnostic study, level II.
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Affiliation(s)
- Lorraine B Ware
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ryan M Brown
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Matthew W Semler
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - David R Janz
- Department of Medicine, Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University School of Medicine in New Orleans, New Orleans, Louisiana, USA
| | - Addison K May
- Department of Surgical Science, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Richard D Fremont
- Department of Medicine, Meharry Medical College, Nashville, Tennessee, USA
| | - Michael A Matthay
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, California, USA
| | - Mitchell J Cohen
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA.,University of Colorado, Aurora, Colorado, USA
| | - Carolyn S Calfee
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, California, USA
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Coccolini F, Montori G, Ceresoli M, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, Coimbra R, Rizoli S, Kluger Y, Abu-Zidan FM, Sartelli M, De Moya M, Velmahos G, Fraga GP, Pereira BM, Leppaniemi A, Boermeester MA, Kirkpatrick AW, Maier R, Bala M, Sakakushev B, Khokha V, Malbrain M, Agnoletti V, Martin-Loeches I, Sugrue M, Di Saverio S, Griffiths E, Soreide K, Mazuski JE, May AK, Montravers P, Melotti RM, Pisano M, Salvetti F, Marchesi G, Valetti TM, Scalea T, Chiara O, Kashuk JL, Ansaloni L. The role of open abdomen in non-trauma patient: WSES Consensus Paper. World J Emerg Surg 2017; 12:39. [PMID: 28814969 PMCID: PMC5557069 DOI: 10.1186/s13017-017-0146-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/25/2017] [Indexed: 12/19/2022] Open
Abstract
The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Marco Ceresoli
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore hospital, Parma, Italy
| | | | - Rao Ivatury
- Trauma Surgery, Virginia Commonwealth University, Richmond, VA 23284 USA
| | - Walter Biffl
- Acute Care Surgery, The Queen’s Medical Center, Honolulu, HI 96813 USA
| | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, 15213 USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, 92103 USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael’s Hospital, Toronto, ON Canada
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Marc De Moya
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | - George Velmahos
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | | | - Bruno M. Pereira
- Faculdade de Ciências Médicas (FCM) – Unicamp Campinas, São Paulo, Brazil
| | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | | | | | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, 98104 USA
| | - Miklosh Bala
- General Surgery Department, Hadassah Medical Centre, Jerusalem, Israel
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital/UMBAL/St George Plovdiv, Plovdiv, Bulgaria
| | | | - Manu Malbrain
- ICU and High Care Burn Unit, Ziekenhius Netwerk Antwerpen, Antwerpen, Belgium
| | | | | | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | | | - Ewen Griffiths
- Upper Gatrointestinal Surgery, Birmigham Hospital, Birmigham, UK
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - John E. Mazuski
- Department of Surgery, School of Medicine, Washington University, Saint Louis, MO 63130 USA
| | - Addison K. May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN 37232 USA
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | | | - Michele Pisano
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Francesco Salvetti
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Tino M. Valetti
- ICU Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Thomas Scalea
- Trauma Surgery department, University of Maryland School of Medicine, Baltimore, MD 21201 USA
| | - Osvaldo Chiara
- Emergency and Trauma Surgery department, Niguarda Hospital, Milan, Italy
| | - Jeffry L. Kashuk
- General Surgery department, Assuta Medical Centers, Tel Aviv, Israel
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
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Zhao Z, Wickersham N, Kangelaris KN, May AK, Bernard GR, Matthay MA, Calfee CS, Koyama T, Ware LB. External validation of a biomarker and clinical prediction model for hospital mortality in acute respiratory distress syndrome. Intensive Care Med 2017; 43:1123-1131. [PMID: 28593401 PMCID: PMC5978765 DOI: 10.1007/s00134-017-4854-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/25/2017] [Indexed: 01/11/2023]
Abstract
PURPOSE Mortality prediction in ARDS is important for prognostication and risk stratification. However, no prediction models have been independently validated. A combination of two biomarkers with age and APACHE III was superior in predicting mortality in the NHLBI ARDSNet ALVEOLI trial. We validated this prediction tool in two clinical trials and an observational cohort. METHODS The validation cohorts included 849 patients from the NHLBI ARDSNet Fluid and Catheter Treatment Trial (FACTT), 144 patients from a clinical trial of sivelestat for ARDS (STRIVE), and 545 ARDS patients from the VALID observational cohort study. To evaluate the performance of the prediction model, the area under the receiver operating characteristic curve (AUC), model discrimination, and calibration were assessed, and recalibration methods were applied. RESULTS The biomarker/clinical prediction model performed well in all cohorts. Performance was better in the clinical trials with an AUC of 0.74 (95% CI 0.70-0.79) in FACTT, compared to 0.72 (95% CI 0.67-0.77) in VALID, a more heterogeneous observational cohort. The AUC was 0.73 (95% CI 0.70-0.76) when FACTT and VALID were combined. CONCLUSION We validated a mortality prediction model for ARDS that includes age, APACHE III, surfactant protein D, and interleukin-8 in a variety of clinical settings. Although the model performance as measured by AUC was lower than in the original model derivation cohort, the biomarker/clinical model still performed well and may be useful for risk assessment for clinical trial enrollment, an issue of increasing importance as ARDS mortality declines, and better methods are needed for selection of the most severely ill patients for inclusion.
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Affiliation(s)
- Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
- The Institution for Medicine and Public Health, Vanderbilt University, Nashville, TN, USA
| | - Nancy Wickersham
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, T1218 MCN, 1161 21st Avenue S., Nashville, TN, 37232-2650, USA
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Addison K May
- Division of Trauma and Surgical Critical Care, Vanderbilt University, Nashville, TN, USA
| | - Gordon R Bernard
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, T1218 MCN, 1161 21st Avenue S., Nashville, TN, 37232-2650, USA
| | - Michael A Matthay
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Department of Anesthesia and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Carolyn S Calfee
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Department of Anesthesia and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, T1218 MCN, 1161 21st Avenue S., Nashville, TN, 37232-2650, USA.
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA.
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Mazuski JE, Tessier JM, May AK, Sawyer RG, Nadler EP, Rosengart MR, Chang PK, O'Neill PJ, Mollen KP, Huston JM, Diaz JJ, Prince JM. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt) 2017; 18:1-76. [PMID: 28085573 DOI: 10.1089/sur.2016.261] [Citation(s) in RCA: 306] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.
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Affiliation(s)
- John E Mazuski
- 1 Department of Surgery, Washington University School of Medicine , Saint Louis, Missouri
| | | | - Addison K May
- 3 Department of Surgery, Vanderbilt University , Nashville, Tennessee
| | - Robert G Sawyer
- 4 Department of Surgery, University of Virginia , Charlottesville, Virginia
| | - Evan P Nadler
- 5 Division of Pediatric Surgery, Children's National Medical Center , Washington, DC
| | - Matthew R Rosengart
- 6 Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Phillip K Chang
- 7 Department of Surgery, University of Kentucky , Lexington, Kentucky
| | | | - Kevin P Mollen
- 9 Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jared M Huston
- 10 Department of Surgery, Hofstra Northwell School of Medicine , Hempstead, New York
| | - Jose J Diaz
- 11 Department of Surgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jose M Prince
- 12 Departments of Surgery and Pediatrics, Hofstra-Northwell School of Medicine , Hempstead, New York
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Sartelli M, Catena F, Abu-Zidan FM, Ansaloni L, Biffl WL, Boermeester MA, Ceresoli M, Chiara O, Coccolini F, De Waele JJ, Di Saverio S, Eckmann C, Fraga GP, Giannella M, Girardis M, Griffiths EA, Kashuk J, Kirkpatrick AW, Khokha V, Kluger Y, Labricciosa FM, Leppaniemi A, Maier RV, May AK, Malangoni M, Martin-Loeches I, Mazuski J, Montravers P, Peitzman A, Pereira BM, Reis T, Sakakushev B, Sganga G, Soreide K, Sugrue M, Ulrych J, Vincent JL, Viale P, Moore EE. Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference. World J Emerg Surg 2017; 12:22. [PMID: 28484510 PMCID: PMC5418731 DOI: 10.1186/s13017-017-0132-7] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [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] [Received: 02/10/2017] [Accepted: 04/25/2017] [Indexed: 12/18/2022] Open
Abstract
This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.
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Affiliation(s)
| | - Fausto Catena
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Walter L Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, HI USA
| | | | - Marco Ceresoli
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Osvaldo Chiara
- Emergency Department, Trauma Center, Niguarda Hospital, Milan, Italy
| | - Federico Coccolini
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Christian Eckmann
- Department of General, Visceral, and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Hannover, Germany
| | - Gustavo P Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Ewen A Griffiths
- General and Upper GI Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Jeffry Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Andrew W Kirkpatrick
- Departments of Surgery, Critical Care Medicine, and the Regional Trauma Service, Foothills Medical Centre, Calgary, AB Canada
| | - Vladimir Khokha
- Department of Emergency Surgery, Mozyr City Hospital, Mozyr, Belarus
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Francesco M Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, UNIVPM, Ancona, Italy
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Addison K May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN USA
| | | | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Wellcome Trust-HRB Clinical Research, Department of Clinical Medicine, Trinity Centre for Health Sciences, St James's University Hospital, Dublin, Ireland
| | - John Mazuski
- Department of Surgery, School of Medicine, Washington University in Saint Louis, St. Louis, MO USA
| | - Philippe Montravers
- Département d'Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | - Andrew Peitzman
- Department of Surgery, UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Bruno M Pereira
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Tarcisio Reis
- Emergency post-operative Department, Otavio De Freitas Hospital and Osvaldo Cruz Hospital Recife, Recife, Brazil
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Gabriele Sganga
- Department of Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Michael Sugrue
- Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
| | - Jan Ulrych
- 1st Department of Surgery, Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Praha, Czech Republic
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Denver, CO USA
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Mazuski JE, Tessier JM, May AK, Sawyer RG. Response to “Re-Thinking the Definition of Complicated Intra-Abdominal Infection”. Surg Infect (Larchmt) 2017; 18:375-376. [DOI: 10.1089/sur.2017.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Affiliation(s)
- John E. Mazuski
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | | | - Addison K. May
- Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - Robert G. Sawyer
- Department of Surgery, University of Virginia, Charlottesville, Virginia
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35
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Semler MW, Self WH, Wang L, Byrne DW, Wanderer JP, Ehrenfeld JM, Stollings JL, Kumar AB, Hernandez A, Guillamondegui OD, May AK, Siew ED, Shaw AD, Bernard GR, Rice TW. Balanced crystalloids versus saline in the intensive care unit: study protocol for a cluster-randomized, multiple-crossover trial. Trials 2017; 18:129. [PMID: 28302179 PMCID: PMC5356286 DOI: 10.1186/s13063-017-1871-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 12/12/2016] [Accepted: 03/01/2017] [Indexed: 11/17/2022] Open
Abstract
Background Saline, the intravenous fluid most commonly administered to critically ill adults, contains a high chloride content, which may be associated with acute kidney injury and death. Whether using balanced crystalloids rather than saline decreases the risk of acute kidney injury and death among critically ill adults remains unknown. Methods The Isotonic Solutions and Major Adverse Renal Events Trial (SMART) is a pragmatic, cluster-level allocation, cluster-level crossover trial being conducted between 1 June 2015 and 30 April 2017 in five intensive care units at Vanderbilt University Medical Center in Nashville, TN, USA. SMART compares saline (0.9% sodium chloride) with balanced crystalloids (clinician’s choice of lactated Ringer’s solution or Plasma-Lyte A®). Each intensive care unit is assigned to provide either saline or balanced crystalloids each month, with the assigned crystalloid alternating monthly over the course of the trial. All adults admitted to participating intensive care units during the study period are enrolled and followed until hospital discharge or 30 days after enrollment. The anticipated enrollment is approximately 14,000 patients. The primary outcome is Major Adverse Kidney Events within 30 days—the composite of in-hospital death, receipt of new renal replacement therapy, or persistent renal dysfunction (discharge creatinine ≥200% of baseline creatinine). Secondary clinical outcomes include in-hospital mortality, intensive care unit-free days, ventilator-free days, vasopressor-free days, and renal replacement therapy-free days. Secondary renal outcomes include new renal replacement therapy receipt, persistent renal dysfunction, and incidence of stage 2 or higher acute kidney injury. Discussion This ongoing pragmatic trial will provide the largest and most comprehensive comparison to date of clinical outcomes with saline versus balanced crystalloids among critically ill adults. Trial registration For logistical reasons, SMART was prospectively registered separately for the medical ICU (SMART-MED; ClinicalTrials.gov identifier: NCT02444988; registered on 11 May 2015; date of first patient enrollment: 1 June 2015) and the nonmedical ICUs (SMART-SURG; ClinicalTrials.gov identifier: NCT02547779; registered on 9 September 2015; date of first patient enrollment: 1 October 2015). Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1871-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, C-1216 MCN, 1161 21st Avenue South, Nashville, TN, 37232-2650, USA.
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel W Byrne
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jesse M Ehrenfeld
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Avinash B Kumar
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Addison K May
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease (VCKD) and Vanderbilt Integrated Program for AKI Research (VIP-AKI), Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gordon R Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, C-1216 MCN, 1161 21st Avenue South, Nashville, TN, 37232-2650, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, C-1216 MCN, 1161 21st Avenue South, Nashville, TN, 37232-2650, USA
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36
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Russell DW, Janz DR, Emerson WL, May AK, Bernard GR, Zhao Z, Koyama T, Ware LB. Early exposure to hyperoxia and mortality in critically ill patients with severe traumatic injuries. BMC Pulm Med 2017; 17:29. [PMID: 28158980 PMCID: PMC5291954 DOI: 10.1186/s12890-017-0370-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 01/18/2017] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Hyperoxia is common early in the course of resuscitation of critically ill patients. It has been associated with mortality in some, but not all, studies of cardiac arrest patients and other critically ill cohorts. Reasons for the inconsistency are unclear and may depend on unmeasured patient confounders, the timing and duration of hyperoxia, population characteristics, or the way that hyperoxia is defined and measured. We sought to determine whether, in a prospectively collected cohort of mechanically ventilated patients with traumatic injuries with and without head trauma, higher maximum partial pressure of arterial oxygen (PaO2) within 24 hours of admission would be associated with increased risk of in-hospital mortality. METHODS Critically ill patients with traumatic injuries undergoing invasive mechanical ventilation enrolled in the Validating Acute Lung Injury biomarkers for Diagnosis (VALID) study were included in this study. All arterial blood gases (ABGs) from the first 24 hours of admission were recorded. Primary analysis was comparison of the highest PaO2 between hospital survivors and non-survivors. RESULTS A total of 653 patients were evaluated for inclusion. Of these, 182 were not mechanically ventilated or did not have an ABG measured in the first 24 hours, leaving 471 patients in the primary analysis. In survivors, the maximum PaO2 was 141 mmHg (median, interquartile range 103 - 212) compared to 148 mmHg (IQR 105 - 209) in non-survivors (p = 0.82). In the subgroup with head trauma (n = 266), the maximum PaO2 was 133 mmHg (IQR 97 - 187) among survivors and 152 mmHg (108 - 229) among nonsurvivors (p = 0.19). After controlling for age, injury severity score, number of arterial blood gases, and fraction of inspired oxygen, maximum PaO2 was not associated with increased mortality (OR 1.27 for every fold increase of PaO2 (95% CI 0.72 - 2.25). CONCLUSIONS In mechanically ventilated patients with severe traumatic injuries, hyperoxia in the first 24 hours of admission was not associated with increased risk of death or worsened neurological outcomes in a setting without brain tissue oxygenation monitoring.
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Affiliation(s)
- Derek W Russell
- Lung Health Center, Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, 1900 University Blvd., THT 423, Birmingham, AL, 35233, USA.
| | - David R Janz
- Section of Pulmonary and Critical Care Medicine, Louisiana State University School of Medicine New Orleans, New Orleans, LA, USA
| | - William L Emerson
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Addison K May
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Gordon R Bernard
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Zhiguo Zhao
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Tatsuki Koyama
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
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37
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Sartelli M, Labricciosa FM, Barbadoro P, Pagani L, Ansaloni L, Brink AJ, Carlet J, Khanna A, Chichom-Mefire A, Coccolini F, Di Saverio S, May AK, Viale P, Watkins RR, Scudeller L, Abbo LM, Abu-Zidan FM, Adesunkanmi AK, Al-Dahir S, Al-Hasan MN, Alis H, Alves C, Araujo da Silva AR, Augustin G, Bala M, Barie PS, Beltrán MA, Bhangu A, Bouchra B, Brecher SM, Caínzos MA, Camacho-Ortiz A, Catani M, Chandy SJ, Jusoh AC, Cherry-Bukowiec JR, Chiara O, Colak E, Cornely OA, Cui Y, Demetrashvili Z, De Simone B, De Waele JJ, Dhingra S, Di Marzo F, Dogjani A, Dorj G, Dortet L, Duane TM, Elmangory MM, Enani MA, Ferrada P, Esteban Foianini J, Gachabayov M, Gandhi C, Ghnnam WM, Giamarellou H, Gkiokas G, Gomi H, Goranovic T, Griffiths EA, Guerra Gronerth RI, Haidamus Monteiro JC, Hardcastle TC, Hecker A, Hodonou AM, Ioannidis O, Isik A, Iskandar KA, Kafil HS, Kanj SS, Kaplan LJ, Kapoor G, Karamarkovic AR, Kenig J, Kerschaever I, Khamis F, Khokha V, Kiguba R, Kim HB, Ko WC, Koike K, Kozlovska I, Kumar A, Lagunes L, Latifi R, Lee JG, Lee YR, Leppäniemi A, Li Y, Liang SY, Lowman W, Machain GM, Maegele M, Major P, Malama S, Manzano-Nunez R, Marinis A, Martinez Casas I, Marwah S, Maseda E, McFarlane ME, Memish Z, Mertz D, Mesina C, Mishra SK, Moore EE, Munyika A, Mylonakis E, Napolitano L, Negoi I, Nestorovic MD, Nicolau DP, Omari AH, Ordonez CA, Paiva JA, Pant ND, Parreira JG, Pędziwiatr M, Pereira BM, Ponce-de-Leon A, Poulakou G, Preller J, Pulcini C, Pupelis G, Quiodettis M, Rawson TM, Reis T, Rems M, Rizoli S, Roberts J, Pereira NR, Rodríguez-Baño J, Sakakushev B, Sanders J, Santos N, Sato N, Sawyer RG, Scarpelini S, Scoccia L, Shafiq N, Shelat V, Sifri CD, Siribumrungwong B, Søreide K, Soto R, de Souza HP, Talving P, Trung NT, Tessier JM, Tumbarello M, Ulrych J, Uranues S, Van Goor H, Vereczkei A, Wagenlehner F, Xiao Y, Yuan KC, Wechsler-Fördös A, Zahar JR, Zakrison TL, Zuckerbraun B, Zuidema WP, Catena F. The Global Alliance for Infections in Surgery: defining a model for antimicrobial stewardship-results from an international cross-sectional survey. World J Emerg Surg 2017; 12:34. [PMID: 28775763 PMCID: PMC5540347 DOI: 10.1186/s13017-017-0145-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/24/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. METHODS A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. RESULTS The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). CONCLUSION The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.
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Affiliation(s)
| | - Francesco M. Labricciosa
- 0000 0001 1017 3210grid.7010.6Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Pamela Barbadoro
- 0000 0001 1017 3210grid.7010.6Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Leonardo Pagani
- Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
| | - Luca Ansaloni
- 0000 0004 1757 8431grid.460094.fGeneral Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Adrian J. Brink
- 0000 0004 0634 9246grid.415666.6Department of Clinical microbiology, Ampath National Laboratory Services, Milpark Hospital, Johannesburg, South Africa
- 0000 0004 1937 1151grid.7836.aDivision of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape town, South Africa
| | - Jean Carlet
- World Alliance against Antibiotics Resistance, Rome, Italy
| | - Ashish Khanna
- 0000 0001 0675 4725grid.239578.2Center for Critical Care, Anaesthesiology Institute and Department of Outcomes Research, Cleveland Clinic, Cleveland, OH USA
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | | | - Salomone Di Saverio
- 0000 0004 1759 7093grid.416290.8Department of Surgery, Maggiore Hospital, Bologna, Italy
| | - Addison K. May
- 0000 0004 1936 9916grid.412807.8Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee USA
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’Orsola Hospital, University of Bologna, Bologna, Italy
| | - Richard R. Watkins
- 0000 0001 0675 4725grid.239578.2Division of Infectious Diseases, Cleveland Clinic Akron General, Akron, OH USA
- 0000 0004 0459 7529grid.261103.7Department of Medicine, Northeast Ohio Medical University, Rootstown, OH USA
| | - Luigia Scudeller
- 0000 0004 1760 3027grid.419425.fClinical Epidemiology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Lilian M. Abbo
- 0000 0004 1936 8606grid.26790.3aDivision of Infectious Diseases, Jackson Health System, University of Miami Miller School of Medicine, Miami, FL USA
| | - Fikri M. Abu-Zidan
- 0000 0001 2193 6666grid.43519.3aDepartment of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Abdulrashid K. Adesunkanmi
- 0000 0001 2183 9444grid.10824.3fDepartment of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Sara Al-Dahir
- 0000 0000 9679 3586grid.268355.fDivision of Clinical and Administrative Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA USA
| | - Majdi N. Al-Hasan
- 0000 0000 9075 106Xgrid.254567.7Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC USA
| | - Halil Alis
- 0000 0004 0419 1043grid.414177.0General Surgery Department, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Instanbul, Turkey
| | - Carlos Alves
- 0000 0000 9375 4688grid.414556.7Unit of Prevention and Infection Control, Center of Hospital Epidemiology, São João Hospital Centre, Porto, Portugal
| | | | - Goran Augustin
- 0000 0004 0397 9648grid.412688.1Department of Surgery, University Hospital Center, Zagreb, Croatia
| | - Miklosh Bala
- 0000 0001 2221 2926grid.17788.31Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Philip S. Barie
- 000000041936877Xgrid.5386.8Department of Surgery, Weill Cornell Medicine, New York, NY USA
| | - Marcelo A. Beltrán
- Department of General Surgery, Hospital San Juan de Dios de La Serena, La Serena, Chile
| | - Aneel Bhangu
- 0000 0001 2177 007Xgrid.415490.dAcademic Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Belefquih Bouchra
- Department of Microbiology National Reference Laboratory Cheikh Khalifa Ibn Zaid Hospital, Mohammed 6th University of Health Sciences, Casablanca, Morocco
| | - Stephen M. Brecher
- 0000 0004 4657 1992grid.410370.1Department of Pathology and Laboratory Medicine, VA Boston HealthCare System, Boston, MA USA
- 0000 0004 0367 5222grid.475010.7Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA USA
| | - Miguel A. Caínzos
- 0000 0000 8816 6945grid.411048.8Department of Surgery, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Adrian Camacho-Ortiz
- 0000 0004 1760 058Xgrid.464574.0Hospital Epidemiology and Infectious Diseases, Hospital Universitario Dr Jose Eleuterio Gonzalez, Monterrey, Mexico
| | - Marco Catani
- grid.417007.5Department of Emergency, Umberto I Hospital, Rome, Italy
| | - Sujith J. Chandy
- 0000 0004 1781 1790grid.448741.aDepartment of Pharmacology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala India
| | - Asri Che Jusoh
- Department of General Surgery, Kuala Krai Hospital, Kuala Krai, Kelantan Malaysia
| | - Jill R. Cherry-Bukowiec
- 0000000086837370grid.214458.eDivision of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI USA
| | | | - Elif Colak
- Department of General Surgery, Health Sciences University, Samsun Training and Research Hospital, Samsun, Turkey
| | - Oliver A. Cornely
- 0000 0000 8580 3777grid.6190.eDepartment of Internal Medicine and Infectious Diseases, University of Cologne, Cologne, Germany
| | - Yunfeng Cui
- 0000 0000 9792 1228grid.265021.2Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Zaza Demetrashvili
- Department General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Belinda De Simone
- 0000 0004 1795 3510grid.418062.9Department of Digestive Surgery, Cannes Hospital, Cannes, France
| | - Jan J. De Waele
- 0000 0004 0626 3303grid.410566.0Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Sameer Dhingra
- grid.430529.9School of Pharmacy, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
- Eric Williams Medical Sciences Complex, Uriah Butler Highway, Champ Fleurs, Trinidad and Tobago
| | | | - Agron Dogjani
- Department of Surgery, University Hospital of Trauma, Tirana, Albania
| | - Gereltuya Dorj
- grid.444534.6School of Pharmacy and Biomedicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Laurent Dortet
- 0000 0001 2171 2558grid.5842.bDepartment of Microbiology, Bicêtre Hospital, Paris-Sud University, La Kremlin-Bicêtre, France
| | - Therese M. Duane
- Department of Surgery, John Peter Smith Health Network, Fort Worth, Texas USA
| | - Mutasim M. Elmangory
- grid.414827.cSudan National Public Health Laboratory, Federal Ministry of Health, Khartoum, Sudan
| | - Mushira A. Enani
- 0000 0004 0593 1832grid.415277.2Department of Medicine, Infectious Disease Division, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Paula Ferrada
- 0000 0004 0458 8737grid.224260.0Department of Surgery, Virginia Commonwealth University, Richmond, VA USA
| | | | - Mahir Gachabayov
- Department of Abdominal Surgery, Vladimir City Clinical Hospital of Emergency Medicine, Vladimir, Russia
| | - Chinmay Gandhi
- Department of Surgery, Bharati Vidyapeeth Deemed University Medical College and Hospital, Sangli, Maharashtra India
| | - Wagih Mommtaz Ghnnam
- 0000000103426662grid.10251.37Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Helen Giamarellou
- grid.414012.2Sixth Department of Internal Medicine, Hygeia General Hospital, Athens, Greece
| | - Georgios Gkiokas
- 0000 0001 2155 0800grid.5216.0Second Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Harumi Gomi
- 0000 0001 2369 4728grid.20515.33Center for Global Health, Mito Kyodo General Hospital, University of Tsukuba, Mito, Ibaraki Japan
| | - Tatjana Goranovic
- University Department for Tumours, Sestre Milosrrdnice UHC, Zagreb, Croatia
| | - Ewen A. Griffiths
- 0000 0001 2177 007Xgrid.415490.dGeneral and Upper GI Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Julio C. Haidamus Monteiro
- 0000 0001 2198 9354grid.415169.eDepartment of Gastrointestinal Surgery, Santa Casa Hospital, Campo Grande, Brazil
| | - Timothy C. Hardcastle
- 0000 0001 0723 4123grid.16463.36Trauma and Trauma ICU, Inkosi Albert Luthuli Central Hospital and Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Andreas Hecker
- 0000 0000 8584 9230grid.411067.5Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | - Adrien M. Hodonou
- grid.440525.2Department of Surgery, Faculty of Medicine, University of Parakou, BP 123 Parakou, Benin
| | - Orestis Ioannidis
- 0000000109457005grid.4793.9Fourth Surgical Department, General Hospital G. Papanikolaou, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Arda Isik
- 0000 0001 1498 7262grid.412176.7Department of General Surgery, Erzincan University, Faculty of Medicine, Erzincan, Turkey
| | - Katia A. Iskandar
- Department of Pharmacy, Lebanese, International University, Beirut, Lebanon
| | - Hossein S. Kafil
- 0000 0001 2174 8913grid.412888.fDrug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Souha S. Kanj
- 0000 0004 1936 9801grid.22903.3aDivision of Infectious Diseases, American University of Beirut, Beirut, Lebanon
| | - Lewis J. Kaplan
- 0000 0004 1936 8972grid.25879.31Department of Surgery Philadelphia VA Medical Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Garima Kapoor
- grid.415285.fDepartment of Microbiology, Gandhi Medical College, Bhopal, India
| | - Aleksandar R. Karamarkovic
- 0000 0001 2166 9385grid.7149.bClinic for Emergency Surgery, Medical Faculty University of Belgrade, Belgrade, Serbia
| | - Jakub Kenig
- 0000 0001 2162 9631grid.5522.0Third Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Ivan Kerschaever
- Department of Abdominal Surgery, Regional Hospital of Tienen, Tienen, Belgium
| | - Faryal Khamis
- 0000 0004 1772 5665grid.416132.3Department of Internal Medicine, Royal Hospital, Muscat, Oman
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Ronald Kiguba
- 0000 0004 0620 0548grid.11194.3cDepartment of Pharmacology and Therapeutics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Hong B. Kim
- 0000 0004 0647 3378grid.412480.bDepartment of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Wen-Chien Ko
- 0000 0004 0639 0054grid.412040.3Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Kaoru Koike
- 0000 0004 0372 2033grid.258799.8Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Iryna Kozlovska
- Department of Surgery n. 2, Higher educational institutions of Ukraine Bukovina State Medical University, Chernivtci City, Ukraine
| | - Anand Kumar
- 0000 0004 1936 9609grid.21613.37Section of Critical Care Medicine and Section of Infectious Diseases, Department of Medicine, Medical Microbiology and Pharmacology/Therapeutics, University of Manitoba, Winnipeg, MB Canada
| | - Leonel Lagunes
- 0000 0004 0633 6808grid.414410.4Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico
| | - Rifat Latifi
- 0000 0001 2168 186Xgrid.134563.6Department of Surgery, Division of Trauma, University of Arizona, Tucson, AZ USA
| | - Jae G. Lee
- 0000 0004 0470 5454grid.15444.30Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Young R. Lee
- grid.449754.fTexas Tech University, Health Sciences Center School of Pharmacy, Abilene, TX USA
| | - Ari Leppäniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Yousheng Li
- 0000 0001 2314 964Xgrid.41156.37Department of Surgery, Inling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Stephen Y. Liang
- 0000 0001 2355 7002grid.4367.6Division of Infectious Diseases, Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO USA
| | - Warren Lowman
- 0000 0004 1937 1135grid.11951.3dClinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gustavo M. Machain
- 0000 0001 2289 5077grid.412213.7Department of Surgery, Universidad Nacional de Asuncion, Asuncion, Paraguay
| | - Marc Maegele
- 0000 0000 9024 6397grid.412581.bDepartment for Traumatology and Orthopedic Surgery, Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke (UW/H), Cologne, Germany
| | - Piotr Major
- 0000 0001 2162 9631grid.5522.0Second Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Sydney Malama
- 0000 0000 8914 5257grid.12984.36Health Research Program, Institute of Economic and Social Research, University of Zambia, Lusaka, Zambia
| | | | - Athanasios Marinis
- grid.417374.2First Department of Surgery, Tzaneion General Hospital, Piraeus, Greece
| | | | - Sanjay Marwah
- 0000 0004 1771 1642grid.412572.7Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | - Emilio Maseda
- Servicio de Anestesia y Reanimación, Hospital Universitario La Paz Madrid, Madrid, Spain
| | - Michael E. McFarlane
- 0000 0004 0500 5353grid.412963.bDepartment of Surgery, Radiology, University Hospital of the West Indies, Kingston, Jamaica
| | - Ziad Memish
- grid.415696.9Infectious Diseases Division, Department of Medicine, Prince Mohamed Bin Abdulaziz Hospital, Ministry of Health, Riyadh, Saudi Arabia
| | - Dominik Mertz
- 0000 0004 1936 8227grid.25073.33Departments of Medicine, Clinical Epidemiology and Biostatistics, and Pathology and Molecular Medicine, McMaster University, Hamilton, ON Canada
| | - Cristian Mesina
- Second Surgical Clinic, Emergency Hospital of Craiova, Craiova, Romania
| | - Shyam K. Mishra
- Department of Microbiology, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
| | - Akutu Munyika
- Department of Surgery, Onandjokwe Hospital, Ondangwa, Namibia
| | - Eleftherios Mylonakis
- 0000 0004 1936 9094grid.40263.33Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI USA
| | - Lena Napolitano
- 0000000086837370grid.214458.eDepartment of Surgery, University of Michigan, Ann Arbor, MI USA
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Milica D. Nestorovic
- 0000 0004 0517 2741grid.418653.dClinic for General Surgery, Clinical Centre, Nis, Serbia
| | - David P. Nicolau
- Center of Anti-Infective Research and Development, Hartford, CT USA
| | - Abdelkarim H. Omari
- 0000 0004 0411 3985grid.460946.9Department of Surgery, King Abdullah University Hospital, Irbid, Jordan
| | - Carlos A. Ordonez
- 0000 0001 2295 7397grid.8271.cDepartment of Surgery and Critical Care, Universidad del Valle, Fundación Valle del Lili, Cali, Colombia
| | - José-Artur Paiva
- 0000 0001 1503 7226grid.5808.5Intensive Care Medicine Department, Centro Hospitalar São João, University of Porto, Porto, Portugal
| | - Narayan D. Pant
- grid.461024.5Department of Microbiology, Grande International Hospital, Dhapasi, Kathmandu, Nepal
| | - Jose G. Parreira
- 0000 0004 0576 9812grid.419014.9Department of Surgery, Santa Casa de Sao Paulo School of Medical Sciences, São Paulo, Brazil
| | - Michal Pędziwiatr
- 0000 0001 1216 0093grid.412700.0Department of General and Emergency Surgery, University Hospital Kraków, Kraków, Poland
| | - Bruno M. Pereira
- 0000 0001 0723 2494grid.411087.bDepartment of Surgery, University of Campinas, Campinas, Brazil
| | - Alfredo Ponce-de-Leon
- 0000 0001 0698 4037grid.416850.eLaboratory of Clinical Microbiology, Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Garyphallia Poulakou
- 0000 0004 0622 4662grid.411449.dFourth Department of Internal Medicine and Infectious Diseases Unit, National and Kapodstrian University-Medical School, Attikon University General Hospital, Athens, Greece
| | - Jacobus Preller
- John Farman Intensive Care Unit, University Hospitals, NHS Foundation Trust, Cambridge, UK
| | - Céline Pulcini
- Infectious and Tropical Diseases Department, University Hospital of Nancy, and EA 4360 APEMAC, Lorraine University, Nancy, France
| | - Guntars Pupelis
- Department of General and Emergency Surgery, Riga East University Hospital ‘Gailezers’, Riga, Latvia
| | - Martha Quiodettis
- 0000 0004 0465 2778grid.461067.2Department of Trauma, Hospital Santo Tomas, Panama, Panama
| | - Timothy M. Rawson
- 0000 0001 2113 8111grid.7445.2National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
| | - Tarcisio Reis
- Emergency Post-operative Department, Otavio de Freitas Hospital and Hosvaldo Cruz Hospital, Recife, Brazil
| | - Miran Rems
- Department of General Surgery, Jesenice General Hospital, Jesenice, Slovenia
| | - Sandro Rizoli
- 0000 0001 2157 2938grid.17063.33Trauma and Acute Care Service, St Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Jason Roberts
- 0000 0000 9320 7537grid.1003.2Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland Australia
| | - Nuno Rocha Pereira
- 0000 0000 9375 4688grid.414556.7Unit of Prevention and Infection Control, Center of Hospital Epidemiology, São João Hospital Centre, Porto, Portugal
| | - Jesús Rodríguez-Baño
- 0000 0001 2168 1229grid.9224.dUnidad Clínica Intercentros de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío-IBiS and Departamento de Medicina, Universidad de Sevilla, Seville, Spain
| | - Boris Sakakushev
- 0000 0001 0726 0380grid.35371.33General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | | | | | - Norio Sato
- 0000 0001 1011 3808grid.255464.4Department of Aeromedical Services for Emergency and Trauma Care, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Robert G. Sawyer
- 0000 0004 1936 9932grid.412587.dDepartment of Surgery, University of Virginia Health System, Charlottesville, VA USA
| | - Sandro Scarpelini
- 0000 0004 1937 0722grid.11899.38Department of Surgery, University of Sao Paulo, Ribeirao Preto, Brazil
| | | | - Nusrat Shafiq
- 0000 0004 1767 2903grid.415131.3Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishalkumar Shelat
- grid.240988.fDepartment of General Surgery, Tan Tock Seng Hospital, Tan Tock Seng, Singapore
| | - Costi D. Sifri
- 0000 0004 1936 9932grid.412587.dOffice of Hospital Epidemiology/Infection Prevention and Control, University of Virginia Health System, Charlottesville, VA USA
| | - Boonying Siribumrungwong
- 0000 0004 1937 1127grid.412434.4Department of Surgery, Faculty of Medicine, Thammasat University Hospital, Thammasat University, Pathum Thani, Thailand
| | - Kjetil Søreide
- 0000 0004 0627 2891grid.412835.9Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- 0000 0004 1936 7443grid.7914.bDepartment of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Rodolfo Soto
- Department of Emergency Surgery and Critical Care, Centro Medico Imbanaco, Cali, Colombia
| | - Hamilton P. de Souza
- 0000 0001 2166 9094grid.412519.aDepartment of Surgery, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Peep Talving
- Department of Surgery, North Estonia Medical Center, Tallinn, Estonia
| | - Ngo Tat Trung
- Department of Molecular Biology, Tran Hung Dao Hospital, No 1, Tran Hung Dao Street, Hai Ba Trung Dist, Hanoi, Vietnam
| | - Jeffrey M. Tessier
- Department of Infectious Diseases, John Peter Smith Health Network, Fort Worth, Texas USA
| | - Mario Tumbarello
- 0000 0001 0941 3192grid.8142.fInstitute of Infectious Diseases, Catholic University, Rome, Italy
| | - Jan Ulrych
- 0000 0000 9100 9940grid.411798.2First Department of Surgery—Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Prague, Czech Republic
| | - Selman Uranues
- 0000 0000 8988 2476grid.11598.34Department of Surgery, Medical University of Graz, Graz, Austria
| | - Harry Van Goor
- 0000 0004 0444 9382grid.10417.33Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Andras Vereczkei
- 0000 0001 0663 9479grid.9679.1Department of Surgery, Medical School University of Pécs, Pécs, Hungary
| | - Florian Wagenlehner
- 0000 0001 2165 8627grid.8664.cDepartment of Urology, Pediatric Urology and Andrology, Medical Faculty of the Justus Liebig University Giessen, Giessen, Germany
| | - Yonghong Xiao
- 0000 0004 1759 700Xgrid.13402.34State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affilliated Hospital, Zhejiang University, Zhejiang, China
| | - Kuo-Ching Yuan
- 0000 0004 1756 1461grid.454210.6Trauma and Emergency Surgery Department, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Agnes Wechsler-Fördös
- 0000 0004 0522 8258grid.413303.6Department of Antibiotics and Infection Control, Rudolfstiftung Hospital, Vienna, Austria
| | - Jean-Ralph Zahar
- Infection Control Unit, Angers University, CHU d’Angers, Angers, France
| | - Tanya L. Zakrison
- 0000 0004 1936 8606grid.26790.3aDivision of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL USA
| | - Brian Zuckerbraun
- 0000 0004 1936 9000grid.21925.3dDepartment of Surgery, University of Pittsburgh, Pittsburgh, PA USA
| | - Wietse P. Zuidema
- 0000 0004 0435 165Xgrid.16872.3aVU University Medical Center, Amsterdam, The Netherlands
| | - Fausto Catena
- Department of General Surgery, Maggiore Hospital, Parma, Italy
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Sartelli M, Duane TM, Catena F, Tessier JM, Coccolini F, Kao LS, De Simone B, Labricciosa FM, May AK, Ansaloni L, Mazuski JE. Antimicrobial Stewardship: A Call to Action for Surgeons. Surg Infect (Larchmt) 2016; 17:625-631. [PMID: 27828764 DOI: 10.1089/sur.2016.187] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [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] Open
Abstract
Despite current antimicrobial stewardship programs (ASPs) being advocated by infectious disease specialists and discussed by national and international policy makers, ASPs coverage remains limited to only certain hospitals as well as specific service lines within hospitals. The ASPs incorporate a variety of strategies to optimize antimicrobial agent use in the hospital, yet the exact set of interventions essential to ASP success remains unknown. Promotion of ASPs across clinical practice is crucial to their success to ensure standardization of antimicrobial agent use within an institution. To effectively accomplish this standardization, providers who actively engage in antimicrobial agent prescribing should participate in the establishment and support of these programs. Hence, surgeons need to play a major role in these collaborations. Surgeons must be aware that judicious antibiotic utilization is an integral part of any stewardship program and necessary to maximize clinical cure and minimize emergence of antimicrobial resistance. The battle against antibiotic resistance should be fought by all healthcare professionals. If surgeons around the world participate in this global fight and demonstrate awareness of the major problem of antimicrobial resistance, they will be pivotal leaders. If surgeons fail to actively engage and use antibiotics judiciously, they will find themselves deprived of the autonomy to treat their patients.
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Affiliation(s)
| | - Therese M Duane
- 2 Department of Surgery, John Peter Smith Health Network , Fort Worth, Texas
| | - Fausto Catena
- 3 Department of Emergency Surgery, Maggiore Hospital , Parma, Italy
| | - Jeffrey M Tessier
- 4 Department of Infectious Diseases, John Peter Smith Health Network , Fort Worth, Texas
| | | | - Lillian S Kao
- 6 Department of Surgery, McGovern Medical School, University of Texas Health Science Center , Houston, Texas
| | | | - Francesco M Labricciosa
- 7 Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health , UNIVPM, Ancona, Italy
| | - Addison K May
- 8 Department of Surgery, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Luca Ansaloni
- 5 Department of Surgery, Papa XXIII Hospital , Bergamo, Italy
| | - John E Mazuski
- 9 Department of Surgery, Section of Acute and Critical Care Surgery, Washington University School of Medicine , St. Louis, Missouri
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39
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Merchant A, Valenzuela JY, Lyon C, Mcqueen K, May AK. Creating a Global Acute Care Surgery Fellowship to Meet International Need. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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McBeth PB, Weinberg JA, Sarani B, Yeung LYY, May AK. A surgeon's guide to anticoagulant and antiplatelet medications part one: warfarin and new direct oral anticoagulant medications. Trauma Surg Acute Care Open 2016; 1:e000020. [PMID: 29767647 PMCID: PMC5891717 DOI: 10.1136/tsaco-2016-000020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2016] [Indexed: 12/26/2022] Open
Abstract
An increasing number of potent antiplatelet and anticoagulant medications are being used for the long-term management of cardiac, cerebrovascular, and peripheral vascular conditions. Management of these medications in the perioperative and peri-injury settings can be challenging for surgeons, mandating an understanding of these agents and the risks and benefits of various management strategies. In this two-part review, agents commonly encounter by surgeons in the perioperative and peri-injury settings are discussed and management strategies for patients on long-term antiplatelet and anticoagulant therapy reviewed. In part I, we review warfarin and the new direct oral anticoagulants. In part II, we review antiplatelet agents and assessment of platelet function and the perioperative management of long-term anticoagulant and antiplatelet therapy.
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Affiliation(s)
- Paul B McBeth
- Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jordan A Weinberg
- Department of Surgery, Dignity Health/St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Babak Sarani
- Center for Trauma and Critical Care, George Washington University, Washington DC, USA
| | | | - Addison K May
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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41
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Yeung LYY, Sarani B, Weinberg JA, McBeth PB, May AK. Surgeon's guide to anticoagulant and antiplatelet medications part two: antiplatelet agents and perioperative management of long-term anticoagulation. Trauma Surg Acute Care Open 2016; 1:e000022. [PMID: 29767644 PMCID: PMC5891708 DOI: 10.1136/tsaco-2016-000022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2016] [Indexed: 02/01/2023] Open
Abstract
An increasing number of potent antiplatelet and anticoagulant medications are being used for the long-term management of cardiac, cerebrovascular, and peripheral vascular conditions. Management of these medications in the perioperative and peri-injury settings can be challenging for surgeons, mandating an understanding of these agents and the risks and benefits of various management strategies. In this two part review, agents commonly encountered by surgeons in the perioperative and peri-injury settings are discussed and management strategies for patients on long-term antiplatelet and anticoagulant therapy reviewed. In part one, we review warfarin and the new direct oral anticoagulants. In part two, we review antiplatelet agents and assessment of platelet function and the perioperative management of long-term anticoagulation and antiplatelet therapy.
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Affiliation(s)
| | - Babak Sarani
- Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia, USA
| | - Jordan A Weinberg
- Department of Surgery, Dignity Health/St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Paul B McBeth
- Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Addison K May
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Ware LB, Zhao Z, Koyama T, May AK, Matthay MA, Lurmann FW, Balmes JR, Calfee CS. Long-Term Ozone Exposure Increases the Risk of Developing the Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2016; 193:1143-50. [PMID: 26681363 PMCID: PMC4872663 DOI: 10.1164/rccm.201507-1418oc] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/16/2015] [Indexed: 01/01/2023] Open
Abstract
RATIONALE The contribution of air pollution to the risk of acute respiratory distress syndrome (ARDS) is unknown. METHODS We studied 1,558 critically ill patients enrolled in a prospective observational study at a tertiary medical center who lived less than 50 km from an air quality monitor and had an ARDS risk factor. Pollutant exposures (ozone, NO2, SO2, particulate matter < 2.5 μm, particulate matter < 10 μm) were assessed by weighted average of daily levels from the closest monitors for the prior 3 years. Associations between pollutant exposure and ARDS risk were evaluated by logistic regression controlling for age, race, sex, smoking, alcohol, insurance status, rural versus urban residence, distance to study hospital, and Acute Physiology and Chronic Health Evaluation II. MEASUREMENTS AND MAIN RESULTS The incidence of ARDS increased with increasing ozone exposure: 28% in the lowest exposure quartile versus 32, 40, and 42% in the second, third, and fourth quartiles (P < 0.001). In a logistic regression model controlling for potential confounders, ozone exposure was associated with risk of ARDS in the entire cohort (odds ratio, 1.58 [95% confidence interval, 1.27-1.96]) and more strongly associated in the subgroup with trauma as their ARDS risk factor (odds ratio, 2.26 [95% confidence interval, 1.46-3.50]). There was a strong interaction between ozone exposure and current smoking status (P = 0.007). NO2 exposure was also associated with ARDS but not independently of ozone exposure. SO2, particulate matter less than 2.5 μm, and particulate matter less than 10 μm were not associated with ARDS. CONCLUSIONS Long-term ozone exposure is associated with development of ARDS in at-risk critically ill patients, particularly in trauma patients and current smokers. Ozone exposure may represent a previously unrecognized environmental risk factor for ARDS.
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Affiliation(s)
- Lorraine B. Ware
- Department of Medicine and
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | - Addison K. May
- Division of Trauma and Surgical Critical Care, Vanderbilt University, Nashville, Tennessee
| | - Michael A. Matthay
- Department of Medicine and
- Department of Anesthesia and Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | | | - John R. Balmes
- Department of Medicine and
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California
| | - Carolyn S. Calfee
- Department of Medicine and
- Department of Anesthesia and Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
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Abstract
BACKGROUND Appropriate empiric antibiotic therapy for ventilator-associated pneumonia improves outcomes. Controversy exists regarding the inclusion of aminoglycosides in empiric therapeutic regimens. METHODS The Ovid and Cochrane databases were searched for relevant literature regarding the use of aminoglycosides in combination therapy for ventilator-associated pneumonia. The data supporting the use of aminoglycosides in certain populations and strategies to limit toxicity are summarized. RESULTS In patients at high risk of infection with antibiotic-resistant gram-negative bacilli and in those with severe illness, aminoglycosides improve clinical outcomes. In critically ill populations, short-duration therapy and high-dose extended-interval dosing of aminoglycosides can improve therapeutic efficacy while limiting nephrotoxicity. CONCLUSIONS In selected populations using appropriate dosing strategies, aminoglycosides should be considered for empiric treatment of ventilator-associated pneumonia.
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Affiliation(s)
- Addison K May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
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Sartelli M, Weber DG, Ruppé E, Bassetti M, Wright BJ, Ansaloni L, Catena F, Coccolini F, Abu-Zidan FM, Coimbra R, Moore EE, Moore FA, Maier RV, De Waele JJ, Kirkpatrick AW, Griffiths EA, Eckmann C, Brink AJ, Mazuski JE, May AK, Sawyer RG, Mertz D, Montravers P, Kumar A, Roberts JA, Vincent JL, Watkins RR, Lowman W, Spellberg B, Abbott IJ, Adesunkanmi AK, Al-Dahir S, Al-Hasan MN, Agresta F, Althani AA, Ansari S, Ansumana R, Augustin G, Bala M, Balogh ZJ, Baraket O, Bhangu A, Beltrán MA, Bernhard M, Biffl WL, Boermeester MA, Brecher SM, Cherry-Bukowiec JR, Buyne OR, Cainzos MA, Cairns KA, Camacho-Ortiz A, Chandy SJ, Che Jusoh A, Chichom-Mefire A, Colijn C, Corcione F, Cui Y, Curcio D, Delibegovic S, Demetrashvili Z, De Simone B, Dhingra S, Diaz JJ, Di Carlo I, Dillip A, Di Saverio S, Doyle MP, Dorj G, Dogjani A, Dupont H, Eachempati SR, Enani MA, Egiev VN, Elmangory MM, Ferrada P, Fitchett JR, Fraga GP, Guessennd N, Giamarellou H, Ghnnam W, Gkiokas G, Goldberg SR, Gomes CA, Gomi H, Guzmán-Blanco M, Haque M, Hansen S, Hecker A, Heizmann WR, Herzog T, Hodonou AM, Hong SK, Kafka-Ritsch R, Kaplan LJ, Kapoor G, Karamarkovic A, Kees MG, Kenig J, Kiguba R, Kim PK, Kluger Y, Khokha V, Koike K, Kok KYY, Kong V, Knox MC, Inaba K, Isik A, Iskandar K, Ivatury RR, Labbate M, Labricciosa FM, Laterre PF, Latifi R, Lee JG, Lee YR, Leone M, Leppaniemi A, Li Y, Liang SY, Loho T, Maegele M, Malama S, Marei HE, Martin-Loeches I, Marwah S, Massele A, McFarlane M, Melo RB, Negoi I, Nicolau DP, Nord CE, Ofori-Asenso R, Omari AH, Ordonez CA, Ouadii M, Pereira Júnior GA, Piazza D, Pupelis G, Rawson TM, Rems M, Rizoli S, Rocha C, Sakakhushev B, Sanchez-Garcia M, Sato N, Segovia Lohse HA, Sganga G, Siribumrungwong B, Shelat VG, Soreide K, Soto R, Talving P, Tilsed JV, Timsit JF, Trueba G, Trung NT, Ulrych J, van Goor H, Vereczkei A, Vohra RS, Wani I, Uhl W, Xiao Y, Yuan KC, Zachariah SK, Zahar JR, Zakrison TL, Corcione A, Melotti RM, Viscoli C, Viale P. Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA). World J Emerg Surg 2016; 11:33. [PMID: 27429642 PMCID: PMC4946132 DOI: 10.1186/s13017-016-0089-y] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 07/04/2016] [Indexed: 02/08/2023] Open
Abstract
Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Dieter G. Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Etienne Ruppé
- Genomic Research Laboratory, Geneva University Hospitals, Geneva, Switzerland
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy
| | - Brian J. Wright
- Department of Emergency Medicine and Surgery, Stony Brook University School of Medicine, Stony Brook, NY USA
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Fausto Catena
- Department of General, Maggiore Hospital, Parma, Italy
| | | | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Raul Coimbra
- Department of Surgery, UC San Diego Medical Center, San Diego, USA
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
| | - Frederick A. Moore
- Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, FL USA
| | - Ronald V. Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Jan J. De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andrew W. Kirkpatrick
- General, Acute Care, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Ewen A. Griffiths
- General and Upper GI Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Christian Eckmann
- Department of General, Visceral, and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Peine, Germany
| | - Adrian J. Brink
- Department of Clinical microbiology, Ampath National Laboratory Services, Milpark Hospital, Johannesburg, South Africa
| | - John E. Mazuski
- Department of Surgery, School of Medicine, Washington University in Saint Louis, Missouri, USA
| | - Addison K. May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN USA
| | - Rob G. Sawyer
- Department of Surgery, University of Virginia Health System, Charlottesville, VA USA
| | - Dominik Mertz
- Departments of Medicine, Clinical Epidemiology and Biostatistics, and Pathology and Molecular Medicine, McMaster University, Hamilton, ON Canada
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | - Anand Kumar
- Section of Critical Care Medicine and Section of Infectious Diseases, Department of Medicine, Medical Microbiology and Pharmacology/Therapeutics, University of Manitoba, Winnipeg, MB Canada
| | - Jason A. Roberts
- Australia Pharmacy Department, Royal Brisbane and Womens’ Hospital; Burns, Trauma, and Critical Care Research Centre, Australia School of Pharmacy, The University of Queensland, Brisbane, QLD Australia
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Richard R. Watkins
- Department of Internal Medicine, Division of Infectious Diseases, Akron General Medical Center, Northeast Ohio Medical University, Akron, OH USA
| | - Warren Lowman
- Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Brad Spellberg
- Division of Infectious Diseases, Los Angeles County-University of Southern California (USC) Medical Center, Keck School of Medicine at USC, Los Angeles, CA USA
| | - Iain J. Abbott
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC Australia
| | | | - Sara Al-Dahir
- Division of Clinical and Administrative Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA USA
| | - Majdi N. Al-Hasan
- Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC USA
| | | | | | - Shamshul Ansari
- Department of Microbiology, Chitwan Medical College, and Department of Environmental and Preventive Medicine, Oita University, Oita, Japan
| | - Rashid Ansumana
- Centre for Neglected Tropical Diseases, Liverpool School of Tropical Medicine, University of Liverpool, and Mercy Hospital Research Laboratory, Njala University, Bo, Sierra Leone
| | - Goran Augustin
- Department of Surgery, University Hospital Center, Zagreb, Croatia
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | | | - Aneel Bhangu
- Academic Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Marcelo A. Beltrán
- Department of General Surgery, Hospital San Juan de Dios de La Serena, La Serena, Chile
| | | | - Walter L. Biffl
- Department of Surgery, University of Colorado, Denver, CO USA
| | | | - Stephen M. Brecher
- Department of Pathology and Laboratory Medicine, VA Boston HealthCare System, and Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA USA
| | - Jill R. Cherry-Bukowiec
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI USA
| | - Otmar R. Buyne
- Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Miguel A. Cainzos
- Department of Surgery, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Kelly A. Cairns
- Pharmacy Department, Alfred Health, Melbourne, VIC Australia
| | - Adrian Camacho-Ortiz
- Hospital Epidemiology and Infectious Diseases, Hospital Universitario Dr Jose Eleuterio Gonzalez, Monterrey, Mexico
| | - Sujith J. Chandy
- Department of Pharmacology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala India
| | - Asri Che Jusoh
- Department of General Surgery, Kuala Krai Hospital, Kuala Krai, Kelantan Malaysia
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Caroline Colijn
- Department of Mathematics, Imperial College London, London, UK
| | - Francesco Corcione
- Department of Laparoscopic and Robotic Surgery, Colli-Monaldi Hospital, Naples, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Daniel Curcio
- Infectología Institucional SRL, Hospital Municipal Chivilcoy, Buenos Aires, Argentina
| | - Samir Delibegovic
- Department of Surgery, University Clinical Center of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Zaza Demetrashvili
- Department General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
| | | | - 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, Trinidad and Tobago
| | - José J. Diaz
- Division of Acute Care Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - Isidoro Di Carlo
- Department of Surgical Sciences, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Angel Dillip
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Michael P. Doyle
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, Griffin, GA USA
| | - Gereltuya Dorj
- School of Pharmacy and Biomedicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Agron Dogjani
- Department of Surgery, University Hospital of Trauma, Tirana, Albania
| | - Hervé Dupont
- Département d’Anesthésie-Réanimation, CHU Amiens-Picardie, and INSERM U1088, Université de Picardie Jules Verne, Amiens, France
| | - Soumitra R. Eachempati
- Department of Surgery, Division of Burn, Critical Care, and Trauma Surgery (K.P.S., S.R.E.), Weill Cornell Medical College/New York-Presbyterian Hospital, New York, USA
| | - Mushira Abdulaziz Enani
- Department of Medicine, Infectious Disease Division, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Valery N. Egiev
- Department of Surgery, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Mutasim M. Elmangory
- Sudan National Public Health Laboratory, Federal Ministry of Health, Khartoum, Sudan
| | - Paula Ferrada
- Department of Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Joseph R. Fitchett
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA USA
| | - Gustavo P. Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | | | - Helen Giamarellou
- 6th Department of Internal Medicine, Hygeia General Hospital, Athens, Greece
| | - Wagih Ghnnam
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - George Gkiokas
- 2nd Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Carlos Augusto Gomes
- Department of Surgery, Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Juiz de Fora, Brazil
| | - Harumi Gomi
- Center for Global Health, Mito Kyodo General Hospital, University of Tsukuba, Mito, Ibaraki Japan
| | - Manuel Guzmán-Blanco
- Hospital Privado Centro Médico de Caracas and Hospital Vargas de Caracas, Caracas, Venezuela
| | - Mainul Haque
- Unit of Pharmacology, Faculty of Medicine and Defense Health, National Defence University of Malaysia, Kuala Lumpur, Malaysia
| | - Sonja Hansen
- Institute of Hygiene, Charité-Universitätsmedizin Berlin, Hindenburgdamm 27, 12203 Berlin, Germany
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | | | - Torsten Herzog
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Adrien Montcho Hodonou
- Department of Surgery, Faculté de médecine, Université de Parakou, BP 123 Parakou, Bénin
| | - Suk-Kyung Hong
- Division of Trauma and Surgical Critical Care, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Reinhold Kafka-Ritsch
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Lewis J. Kaplan
- Department of Surgery Philadelphia VA Medical Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Garima Kapoor
- Department of Microbiology, Gandhi Medical College, Bhopal, India
| | | | - Martin G. Kees
- Department of Anesthesiology and Intensive Care, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Jakub Kenig
- 3rd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Ronald Kiguba
- Department of Pharmacology and Therapeutics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Peter K. Kim
- Department of Surgery, Albert Einstein College of Medicine and Jacobi Medical Center, Bronx, NY USA
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenneth Y. Y. Kok
- Department of Surgery, The Brunei Cancer Centre, Jerudong Park, Brunei
| | - Victory Kong
- Department of Surgery, Edendale Hospital, Pietermaritzburg, South Africa
| | - Matthew C. Knox
- School of Medicine, Western Sydney University, Campbelltown, NSW Australia
| | - Kenji Inaba
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA USA
| | - Arda Isik
- Department of General Surgery, Erzincan University, Faculty of Medicine, Erzincan, Turkey
| | - Katia Iskandar
- Department of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Rao R. Ivatury
- Department of Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Maurizio Labbate
- School of Life Science and The ithree Institute, University of Technology, Sydney, NSW Australia
| | - Francesco M. Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, UNIVMP, Ancona, Italy
| | - Pierre-François Laterre
- Department of Critical Care Medicine, Cliniques Universitaires Saint Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Rifat Latifi
- Department of Surgery, Division of Trauma, University of Arizona, Tucson, AZ USA
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Ran Lee
- Texas Tech University Health Sciences Center School of Pharmacy, Abilene, TX USA
| | - Marc Leone
- Department of Anaesthesiology and Critical Care, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Yousheng Li
- Department of Surgery, Inling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Stephen Y. Liang
- Division of Infectious Diseases, Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO USA
| | - Tonny Loho
- Division of Infectious Diseases, Department of Clinical Pathology, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Marc Maegele
- Department for Traumatology and Orthopedic Surgery, Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke (UW/H), Cologne, Germany
| | - Sydney Malama
- Health Research Program, Institute of Economic and Social Research, University of Zambia, Lusaka, Zambia
| | - Hany E. Marei
- Biomedical Research Center, Qatar University, Doha, Qatar
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Wellcome Trust-HRB Clinical Research, Department of Clinical Medicine, Trinity Centre for Health Sciences, St James’ University Hospital, Dublin, Ireland
| | - Sanjay Marwah
- Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | - Amos Massele
- Department of Clinical Pharmacology, School of Medicine, University of Botswana, Gaborone, Botswana
| | - Michael McFarlane
- Department of Surgery, Radiology, University Hospital of the West Indies, Kingston, Jamaica
| | - Renato Bessa Melo
- General Surgery Department, Centro Hospitalar de São João, Porto, Portugal
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - David P. Nicolau
- Center of Anti-Infective Research and Development, Hartford, CT USA
| | - Carl Erik Nord
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | | | | | - Carlos A. Ordonez
- Department of Surgery and Critical Care, Universidad del Valle, Fundación Valle del Lili, Cali, Colombia
| | - Mouaqit Ouadii
- Department of Surgery, Hassan II University Hospital, Medical School of Fez, Sidi Mohamed Benabdellah University, Fez, Morocco
| | | | - Diego Piazza
- Division of Surgery, Vittorio Emanuele Hospital, Catania, Italy
| | - Guntars Pupelis
- Department of General and Emergency Surgery, Riga East University Hospital ‘Gailezers’, Riga, Latvia
| | - Timothy Miles Rawson
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
| | - Miran Rems
- Department of General Surgery, Jesenice General Hospital, Jesenice, Slovenia
| | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael’s Hospital, University of Toronto, Toronto, Canada
| | | | - Boris Sakakhushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | | | - Norio Sato
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Helmut A. Segovia Lohse
- II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Gabriele Sganga
- Department of Surgery, Catholic University of Sacred Heart, Policlinico A Gemelli, Rome, Italy
| | - Boonying Siribumrungwong
- Department of Surgery, Faculty of Medicine, Thammasat University Hospital, Thammasat University, Pathum Thani, Thailand
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Tan Tock Seng, Singapore
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Rodolfo Soto
- Department of Emergency Surgery and Critical Care, Centro Medico Imbanaco, Cali, Colombia
| | - Peep Talving
- Department of Surgery, North Estonia Medical Center, Tallinn, Estonia
| | - Jonathan V. Tilsed
- Surgery Health Care Group, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - Gabriel Trueba
- Institute of Microbiology, Biological and Environmental Sciences College, University San Francisco de Quito, Quito, Ecuador
| | - Ngo Tat Trung
- Department of Molecular Biology, Tran Hung Dao Hospital, No 1, Tran Hung Dao Street, Hai Ba Trung Dist, Hanoi, Vietnam
| | - Jan Ulrych
- 1st Department of Surgery - Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Prague, Czech Republic
| | - Harry van Goor
- Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Andras Vereczkei
- Department of Surgery, Medical School University of Pécs, Pécs, Hungary
| | - Ravinder S. Vohra
- Nottingham Oesophago-Gastric Unit, Nottingham University Hospitals, Nottingham, UK
| | - Imtiaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Waldemar Uhl
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affilliated Hospital, Zhejiang University, Zhejiang, China
| | - Kuo-Ching Yuan
- Trauma and Emergency Surgery Department, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | | | - Jean-Ralph Zahar
- Infection Control Unit, Angers University, CHU d’Angers, Angers, France
| | - Tanya L. Zakrison
- Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgry, University of Miami, Miami, FL USA
| | - Antonio Corcione
- Anesthesia and Intensive Care Unit, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Rita M. Melotti
- Anesthesiology and Intensive Care Unit, Sant’Orsola University Hospital, Bologna, Italy
| | - Claudio Viscoli
- Infectious Diseases Unit, University of Genoa (DISSAL) and IRCCS San Martino-IST, Genoa, Italy
| | - Perluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’ Orsola Hospital, University of Bologna, Bologna, Italy
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Mukherjee K, Sowards KJ, Brooks SE, Norris PR, Boord JB, May AK. Insulin resistance increases before ventilator-associated pneumonia in euglycemic trauma patients. Surg Infect (Larchmt) 2015; 15:713-20. [PMID: 25215464 DOI: 10.1089/sur.2013.164] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Hyperglycemia caused by stress-induced insulin resistance is associated with both infection and mortality in critically injured patients. The onset of infection may increase stress-induced insulin resistance, leading to hyperglycemia. Hyperglycemia has been shown to precede the diagnosis of ventilator-associated pneumonia (VAP) in critically injured adults and has been suggested to have potential diagnostic importance. However, glycemic control (GC) protocols in critically ill patients limit the development of hyperglycemia despite increasing insulin resistance. Our computer-assisted GC protocol achieves excellent GC, limiting infection-related hyperglycemia while capturing prospectively all glucose values, insulin infusion rates, and the multiplier (M) used to calculate the insulin rate. We hypothesized that surrogate measures of insulin resistance, the insulin infusion rate and multiplier M, would increase prior to the clinical suspicion of VAP, even in euglycemic critically injured patients. METHODS All critically injured patients (2,656) on the computerized glycemic control protocol were included in the analysis and categorized by those developing VAP and those without pneumonia on days 3-10 of their intensive care unit (ICU) stay. Median blood glucose concentration (BG), insulin infusion rate (IDR), and multiplier (M) [Insulin Drip Rate=M*(BG-60)] were determined for VAP patients (n=329) and non-infected ventilated (NIV) patients (n=2,327) on each day of mechanical ventilation. The day of VAP diagnosis according to U.S. Centers for Disease Control and Prevention (CDC) criteria was defined as day zero and VAP patients matched with NIV patients according to ventilator day from -10 to +10. Comparisons were conducted using the Mann-Whitney U test. RESULTS Baseline characteristics between VAP and NIV groups did not differ. Measures of insulin resistance increased from the time of injury in both groups. Patients with VAP had significantly greater change in both measures of insulin resistance, IDR and M, in the 48 hours preceding the diagnosis of VAP. These changes occurred despite the fact that the computer-assisted GC protocol achieved lower glucose values in VAP patients for the majority of study days. CONCLUSIONS Measures of insulin resistance increase in the two days prior to the clinical suspicion of VAP for critically injured patients on the GC protocol. These changes occur despite the protocol maintaining euglycemia. This data suggests that markers of insulin resistance may provide clinically useful information in the early diagnosis of VAP.
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Affiliation(s)
- Kaushik Mukherjee
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
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Calfee CS, Janz DR, Bernard GR, May AK, Kangelaris KN, Matthay MA, Ware LB. Distinct molecular phenotypes of direct vs indirect ARDS in single-center and multicenter studies. Chest 2015; 147:1539-1548. [PMID: 26033126 DOI: 10.1378/chest.14-2454] [Citation(s) in RCA: 248] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND ARDS is a heterogeneous syndrome that encompasses lung injury from both direct and indirect sources. Direct ARDS (pneumonia, aspiration) has been hypothesized to cause more severe lung epithelial injury than indirect ARDS (eg, nonpulmonary sepsis); however, this hypothesis has not been well studied in humans. METHODS We measured plasma biomarkers of lung epithelial and endothelial injury and inflammation in a single-center study of 100 patients with ARDS and severe sepsis and in a secondary analysis of 853 patients with ARDS drawn from a multicenter randomized controlled trial. Biomarker levels in patients with direct vs indirect ARDS were compared in both cohorts. RESULTS In both studies, patients with direct ARDS had significantly higher levels of a biomarker of lung epithelial injury (surfactant protein D) and significantly lower levels of a biomarker of endothelial injury (angiopoietin-2) than those with indirect ARDS. These associations were robust to adjustment for severity of illness and ARDS severity. In the multicenter study, patients with direct ARDS also had lower levels of von Willebrand factor antigen and IL-6 and IL-8, markers of endothelial injury and inflammation, respectively. The prognostic value of the biomarkers was similar in direct and indirect ARDS. CONCLUSIONS Direct lung injury in humans is characterized by a molecular phenotype consistent with more severe lung epithelial injury and less severe endothelial injury. The opposite pattern was identified in indirect lung injury. Clinical trials of novel therapies targeted specifically at the lung epithelium or endothelium may benefit from preferentially enrolling patients with direct and indirect ARDS, respectively.
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Affiliation(s)
- Carolyn S Calfee
- Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA; Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA.
| | - David R Janz
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, Vanderbilt University, Nashville, TN
| | - Gordon R Bernard
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, Vanderbilt University, Nashville, TN
| | - Addison K May
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, Vanderbilt University, Nashville, TN
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Michael A Matthay
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, Vanderbilt University, Nashville, TN
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May AK, Brady JS, Romano-Keeler J, Drake WP, Norris PR, Jenkins JM, Isaacs RJ, Boczko EM. A pilot study of the noninvasive assessment of the lung microbiota as a potential tool for the early diagnosis of ventilator-associated pneumonia. Chest 2015; 147:1494-1502. [PMID: 25474571 DOI: 10.1378/chest.14-1687] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) remains a common complication in critically ill surgical patients, and its diagnosis remains problematic. Exhaled breath contains aerosolized droplets that reflect the lung microbiota. We hypothesized that exhaled breath condensate fluid (EBCF) in hygroscopic condenser humidifier/heat and moisture exchanger (HCH/HME) filters would contain bacterial DNA that qualitatively and quantitatively correlate with pathogens isolated from quantitative BAL samples obtained for clinical suspicion of pneumonia. METHODS Forty-eight adult patients who were mechanically ventilated and undergoing quantitative BAL (n = 51) for suspected pneumonia in the surgical ICU were enrolled. Per protocol, patients fulfilling VAP clinical criteria undergo quantitative BAL bacterial culture. Immediately prior to BAL, time-matched HCH/HME filters were collected for study of EBCF by real-time polymerase chain reaction. Additionally, convenience samples of serially collected filters in patients with BAL-diagnosed VAP were analyzed. RESULTS Forty-nine of 51 time-matched EBCF/BAL fluid samples were fully concordant (concordance > 95% by κ statistic) relative to identified pathogens and strongly correlated with clinical cultures. Regression analysis of quantitative bacterial DNA in paired samples revealed a statistically significant positive correlation (r = 0.85). In a convenience sample, qualitative and quantitative polymerase chain reaction analysis of serial HCH/HME samples for bacterial DNA demonstrated an increase in load that preceded the suspicion of pneumonia. CONCLUSIONS Bacterial DNA within EBCF demonstrates a high correlation with BAL fluid and clinical cultures. Bacterial DNA within EBCF increases prior to the suspicion of pneumonia. Further study of this novel approach may allow development of a noninvasive tool for the early diagnosis of VAP.
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Affiliation(s)
- Addison K May
- Division of Trauma and Surgical Critical Care, Vanderbilt University, Nashville, TN.
| | - Jacob S Brady
- Division of Trauma and Surgical Critical Care, Vanderbilt University, Nashville, TN
| | | | - Wonder P Drake
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, TN
| | - Patrick R Norris
- Division of Trauma and Surgical Critical Care, Vanderbilt University, Nashville, TN
| | - Judith M Jenkins
- Division of Trauma and Surgical Critical Care, Vanderbilt University, Nashville, TN
| | | | - Erik M Boczko
- Department of Mathematics, Ohio University, Athens, OH
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Mukherjee K, Sowards KJ, Brooks SE, Norris PR, Jenkins JM, Smith MA, Bonney PM, Boord JB, May AK. Insulin Resistance in Critically Injured Adults: Contribution of Pneumonia, Diabetes, Nutrition, and Acuity. Surg Infect (Larchmt) 2015; 16:490-7. [PMID: 26270204 DOI: 10.1089/sur.2014.179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Changes in insulin resistance (IR) cause stress-induced hyperglycemia after trauma, but the numerous factors involved in IR have not been delineated clearly. We hypothesized that a statistical model could help determine the relative contribution of different clinical co-variates to IR in critically injured patients. PATIENTS AND METHODS We retrospectively studied 726 critically injured patients managed with a computer-assisted glycemic protocol at an academic level I trauma center (639 ventilated controls without pneumonia (VWP) and 87 patients with ventilator-associated pneumonia (VAP). Linear regression using age, gender, body mass index (BMI), diabetes mellitus, pneumonia, and glycemic provision was used to estimate M, a marker of IR that incorporates both the serum blood glucose concentration (BG) and insulin dose. RESULTS Increasing M (p<0.001) was associated with age (1.62%; 95% confidence interval [CI] 1.27%-1.97% per decade), male gender (9.78%; 95% CI 8.28%-12.6%), BMI (4.32% [95% CI 4.02%-4.62%] per 5 points), diabetes mellitus (21.2%; 95% CI 19.2%-23.2%), pneumonia (10.9%; 95% CI 9.31%-12.6%), and glycemic provision (27.3% [95% CI 6.6%-28.1%] per 100 g of glucose). Total parenteral nutrition was associated with a decrease in M of 10.3%; 95% CI 8.52%-12.1%; p<0.001. CONCLUSIONS Clinical factors can be used to construct a model of IR. Prospective validation might enable early detection and treatment of infection or other conditions associated with increased IR.
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Affiliation(s)
- Kaushik Mukherjee
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Kendell J Sowards
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Steven E Brooks
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Patrick R Norris
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Judith M Jenkins
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Miya A Smith
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Paul M Bonney
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Jeffrey B Boord
- 2 Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Addison K May
- 1 Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center , Nashville, Tennessee
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Kahn SA, Davis SA, Banes CT, Dennis BM, May AK, Gunter OD. Impact of advanced practice providers (nurse practitioners and physician assistants) on surgical residents' critical care experience. J Surg Res 2015; 199:7-12. [PMID: 26173380 DOI: 10.1016/j.jss.2015.05.036] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 05/15/2015] [Accepted: 05/21/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Teaching hospitals often employ advanced practice providers (nurse practitioners and physician assistants or APPs) to counteract residents' work-hour restrictions. With increased utilization of APPs in labor-intense areas, such as intensive care units (ICUs), APPs may have an impact on resident education and experience. No studies have investigated the direct role an APP plays on the training experience of a surgical resident in the ICU. MATERIALS AND METHODS An institutional review board-approved survey was emailed to residents in Accreditation Council for Graduate Medical Education-accredited general surgery programs. Surveys asked about demographics, residency and/or ICU characteristics, and the effects of APPs on patient care, workflow, and educational experience. Regression analysis determined predictors of resident perception. RESULTS A total of 354 of 1178 residents responded to the survey (30%). Some residents felt that nurses calling APPs preferentially for patient-care issues interfered with education (17%) and residents' ability to follow patients (12%) and was associated with overall detrimental effects to ICU experience on regression (odds ratio, 3.7; confidence interval, 1.5-9.1). Most residents reported positive effects of APPs, such as reduced resident workload (79.8%), teaching protocols and/or guidelines (60.3%), enhanced patient care (60.3%), and enhanced communication (50.5%). When asked how APPs affected their overall ICU experience, 48.4% reported positive effects, 20.6% reported "no effect," and 31% reported detrimental effects. CONCLUSIONS Only a minority of residents perceived that APPs detract from training, particularly those who felt excluded when nurses preferentially contact APPs with patient-care issues. APPs have the potential to enhance training and ICU experience, as reflected in many of the responses. Strategies to maintain direct nurse and resident communication might preserve residents' perception of the educational value of APPs.
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Affiliation(s)
- Steven A Kahn
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Sarah A Davis
- Department of Anesthesiology, Surgical Intensive Care Unit, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Caroline T Banes
- Department of Anesthesiology, Surgical Intensive Care Unit, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bradley M Dennis
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Addison K May
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Oliver D Gunter
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Talbot TR, May AK, Obremskey WT, Wright PW, Daniels TL. Intraoperative Patient-to-Healthcare-Worker Transmission of Invasive Group A Streptococcal Infection. Infect Control Hosp Epidemiol 2015; 32:924-6. [DOI: 10.1086/661596] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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