Association between perioperative allogeneic red blood cell transfusion and infection after clean-contaminated surgery: a retrospective cohort study

BACKGROUND

Allogeneic red blood cell (RBC) transfusion can induce immunosuppression, which can then increase the susceptibility to postoperative infection. However, studies in different types of surgery show conflicting results regarding this effect.

METHODS

In this retrospective cohort study conducted in a tertiary referral centre, we included adult patients undergoing clean-contaminated surgery from 2014 to 2018. Patients who received allogeneic RBC transfusion from preoperative Day 30 to postoperative Day 30 were included into the transfusion group. The control group was matched for the type of surgery in a 1:1 ratio. The primary outcome was infection within 30 days after surgery, which was defined by healthcare-associated infection, and identified mainly based on antibiotic regimens, microbiology tests, and medical notes.

RESULTS

Among the 8098 included patients, 1525 (18.8%) developed 1904 episodes of postoperative infection. Perioperative RBC transfusion was associated with an increased risk of postoperative infection after controlling for 27 confounders by multivariable regression analysis (odds ratio [OR]: 1.60; 95% confidence interval [CI]: 1.39-1.84; P<0.001) and propensity score weighing (OR: 1.64; 95% CI: 1.45-1.85; P<0.001) and matching (OR: 1.70; 95% CI: 1.43-2.01; P<0.001), and a dose-response relationship was observed. The transfusion group also showed higher risks of surgical site infection, pneumonia, bloodstream infection, multiple infections, intensive care admission, unplanned reoperation, prolonged postoperative length of hospital stay, and all-cause death.

CONCLUSIONS

Perioperative allogeneic RBC transfusion is associated with an increased risk of infection after clean-contaminated surgery in a dose-response manner. Close monitoring of infections and enhanced prophylactic strategies should be considered after transfusion.

IsdB antibody-mediated sepsis following S. aureus surgical site infection

Staphylococcus aureus is prevalent in surgical site infections (SSI) and leads to death in approximately 1% of patients. Phase IIB/III clinical trial results have demonstrated that vaccination against the iron-regulated surface determinant protein B (IsdB) is associated with an increased mortality rate in patients with SSI. Thus, we hypothesized that S. aureus induces nonneutralizing anti-IsdB antibodies, which facilitate bacterial entry into leukocytes to generate "Trojan horse" leukocytes that disseminate the pathogen. Since hemoglobin (Hb) is the primary target of IsdB, and abundant Hb-haptoglobin (Hb-Hp) complexes in bleeding surgical wounds are normally cleared via CD163-mediated endocytosis by macrophages, we investigated this mechanism in vitro and in vivo. Our results demonstrate that active and passive IsdB immunization of mice renders them susceptible to sepsis following SSI. We also found that a multimolecular complex containing S. aureus protein A-anti-IsdB-IsdB-Hb-Hp mediates CD163-dependent bacterial internalization of macrophages in vitro. Moreover, IsdB-immunized CD163-/- mice are resistant to sepsis following S. aureus SSI, as are normal healthy mice given anti-CD163-neutralizing antibodies. These genetic and biologic CD163 deficiencies did not exacerbate local infection. Thus, anti-IsdB antibodies are a risk factor for S. aureus sepsis following SSI, and disruption of the multimolecular complex and/or CD163 blockade may intervene.

Surgical Upper Extremity Infections in Immunosuppressed Patients: A Comparative Analysis With Diagnosis and Treatment Recommendations for Hand Surgeons

Background: Immunosuppression is encountered in patients with oncologic, transplant, and autoimmune disorders. The purpose of this study is to provide guidance for physicians treating surgical hand and upper extremity (UE) infections in immunosuppressed (IS) patients. Methods: We retrospectively reviewed our database of patients presenting with UE infections over 3 years. IS patients were matched randomly to non-IS patients. Patient background, infection presentation, surgical evaluation, and microbiology variables were recorded. Infection variables included mechanism, location, and type. Outcomes included inpatient length of stay (LOS) and need for repeat drainage. Results: We identified 35 IS and 35 non-IS out of 409 UE infection patients. Patients most commonly had a hematologic malignancy (34%) as their IS class, and the most frequent immunosuppressive medication was glucocorticoids (57%). IS patients were more likely to be older and less likely to have a history of drug abuse or hepatitis C virus infections. IS infections were more likely to have idiopathic mechanisms, more likely to involve deeper anatomy such as joints, bone, tendon sheath, or muscle/fascia, and less likely to present with leukocytosis. IS cultures more commonly exhibited atypical Mycoplasma or fungus. There was no difference between IS and non-IS patients regarding LOS or recurrent drainage. Conclusions: Mechanism and white blood cell count are less reliable markers of infection severity in IS patients. Physicians treating infections in IS patients should maintain a higher suspicion for deeper involved anatomy and atypical microbiology. Nonetheless, with careful inpatient management and closer surveillance, outcomes in IS patients can approach that of non-IS patients.

Early Postoperative Anti-TNF Therapy Does Not Increase Complications Following Abdominal Surgery in Crohn's Disease

BACKGROUND

The impact of postoperative anti-TNF therapy on infectious complications following Crohn's disease surgery remains controversial. Use of anti-TNF therapy 2-4 weeks postoperatively appears safe, but safety of use within 2 weeks is unknown.

AIMS

We sought to evaluate the effect of anti-TNF therapy initiated within 2 weeks of abdominal surgery in patients with Crohn's disease.

METHODS

We conducted a retrospective review of adult Crohn's disease patients undergoing abdominal surgery between 2004 and 2011. Infectious and non-infectious complications were compared between patients exposed to anti-TNF therapy within 2 weeks or between 2 and 4 weeks postoperatively and to those without exposure using chi-squared and regression analysis.

RESULTS

Three hundred thirty-one abdominal surgeries were included; 241 were without anti-TNF exposure, 46 received postoperative anti-TNF within 2 weeks of surgery, and 44 received anti-TNF therapy 2-4 weeks after surgery. Patients who received anti-TNF therapy within 2 weeks of surgery, those initiated between 2 and 4 weeks of surgery, and those who did not receive anti-TNF therapy within 4 weeks of surgery had no significant difference in rates of infectious complications (22%, 32%, 33%, p = 0.332). Rates of non-infectious complications (4%, 9%, 14%, p = 0.143), mortality (0%, 0%, 3%, p = 0.105), hospital readmission (17%, 16%, 15%, p = 0.940), and reoperation (11%, 11%, 16%, p = 0.563) were also similar between groups.

CONCLUSIONS

Use of early anti-TNF therapy within 2 weeks or between 2 and 4 weeks following abdominal surgery did not increase risk of postoperative surgical infections in Crohn's patients.

Deep Sternal Wound Tuberculosis with Hypo-gamma-globulinemia

A 44-year-old man was referred to our hospital for the treatment of a pulmonary and deep sternal wound tuberculosis infection, which is an extremely rare type of extrapulmonary tuberculosis. Laboratory testing revealed a serum immunoglobulin (Ig) G level of 286 mg/dL, IgA of 22 mg/dL and IgM of 13 mg/dL. We therefore diagnosed him with hypo-gamma-globulinemia. He was treated with anti-tuberculosis medications and intravenous immunoglobulin. At present, the tuberculosis has not relapsed in the past six years. It may be useful to assess the humoral immunity status in tuberculosis patients with a normal T cell function, and immunoglobulin therapy may be beneficial for protecting such patients from reactivation of tuberculosis.

Do smokers have greater risk of delayed and non-union after fracture, osteotomy and arthrodesis? A systematic review with meta-analysis

OBJECTIVES

Systematic review and meta-analysis of published observational cohort studies. To quantify the increased risk smokers have of experiencing a delayed and/or non-union in fractures, spinal fusion, osteotomy, arthrodesis or established non-unions.

SETTING

Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), Allied and Complementary Medicine Database (AMED) and Web of Science Core Collection from 1966 to 2015.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Observational cohort studies that reported adult smokers and non-smokers with delayed and/or non-union or time to union of the fracture, spinal fusion, osteotomy, arthrodesis or established non-union were eligible.

DATA EXTRACTION AND OUTCOME MEASURES

2 authors screen titles, abstracts and full papers. Data were extracted by 1 author and checked independently by a second. The relative risk ratios of smoking versus non-smoking and the mean difference in time to union patients developing a delayed and/or non-union were calculated.

RESULTS

The search identified 3013 articles; of which, 40 studies were included. The meta-analysis of 7516 procedures revealed that smoking is linked to an increased risk of delayed and/or non-union. When considered collectively, smokers have 2.2 (1.9 to 2.6) times the risk of experiencing delayed and/or non-union. In all the subgroups, the increased risk was always ≥1.6 times that of non-smokers. In the patients where union did occur, it was a longer process in the smokers. The data from 923 procedures were included and revealed an increase in time to union of 27.7 days (14.2 to 41.3).

CONCLUSIONS

Smokers have twice the risk of experiencing a non-union after fracture, spinal fusion, osteotomy, arthrodesis or treatment of non-union. Time to union following fracture, osteotomy, arthrodesis or treatment of an established non-union is longer in smokers. Smokers should be encouraged to abstain from smoking to improve the outcome of these orthopaedic treatments.

Do smokers have greater risk of delayed and non-union after fracture, osteotomy and arthrodesis? A systematic review with meta-analysis

OBJECTIVES

Systematic review and meta-analysis of published observational cohort studies. To quantify the increased risk smokers have of experiencing a delayed and/or non-union in fractures, spinal fusion, osteotomy, arthrodesis or established non-unions.

SETTING

Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), Allied and Complementary Medicine Database (AMED) and Web of Science Core Collection from 1966 to 2015.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Observational cohort studies that reported adult smokers and non-smokers with delayed and/or non-union or time to union of the fracture, spinal fusion, osteotomy, arthrodesis or established non-union were eligible.

DATA EXTRACTION AND OUTCOME MEASURES

2 authors screen titles, abstracts and full papers. Data were extracted by 1 author and checked independently by a second. The relative risk ratios of smoking versus non-smoking and the mean difference in time to union patients developing a delayed and/or non-union were calculated.

RESULTS

The search identified 3013 articles; of which, 40 studies were included. The meta-analysis of 7516 procedures revealed that smoking is linked to an increased risk of delayed and/or non-union. When considered collectively, smokers have 2.2 (1.9 to 2.6) times the risk of experiencing delayed and/or non-union. In all the subgroups, the increased risk was always ≥1.6 times that of non-smokers. In the patients where union did occur, it was a longer process in the smokers. The data from 923 procedures were included and revealed an increase in time to union of 27.7 days (14.2 to 41.3).

CONCLUSIONS

Smokers have twice the risk of experiencing a non-union after fracture, spinal fusion, osteotomy, arthrodesis or treatment of non-union. Time to union following fracture, osteotomy, arthrodesis or treatment of an established non-union is longer in smokers. Smokers should be encouraged to abstain from smoking to improve the outcome of these orthopaedic treatments.

Innate lymphoid cells: a paradigm for low SSI in cleft lip repair

BACKGROUND

Cleft lip and palate reconstructions demonstrate significantly lower surgical site infection rates compared with clean-contaminated cases, prompting investigation into the pathophysiology causing this discrepancy. Recent studies have identified a new group of innate lymphocytes called innate lymphoid cells (ILCs), located in barrier surfaces of the skin, airways, and intestine. Our objectives were to explore for the first time the presence of ILCs in the vermillion of neonates and young children undergoing cleft lip reconstruction and characterize their composition by measuring the three classes of ILCs.

MATERIALS AND METHODS

Lip tissue samples were collected from 13 subjects undergoing vermillion resection during cleft lip reconstructive surgery. Preparative, transmission electron microscopy, and analytical flow cytometry were performed. The functionality of ILCs was tested in terms of their capacity to produce type 1 (IFN-γ/TNF-α), type 2 (IL-5/IL-13), and type 3 (IL-17/IL-22) cytokines. Data were analyzed using Student t test or the analysis of variance to establish significance (P < 0.05) among groups for all other data.

RESULTS

All three classes of ILCs were detected and visualized in the tissue samples. In all samples, the level of ILC2 subset was significantly higher than the other two ILC subsets (P < 0.01), followed by the ILC1 subset, which was present in significantly higher levels than the ILC3 subset (P < 0.05).

CONCLUSIONS

Our data place ILCs for the first time in the interface of oral mucosal immunity, tissue microenvironment, and homeostasis during and after tissue development, possibly explaining lower infection rates in cleft lip or palate reconstructions.

Evidence of the effect of immunonutrition on the prevention of surgical site infection

Surgical candidates are often immunosuppressed patients. Immunodeficiency associated with malnutrition are risk factors for developing postoperative SSI. The term "immunonutrition" refers to the addition of omega-3 fatty acids, glutamine and arginine to liquid nutritional supplements. Diverse studies have shown a reduction in septic complications after perioperative use of immunonutrition, but these results could not be confirmed by other authors. In this issue, we will review the actual evidence about the effect of immunonutrition on the prevention of SSI.

[Complex approach to assessment of condition severity in patients with pyoinflammatory odontogenous diseases]

Dynamics of mean value indices and mean dispersion doesn't exclude the feedback (Mayanskiy D.N., 2008) in process of study the disease according to cooperative processes using system leukocyte-monocyte-lymphocyte (L+M+LM). The authors investigated a dynamic balance between these cell substratums and collagen formation. Acute inflammatory processes in tissues of maxillofacial area accompanied by leukemoid response of peripheral blood in the form of leukocytosis (10 x 10(9)-15 x 10(9)/l and more). The authors completely agree with the opinion of M.M. Solov'yov (2012) and N.K. Artyushenko (2008) that mechanism of this reaction is associated with both the leukocyte redistribution in the inflammation zone and with changes of hematopoietic rostock which aimed to balance the affected compensatory mechanisms of nonspecific resistance.

CD4 count is associated with postoperative infection in patients with orthopaedic trauma who are HIV positive

BACKGROUND

Since the advent of effective antiretroviral therapy, the number of people with AIDS has increased and a certain percentage of these patients will require emergent orthopaedic surgery. Little is known regarding orthopaedic infections and the association of CD4 counts with postoperative infection in patients with HIV infection who experience orthopaedic trauma.

QUESTIONS/PURPOSES

We questioned whether the postoperative infection rate is higher after orthopaedic trauma surgery for patients who are HIV positive than for patients who are HIV negative undergoing similar surgery and aimed to identify preoperative variables that may be important in predicting postoperative infection in patients who are HIV positive.

METHODS

We determined the postoperative infection rate in 64 patients who were HIV positive and who underwent orthopaedic surgery requiring instrumentation or an implant from January 2001 to May 2007. We compared this rate with historical control data from 2003 to 2007 for all orthopaedic procedures at Grady Memorial Hospital. We examined numerous preoperative variables for association with postoperative infection, including CD4 count, length of inpatient stay, polytrauma, and malnutrition.

RESULTS

Of the 64 patients, 15 had postoperative infections develop with an infection rate of 23%, compared with the 3.9% rate for the historical control subjects. Analysis of the 64 patients who were HIV positive revealed CD4 counts less than 300 were associated with development of postoperative infection. Hospital stay, polytrauma, and low serum albumin also were found to be associated with postoperative infection.

CONCLUSIONS

It is evident that patients who are HIV positive with low CD4 counts undergoing emergent orthopaedic intervention are a patient population at risk for infection. Further study is necessary to evaluate preoperative and perioperative interventions that may decrease infections in this population.

LEVEL OF EVIDENCE

Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

[Clinico-morphological aspects of diagnostics and treatment of the surgical sepsis]

Treatment results of 63 patients with surgical sepsis (aged 17-92 years) were analyzed. The necessity of intravenous immunoglobulin infusion in the complex treatment of sepsis was proved by the comparative morphological study of immunocompetent tissues of 30 patients, died of sepsis and nonseptic reasons. The rational use of intravenous immunoglobulin should be based on the condition of the patient and defined by the APACHE II and SOFA scores.

The immunomodulating enteral nutrition in malnourished surgical patients - a prospective, randomized, double-blind clinical trial

BACKGROUND & AIM

The immunomodulating nutrition was supposed to reduce the incidence of complications in surgical patients, but many authors have questioned its value recently. The aim of the study was to assess the impact of enteral immunonutrition in postoperative period.

METHODS

Between January 2003 and December 2009, 305 malnourished patients (123 F, 182 M, m. age 60.8) undergoing resection for pancreatic or gastric cancer, after preoperative 14 days of parenteral feeding, were randomized in double-blind manner to receive either postoperative immunomodulating enteral diet (IMEN) or standard oligopeptide diet (SEN). Outcome measures of the intend-to-treat analysis were: number and type of complications, length of hospitalization, mortality, and vital organ function.

RESULTS

Median postoperative hospital stay was 17.1 days in SEN and 13.1 days in IMEN group (p = 0.006). Infectious complications were observed in 60 patients (39.2%) in SEN and 43 (28.3%) in IMEN group (p = 0.04). Differences were also observed in overall morbidity (47.1 vs 33.5%, p = 0.01) and mortality (5.9 vs 1.3%, p = 0.03), but the ratio of surgical complications, organ function, and treatment tolerance did not differ.

CONCLUSIONS

The study proved that postoperative immunomodulating enteral nutrition should be the treatment of choice in malnourished surgical cancer patients. The Clinical Trials Database registry number: NCT00576940.

Optimizing surgical care: a contemporary assessment of temperature, oxygen, and glucose

Factors such as temperature, oxygen, and glucose have recently been implicated in the development of surgical sepsis by either promoting or attenuating protective components of the innate immune response. Reducing infective sequelae and the improvement of the quality of care of surgical patients is a top practice priority today. These factors and their associated effects are discussed through the examination of recent clinical and scientific studies to provide an up-to-date evidence-based review.

IL-18 Level Correlates with Development of Sepsis in Surgical Patients

Interleukin 18 may play an important role in sepsis. We measured circulating IL-18 levels in 47 patients with surgical wounds, 27 of them had clinical and laboratory evidences of sepsis. The patients had significantly higher IL-18 levels than healthy control (p1 = 0.001), patients with local infection (p4 = 0.001) and patients with clean surgical wound (p5 = 0.001) both at admission and after 48 hours. Serial observations revealed that in all patients, IL-18 levels increased significantly especially in patients with sepsis after 48 h (p = 0.007). IL-18 levels appeared to correlate significantly with leucocytes counts (p = 0.001) and with C-RP (p = 0.007). These results suggest that IL-18 levels are increased in patients with sepsis and correlate with CRP and leukocyte counts suggesting that IL-18 may play a role in sepsis. We suggest that IL-18 could be used as a collaborative evidence of surgical sepsis.

[Surgical trauma and postoperative immunosuppression]

Abdominal surgery is regularly followed by immune dysfunction that can last for several days. In case of septic complications during this period, there is imminent danger of mortality due to reduced immune function. This fact leads to classification of sepsis in regard to its genesis: spontaneously acquired sepsis type A is distinguishable from sepsis type B, which is acquired postoperatively. The main difference between these types is the immunologic condition at the time point of sepsis development. Postoperative immune dysfunction can be described by several parameters, i.e. reduction of HLA-DR expression on monocytes and increased apoptosis of T lymphocytes. A direct correlation exists between magnitude of immune dysfunction and complexity of the previous surgical trauma. For the first time it is now possible to study this phenomenon of postoperative immune dysfunction by use of an adequate animal model. Intestinal manipulation in mice fulfils the necessary criteria to serve as a model of surgically induced immune dysfunction.

Primary cutaneous aspergillosis in a patient with a solid organ transplant: case report and review of the literature

GOAL

To understand primary cutaneous aspergillosis to better manage patients with the condition.

OBJECTIVES

Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Describe risk factors for Aspergillus infection. 2. Identify diagnostic methods for primary cutaneous aspergillosis. 3. Discuss treatment options for primary cutaneous aspergillosis. Primary cutaneous aspergillosis is an uncommon disease in immunocompetent individuals that often affects immunosuppressed hosts. We present the first reported case of primary cutaneous aspergillosis in a solid organ transplant recipient caused by Aspergillus niger. Fruiting bodies were isolated from a necrotic ulcer arising in a surgical wound. Debridement alone failed to resolve the infection, emphasizing the need for early antifungal treatment combined with surgical management of this infection.

Risk factors for surgical site infections and other complications in elective surgery in patients with rheumatoid arthritis with special attention for anti-tumor necrosis factor: a large retrospective study

OBJECTIVE

To identify risk factors for surgical site infection (SSI) in patients with rheumatoid arthritis (RA) with special attention for anti-tumor necrosis factor (anti-TNF) treatment.

METHODS

All patients with RA who had undergone elective orthopedic surgery since introduction of anti-TNF were included in a retrospective parallel-cohort study with a one-year followup. Primary endpoint was a SSI according to the 1992 Centers for Disease Control and Prevention criteria and/or antibiotic use. Cohort 1 did not use anti-TNF, cohort 2 used anti-TNF but had either stopped (2A) or continued anti-TNF preoperatively (2B), the cutoff point being set at 4 times the half-life time of the drug. Infection rates were compared between cohorts, and logistic regression analysis was performed to examine risk factors.

RESULTS

In total, 1219 (768 patients) procedures were included, and crude infection risks were 4.0% (41/1023), 5.8% (6/104), and 8.7% (8/92) in cohorts 1, 2A, and 2B, respectively. Elbow surgery (OR 4.1, 95% CI 1.6-10.1), foot/ankle surgery (OR 3.2, 95% CI 1.6-6.5), and prior skin or wound infection (OR 13.8, 95% CI 5.2-36.7) were associated with increased risk of SSI, whereas duration of surgery (OR 0.42, 95% CI 0.23-0.78) and sulfasalazine use (OR 0.21, 95% CI 0.05-0.89) were associated with decreased risk. Perioperative use of anti-TNF was not significantly associated with an increase in SSI rates (OR 1.5, 95% CI 0.43-5.2).

CONCLUSION

The most important risk factor for SSI is history of SSI or skin infection. Although our study was not powered to detect small differences in infection rates, perioperative continuation of anti-TNF does not seem to be an important risk factor for SSI.

Active hexose correlated compound (AHCC) enhances resistance to infection in a mouse model of surgical wound infection

BACKGROUND

Infection is the most common postoperative complication within the surgical wound and during severe trauma. In spite of the use of modern sterile techniques and prophylaxis, infection continues to be a leading cause of death in these patients. Therefore, it has become crucial to develop new alternatives to prevent the effects of trauma and other complications on the immune system and improve resistance to infection. The objective of this study was to test the prophylactic effects of oral administration of active hexose correlated compound (AHCC), a natural immunoenhancer, on survival in a mouse model of surgical soft tissue infection.

METHODS

The model involves the intramuscular administration of a 50% lethal dose (LD50) of K. pneumoniae to mice that have restricted food intake for 24 hours prior to and six hours after infection and simulates local infection and food deprivation that often occur during trauma or surgical procedures. In the present study, AHCC was administrated orally to Swiss Webster mice for eight days prior to and during the infection period. Survival, time of death, LD50, and clearance of bacteria of this group were compared with those control mice receiving the excipient alone.

RESULTS

Survival and mean time to death were increased significantly in the AHCC-treated group; the LD50 was greater in mice receiving AHCC than in mice receiving the excipient. Mice receiving AHCC were better able to clear bacteria from their systems than were control animals.

CONCLUSIONS

The results suggest that AHCC protects mice in this model by restoring the immune and other systems negatively affected by trauma, infection, and food deprivation. More studies are necessary to determine the intrinsic mechanisms involved in this model and whether AHCC can prevent infection or improve survival in human beings with severe trauma or undergoing surgical procedures.

Effective wound management: identifying criteria for infection

This article provides an overview of the European Wound Management Association's (2005) position document Identifying Criteria for Wound Infection and outlines its relevance and clinical applicability. The document is divided into four parts: understanding wound infection; clinical identification of wound infection--a Delphi approach; identifying criteria for pressure ulcer infection; and identifying surgical site infection in wounds healing by primary intention. Each part is discussed separately.

The effect of treating infected skin grafts with Acticoat™ on immune cells

A study was conducted to determine the effect of Acticoat placed on an infected skin graft on parameters of immunity. Two partial thickness wounds (2 cm x 4 cm) were created on the dorsal midline of Hartley guinea pigs (n=28). Wounds were covered with autologous skin graft and maintained either aseptically (Noninoculated, n=8), inoculated with Staphylococcus aureus (Surgery-Inoculated, n=8) with or without Acticoat bandage (Surgery-Inoculated-Acticoat, n=6). Five days later, splenocytes and blood were collected to estimate natural killer cell (NK) cytotoxicity, proliferative response to T and B cell mitogens and neutrophil oxidative burst. Animals that did not undergo surgery were included as a nonsurgery control group. [(3)H]-thymidine incorporation in response to a variety of T and B cell mitogens was significantly lower for all groups undergoing surgery compared to the nonsurgery control group (p<0.0001) and no additional effect was observed on this immune measure by applying the Acticoat bandage. The Surgery-Inoculated-Acticoat group exhibited greater NK cytotoxic activity (as assessed as the ability to lyse K562 tumor cells) compared to the Surgery-Inoculated group (p<0.006). The Surgery-Inoculated-Acticoat group had higher neutrophil oxidative burst at 5 min post stimulation, but was not different from controls after 15 min. In conclusion, the application of an Acticoat bandage to an inoculated surgery wound did not alter the low cell-mediated immune response that followed surgery, but appeared to increase parameters (NK cytotoxic activity and neutrophil function) of innate immunity.

Aggressive management of surgical emergencies

Increasing evidence suggests that two factors significantly influence outcome in a surgical emergency - premorbid health and the degree of inflammation during the first 24 h following trauma. Repeat observations suggest that the depth of post-trauma immunoparalysis reflects the height of early inflammatory response. Administration to surgical emergencies, as was routine in the past, of larger amounts of fluid and electrolytes, fat, sugar and nutrients seems counterproductive as it increases immune dysfunction, impairs resistance to disease and, in fact, increases morbidity. Instead, strong efforts should be made to limit the obvious superinflammation, which occurs during the first 24 h after trauma and, thereby, reduce the subsequent immunoparalysis. Several approaches show efficacy in limiting early superinflammation such as strict control of blood glucose, avoidance of stored blood when possible, supply of antioxidants, live lactic acid bacteria and plant fibres. This review focuses mainly on use of live lactic acid bacteria and plant fibres, often called synbiotics. Encouraging experience is reported from clinical trials in liver transplantation, severe pancreatitis and extensive trauma. Immediate control of inflammation by enteral nutrition and supply of antioxidants, lactic acid bacteria and fibres is facilitated by feeding tubes, introduced as early as possible on arrival at the hospital.

[Prediction of surgical infections severity at elderly and old patients]

Clinical and immunological characteristics of generalized peritonitis in different age group at complicated and non-complicated postoperative period were analyzed at 246 patients with abdominal purulent infection. Prognostic criteria of complicated postoperative period at elderly and old patients have been determined. It is concluded that interpretation of immune characteristics permits to determine the prognostic criteria of disease course and outcome at various age group, and to use the rational immunocorrection.

Clinical inquiries. Which vaccinations are indicated after splenectomy?

Immunization against encapsulated bacterial pathogens decreases the incidence of post-splenectomy sepsis. Pneumococcal, meningococcal, and Haemophilus influenzae (Hib) vaccinations are indicated for patients after splenectomy. These immunizations should be given at least 14 days before a scheduled splenectomy, or given after the fourteenth postoperative day (strength of recommendation [SOR]: A, based on systematic review of RCTs for the pneumococcal vaccine; SOR: B, based on systematic review of clinical trials for meningococcal and Hib vaccines).

Mediator Responses in Surgical Infections

BACKGROUND

Surgical infections, and sepsis in particular, are characterized by extensive release of mediators. Our laboratories have been interested in understanding how these substances contribute to morbidity and mortality during various stages of surgical infections in order to develop new and more effective therapeutics and treatment strategies.

METHODS

In a series of in vitro studies, human plasma was exposed to lipopolysaccharide (LPS), and whole blood was treated with peptidoglycan from Staphylococcus aureus. The activity of peptidoglycan also was studied in the rat, and LPS infusion was tested in dog and pig models. In a clinical study, the relation of serum LPS to multiple organ dysfunction and failure was studied in patients in the surgical intensive care unit.

RESULTS

Exposure of plasma to LPS led to formation of bradykinin, activation of the plasma kallikrein-kinin system, and reduction of kallikrein inhibitor capacity. The coagulation, fibrinolysis, and complement cascades were activated. Peptidoglycan caused rapid release of tumor necrosis factor-alpha, interleukin-1beta, and interleukin-6 from macrophages and activation of the genes encoding pro-inflammatory and anti-inflammatory cytokines. In the rat, peptidoglycan induced cytokine release, caused liver and kidney dysfunction, and induced matrix metalloproteinase-9 (MMP-9) activity in the liver and lung. In the dog and pig, LPS caused substantial activation of plasma proteases. Clinically, a finding of LPS in the plasma was associated with multiple organ dysfunction and failure. These patients also revealed substantial activation of the plasma cascade systems, as well as systemic cytokine release.

CONCLUSION

On the basis of these observations, we developed a monitoring system to recognize early signs of infection.

CD4+ T cells and CXC chemokines modulate the pathogenesis of Staphylococcus aureus wound infections

T cells are critical for the formation of intraabdominal abscesses by Staphylococcus aureus. We hypothesized that T cells modulate the development of experimental staphylococcal infections by controlling polymorphonuclear leukocyte (PMN) trafficking. In models of staphylococcal s.c. abscess formation, hindpaw infection, and surgical wound infection, S. aureus multiplied in the tissues of WT C57BL/6J mice and elicited a marked inflammatory response. CD4(+) alphabeta T cells homed to the surgical wound infection site of WT animals. In contrast, significantly fewer S. aureus were recovered from the tissues of mice deficient in alphabeta T cells, and the inflammatory response was considerably diminished compared with that of WT animals. Alphabeta T cell receptor (-/-) mice had significantly lower concentrations of PMN-specific CXC chemokines in wound tissue than did WT mice. The severity of the wound infection was enhanced by administration of a CXC chemokine and abrogated by antibodies that blocked the CXC receptor. An acapsular mutant was less virulent than the parental S. aureus strain in both the s.c. abscess and the surgical wound infection models in WT mice. These data reveal an important and underappreciated role for CD4(+) alphabeta T cells in S. aureus infections in controlling local CXC chemokine production, neutrophil recruitment to the site of infection, and subsequent bacterial replication.

Increased plasma levels of IL-6 and IL-8 are associated with surgical site infection after pancreaticoduodenectomy

OBJECTIVES

Cytokines and chemokines potentially modulate postoperative immune response. Association of circulating cytokines and chemokines with postoperative infectious complications after pancreaticoduodenectomy was evaluated.

METHODS

Plasma concentrations of interleukin (IL) 6, IL-10, IL-8, macrophage chemoattractant protein 1, heat shock protein 70, and amylase, as well as amylase levels in peritoneal exudative fluid, were measured perioperatively in 60 consecutive patients who underwent pancreaticoduodenectomy.

RESULTS

Of the 60 patients, 27 patients had surgical site infection (SSI), including peritoneal infection in all, intra-abdominal abscess in 14, and radiologically visualized pancreatic leakage in 6. Postoperative plasma levels of IL-6, IL-8, and macrophage chemoattractant protein 1, as well as peritoneal amylase levels, were significantly higher in patients with SSI than in those without SSI (P < 0.05). Nonpancreatic cancer as a histopathologic diagnosis, high pancreatic juice flow, and increased levels of IL-6 and IL-8 were independently associated with SSI (P < 0.05) in multiple logistic regression analysis. Plasma levels of IL-6 and IL-10 among patients with SSI were significantly higher in those with pancreatic leakage than in those without leakage.

CONCLUSIONS

These results suggest that, in addition to pancreatic exocrine function, IL-6 and IL-8 are associated with postoperative SSI, including pancreatic leakage after pancreaticoduodenectomy.

[Status of immune response and possibilities of its correction during the severe surgical infections of the maxillo-facial region]

The study of the immune status of the 30 patients with suppurative-septic diseases of the maxillo-facial region reveal the marked changes such as the deviation of the functions of antigen-presenting cells (macrophages, monocytes). The antigen specific immune-response system is disturbed as well (CD4+, CD8+); the production of the protective immune globulins (B cells) is abnormal. The serious suppression of interferon system occurs (suppression of the activities of INFalpha and INFgamma). The cytokine therapy using the Ronkoleukine, in association with systemic antibacterial therapy (patients with the severe forms of surgical infection of maxillo-facial region) during the 10-12 days markedly improve deviation of the immune status. It diminishes the degree of the endogen toxemia and reduces the time of recovery.

[The influence of trauma on immunological response (the role of Tgammadelta+ lymphocytes)]

The influence of trauma, especially surgical operation on immunological response has not been clarified sufficiently. The authors discuss the influence of surgical trauma on humoral and cell mediated immune response and on phagocytosis as well. The role of Tgammadelta+ lymphocytes in immunological processes that occur after trauma have been also discussed.

Deficiency in systemic interleukin-1 receptor antagonist production as an operative risk factor in malnourished elderly patients with colorectal carcinoma

OBJECTIVE

Aging and tumor-related malnutrition are associated with increased inflammatory cytokine levels. However, it is unclear whether this influences the outcomes of surgery. We explored the relationships between cytokines and surgical complications among patients undergoing surgery for colorectal cancer.

DESIGN

Laboratory experiment.

SETTING

Surgery department of school of medicine.

PATIENTS

One hundred patients with colorectal cancer.

INTERVENTIONS

The perioperative circulating levels of interleukin (IL)-1beta, IL-6, and IL-1 receptor antagonist (Ra) were determined, and the numbers of circulating lymphocytes and neutrophils were counted.

MEASUREMENTS AND MAIN RESULTS

Trends toward increasing postoperative infection were observed among patients who were older and had lower body mass index. Preoperative IL-1Ra and intraoperative blood loss, however, remained the only two independent predictors of postoperative infection. Clinically, patients with low preoperative IL-1Ra most frequently were the elderly with low body mass index. Postoperatively, elderly patients with low body mass index showed an exaggerated IL-6 response, followed by an exaggerated postoperative inflammatory response and increased postoperative loss of body weight. In contrast, normal immunoreactivity was preserved in well-nourished elderly patients.

CONCLUSIONS

In colorectal cancer patients undergoing surgery, low preoperative IL-1Ra is associated with postoperative infection. In our patient population, lower IL-1Ra level is commonly observed in the elderly with low body mass index. These findings suggest that postoperative infection, frequently seen in the nutritionally deficient elderly, may be the result of defective immunoinflammatory adaptation system.

Postoperative spondylodiscitis from Aspergillus fumigatus in immunocompetent subjects

The authors describe a case of spondylodiscitis from Aspergillus fumigatus which occurred subsequent to surgery for lumbar disc herniation in a non-immunodepressed patient. The results obtained by combined medical and surgical treatment are discussed.

Altered Cell-mediated Immunity and Increased Postoperative Infection Rate in Long-term Alcoholic Patients

Background

Preoperative alteration of T cell-mediated immunity as well as an altered immune response to surgical stress were found in long-term alcoholic patients. The aim of this study was to evaluate perioperative T cell-mediated immune parameters as well as cytokine release from whole blood cells after lipopolysaccharide stimulation and its association with postoperative infections.

Methods

Fifty-four patients undergoing elective surgery of the aerodigestive tract were included in this prospective observational study. Long-term alcoholic patients (n = 31) were defined as having a daily ethanol consumption of at least 60 g and fulfilling the Diagnostic and Statistical Manual of Mental Disorders for either alcohol abuse or alcohol dependence. The nonalcoholic patients (n = 23) were defined as drinking less than 60 g ethanol/day. Blood samples to analyze the immune status were obtained on morning before surgery and on the morning of days 1, 3, and 5 after surgery.

Results

Basic patient characteristics did not differ between groups. Before surgery, the T helper 1:T helper 2 ratio (Th1: Th2) was significantly lower (P &lt; 0.01), whereas plasma interleukin 1beta and lipopolysaccharide-stimulated interleukin 1ra from whole blood cells were increased in long-term alcoholic patients. After surgery, a significant suppression of the cytotoxic lymphocyte ratio (Tc1:Tc2), the interferon gamma:interleukin 10 ratio from lipopolysaccharide-stimulated whole blood cells, and a significant increase of plasma interleukin 10 was observed. Long-term alcoholics had more frequent postoperative infections compared with nonalcoholic patients (54%vs. 26%; P = 0.03).

Conclusions

T helper cell-mediated immunity was significantly suppressed before surgery and possibly led to inadequate cytotoxic lymphocyte and whole blood cell response in long-term alcoholic patients after surgery. This altered cell-mediated immunity might have accounted for the increased infection rate in long-term alcoholic patients after surgery.

Serum monocyte chemoattractant protein-1 in patients with postoperative infectious complications from gastrointestinal surgery for cancer

We examined the kinetics of serum monocyte chemoattractant protein-1 (MCP-1) perioperatively and clarified its significance regarding the development of infectious complications. We studied 94 patients who underwent gastrointestinal surgery for gastric or colorectal cancer at Mie University Hospital from 1996 to 2000. Serum concentrations of MCP-1 and interleukin-6 (IL-6) were measured perioperatively. The number of circulating lymphocytes and neutrophils were counted to assess the apoptotic rate of neutrophils. Patients were divided into two groups at the median preoperative MCP-1 level obtained from 40 gender- and age-matched healthy volunteers. The rate of developing infectious complications was significantly higher and tumor size was significantly larger in the low MCP-1 group than in the high MCP-1 group. The increasing IL-6 ratio (postoperative/preoperative IL-6 level) in the low MCP-1 group was about twofold greater than that in the high MCP-1 group. The neutrophil level calculated for the low MCP-1 group was significantly higher than that in the high MCP-1 group on postoperative day 3. We concluded that a decreased level of serum MCP-1 reflected tumor-related immunosuppression. Low MCP-1 levels were associated with an exaggerated postoperative IL-6 response and delayed neutrophil apoptosis, which affected the incidence of postoperative infectious complications developing in patients with gastrointestinal malignancies.

[Use of cytomedins in combined therapy of surgical infections]

Under study was the influence of cytomedins on the system of immunity in patients with developed surgical infection in a traumatology clinic. The investigation of immune reactions under conditions of purulent infection of different etiology has shown the necessity to include the up-to-date and purposeful immunomodulating therapy (cytomedins) in the complex of treatment which allows arrest of the inflammatory process in the wound in earlier terms.

Postoperative pneumococcal cellulitis in systemic lupus erythematosus

This paper reports a case of nosocomial pneumococcal cellulitis that developed following a lymph-node biopsy in a woman being treated with high-dose intravenous corticosteroids for systemic lupus erythematosis (SLE). Her rapid and severe clinical deterioration was similar to that caused by group A streptococcus. The risk factors for the development of nosocomial pneumococcal cellulitis as a complication of SLE are reviewed and preventive measures discussed.

Cellular, biochemical, and clinical aspects of wound healing

BACKGROUND

The response to tissue injury requires the symphonious interaction of immune cells, keratinocytes, fibroblasts, and endothelial cells, which unite to regenerate the damaged epithelium. Recent insights have elucidated the cellular and molecular mechanisms required for wound healing and have raised the prospect of novel therapeutic targets.

METHODS

Review of the pertinent literature.

RESULTS

The initial inflammatory response leads to the influx of macrophages and neutrophils, which release cytokines, growth factors, and nitric oxide, and induce nearby keratinocytes to migrate across the wounded epithelium. This process, known as re-epithelialization, requires integrin-mediated activation of Rho-GTPases. The subsequent influx of fibroblasts and endothelial cells results in the production of tissue stroma and formation of new blood vessels, which lead to the generation of functional tissue. Importantly, disease states associated with impaired or excessive wound healing can be attributed to defects in these responses, providing a rationale for the use of evidence-based biological therapies.

CONCLUSION

The elucidation of the cellular and biochemical response to wound healing is essential for an understanding to the treatment of clinical conditions during which impaired healing is encountered.

Association between patient-controlled analgesia pump use and postoperative surgical site infection in intestinal surgery patients

BACKGROUND

Patient-controlled analgesia (PCA) pumps are widely used after surgery, but their association with various outcomes is not completely understood. Is PCA pump use related to the incidence of postoperative surgical site infections among patients undergoing open intestinal surgery?

MATERIALS AND METHODS

We undertook a comprehensive retrospective chart review of 515 randomly selected patients over age 18 who had major rectal or intestinal surgery (Diagnosis Related Groups [DRGs] 146-149) between January 1994 and March 1997 from eight community or teaching hospitals along the U.S. west coast. Of these patients, 214 used PCA pumps. Outcome measures were in-hospital postoperative surgical site infections, respiratory complications, ileus/abdominal distention, urinary tract infection/urinary retention, and length of stay.

RESULTS

Use of a PCA pump was significantly associated with increased in-hospital postoperative surgical site infections (10.7% for PCA, 4.0% for no PCA). The odds ratio for PCA use was about 4.0 after controlling for many variables, including severity of illness at admission, body mass index, preadmission use of corticosteroids, perforated viscus, number of previous abdominal operations, wound classification category, hypothermia, malnutrition on admission, preoperative antibiotic use within 2 h before incision, time from hospital admission to surgery, skin prep to incision time, anesthesia start to incision time, surgical skin to skin time, wound closure type, time from incision closure to the start of PCA, use of drains, blood product use, central line use, line infection, mobility assistance required, hospital, DRG, and surgeon.

CONCLUSION

No confounding variables explained the significant association between PCA pump use and in-hospital surgical site infection. These results stand firmly on data that merit additional study to further elucidate possible immunologic effects of PCA pumps.

The influence of diabetes mellitus on postoperative infections

Clinicians and researchers are linking elevated glucose levels with potential infectious outcomes. Physiologic processes to fight foreign agents are potentially impaired during periods of hyperglycemia. Some of these responses, such as immune function and the inflammatory response, are impaired when they are needed most, such as during the recovery from surgical procedures. Investigators have demonstrated the importance of control of serum glucose postoperatively. Outcomes are improved when tighter glycemic control is practiced. The current literature challenges practitioners to become more cognizant of serum glucose in surgical patients and patients who are critically ill, implementing protocols to gain tighter control of serum glucose in any patient may be appropriate. Further investigation of glycemic control in surgical and other populations will reinforce research findings in this area. Studies should be performed on surgical patients who are particularly vulnerable to DM, glycemic alterations, and postoperative infections, such as patients undergoing peripheral vascular surgery. Further investigations are also needed on the role of hyperglycemia and outcomes in nondiabetic individuals, and on the similarities or differences in glycemic control in types 1 and 2 DM. To increase the generalizability of the study findings, definitions used across studies, such as the type of diabetes, should be standardized. When these studies determine optimal glycemic control practices in a variety of patient populations, clinicians will be able to determine the best practice guidelines to optimize patient care and limit adverse infectious outcomes.

Immune responses and prediction of major infection in patients undergoing transhiatal or transthoracic esophagectomy for cancer

OBJECTIVE

To investigate alterations in immune responses after transhiatal versus transthoracic esophageal resection and to evaluate the role of preoperative immune functions in predicting postoperative infectious complications.

SUMMARY BACKGROUND DATA

Impaired immune defense is associated with a decreased resistance to infection. Patients undergoing esophageal resection via a transhiatal or transthoracic approach are prone to develop infectious complications. There are no randomized data on immune responses after two major surgical interventions.

METHODS

The study group consisted of 20 patients who were randomly allocated to a limited transhiatal or extended transthoracic esophagectomy for cancer. Blood samples were taken before the operation and at regular intervals thereafter from day 1 to day 10. Monocyte and T-helper type 1 (Th1) and type 2 (Th2) lymphocyte functions were assessed in stimulated whole blood cultures.

RESULTS

Both surgical groups had severely depressed in vitro production of interleukin (IL)-12, IL-10, interferon-gamma, IL-2, IL-4, and IL-13 on postoperative day 1. Depression of Th2-type cytokine production was more profound after transthoracic than after transhiatal esophagectomy (IL-4, P=.005; IL-13,P=.007). Postoperative reduction in Th1-type cytokine production was similar between the two groups (interferon-gamma, P=.40; IL-2, P=.06). Irrespective of the surgical approach, patients who developed major infectious complications after surgery presented with a diminished T-cell cytokine production before the operation compared to those who had a relatively uneventful recovery (IL-4, P=.045; interferon-gamma, P=.064). In regression analysis, the occurrence of postoperative major infection was best predicted by increased duration of anesthesia ( P<.0001) and low preoperative interferon-gamma production ( P=.006).

CONCLUSIONS

Both transhiatal and transthoracic esophagectomy induced severely depressed monocyte and T-lymphocyte cytokine production. The extent of the surgical procedure had a differential immunosuppressive impact on Th2-type but not on Th1-type cell activity, indicating that the two Th pathways were downregulated through distinct mechanisms. Preoperative interferon-gamma determination would be useful to anticipate the occurrence of postoperative major infectious complications.

[Receptors and signal proteins of the innate immune system as new targets in sepsis therapy. Reprogramming of the immune response]

During polymicrobial sepsis,microbial pathogens and their products activate the innate immune system through signaling receptors of the Toll-like receptor (TLR) family, resulting in hyperinflammation and organ injury. The analysis of preclinical mouse models has shown that inactivation of the common TLR signaling adaptor protein MyD88 prevents the hyperinflammatory response and improves survival.Importantly, MyD88 deficiency does not impair antibacterial defense mechanisms.Thus,TLRs and proteins involved in TLR signaling may represent interesting targets for the development of new drugs for reprogramming pathophysiological immune responses during sepsis.