Within State Variability of Antimicrobial Susceptibility: Missouri as an Archetype to Assess Guidelines for Antimicrobial Prophylaxis for Transurethral Procedures.

OBJECTIVE: To evaluate variability among hospitals in susceptibility of common uropathogens to antimicrobial agents frequently used in transurethral procedures in order to examine whether state-based guidelines might be more appropriate than national prophylactic guidelines. METHODS: Hospital-level antibiograms were requested from all hospitals throughout the state of Missouri. We studied Escherichia coli, Klebsiella, and Proteus sensitivities to evaluate common guideline recommended antimicrobials including trimethoprim sulfamethoxazole (TMP-SMX), third-generation cephalosporins, cefazolin, penicillin combinations, gentamicin, and fluoroquinolones. We evaluated variability and association between hospital characteristics and antimicrobial sensitivities. RESULTS: Data was requested from 81 hospitals across the state and 38 provided the requested data (47% response rate). Susceptibility was highest for third-generation cephalosporins for E. coli (mean of 94%), Proteus (96%), and Klebsiella (96%). Gentamicin also had high susceptibility for the bacteria studied; 94% for E. coli and 96% for Klebsiella. Current first line recommended agents showed more modest coverage for E. coli (cefazolin 84%, TMP-SMX 78%), Proteus (cefazolin 82%, TMP-SMX 71%), and Klebsiella (cefazolin 90%, TMP-SMX 89%). CONCLUSION: Post transurethral procedure infections are common. Rates can be limited with appropriate prophylaxis. Deciding on empirical coverage must take into account local resistance patterns. There is substantial variability among and within states in antimicrobial susceptibility for common uropathogens. When selecting antimicrobial prophylaxis, urologists should consider local- rather than state- or nation-level antibiograms, given the considerable variability. Future studies should consider the merits of very-broad spectrum prophylaxis and the potential role of molecular urinary pathogen (and pathogen-resistance) testing when selecting an optimal regimen.

Modified frailty index as an indicator for outcomes after lower extremity endovascular revascularization.

BACKGROUND: The 5-factor frailty index is associated with adverse outcomes after various procedures. This study aimed to evaluate the performance of the 5-factor frailty index after lower extremity endovascular revascularization. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program Database as retrospectively analyzed for patients undergoing lower extremity endovascular revascularization between 2015 and 2019. Outcomes were assessed using bivariate analyses and multivariate logistic regression analyses. RESULTS: In the study, 11,947 lower extremity endovascular revascularization performed between 2015 and 2019 were identified from National Surgical Quality Improvement Program Database. Median age was 69 (standard deviation 11.44) years, 4,727 (39.6%) were female, and 7,570 (63.4%) were White. In addition, 7,541 (62.9%) were performed for chronic limb threatening ischemia. Thirty-day mortality was 1.7%. Bivariate analysis demonstrated that a 5-factor frailty index score greater than 0.6 was associated with higher rates of discharge to SNF (28.6% vs 8.2%, P < .001, reference 5-factor frailty index = 0), cardiopulmonary arrest (2.0% vs 0.1%, P < .001), readmission (21.1% vs 10.8%, P < .001), reintubation (2.8% vs 0.3%, P < .001), and 30-day mortality (5.1% vs 0.7%, P < .001). Beta blocker use, higher age, chronic limb threatening ischemia indication, and 5-factor frailty index were all associated with increased 30-day mortality. Multivariate logistic regression showed that 5-factor frailty index >0.6 predicted 3 times higher odds for 30-day mortality (odds ratio, 2.988; P = .013), with physiologic high risk (odds ratio, 2.118; P < .001), chronic limb threatening ischemia indication (odds ratio, 2.157; P < .001), and inpatient procedures (odds ratio, 3.409; P < .001) also showing increased risk for mortality. CONCLUSION: For patients undergoing lower extremity endovascular revascularization, higher 5-factor frailty index was associated with increased hospital resource utilization and 30-day mortality. The 5-factor frailty index may be useful for preoperative risk stratification and predicting adverse outcomes in patients undergoing lower extremity endovascular revascularization.

Frailty Index (mFI-5) Predicts Resource Utilization after Nonruptured Endovascular Aneurysm Repair.

INTRODUCTION: The 5- factor frailty index (mFI-5) has reliably predicted outcomes after vascular surgeries. The purpose of this study was to determine the performance of this index in aortic endovascular surgery ( endovascular aneurysm repair [EVAR]) MATERIALS AND METHODS: The American College of Surgeons' National Surgical Quality Improvement Program Database (NSQIP) was retrospectively analyzed for patients undergoing nonruptured EVAR between 2015 and 2019. Outcomes were assessed using bivariate analysis (Mann Whitney U test, chi-squared test, and t-test) and multivariate logistic regression analysis. RESULTS: 10,450 patients were identified with a mean age of 73.59 (SD 8.93) y. 8222 (78.7%) were performed for large diameter with the remaining indications including dissection, symptomatic, and embolization/thrombosis. 30-d mortality was 1.3%. Univariate analysis showed that mFI-5≥0.6 was associated with higher rates of prolonged hospital stay (18.8% versus 5.7%, P < 0.001, reference mFI-5 = 0), readmission (12.3% versus 5.9%, P < 0.001), mortality (3.6 % versus 1.2%, P = 0.01), intensive care unit (ICU) length of stay more than 3 d (7.2% versus 2.7%, P < 0.001). Female gender higher age, indication for surgery, and mFI-5 were all associated with increased mortality. Multivariate logistic regression showed that mFI-5 remained as a significant predictor with mFI-5≥0.6 predicting a close to 3 times higher odds for 30-d mortality (odds ratio OR 2.83, P = 0.003), ICU length of stay >3 d (OR 2.48, P < 0.001), >7 d hospital stay (OR 3.94, P < 0.001), readmission (OR 2.16, P < 0.001), and pneumonia (OR 4.2, P < 0.001) CONCLUSIONS: The modified frailty index (mFI-5) is a good predictor for postoperative complications and hospital resource utilization after nonruptured EVAR.

Performance of the Emergency Surgery Score (ESS) for nonelective infrainguinal open revascularization procedures (NEIOR).

BACKGROUND: The Emergency Surgery Score has been previously validated as a reliable; tool to predict postoperative outcomes in emergency general surgery. The purpose of this study was to assess the performance of the Emergency Surgery Score for infrainguinal open revascularization procedures in the nonelective setting. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program database was retrospectively analyzed for patients undergoing infrainguinal open revascularization procedures in the nonelective setting between 2015 and 2019. The performance of the Emergency Surgery Score in predicting mortality in each procedure was assessed using receiver operating characteristic analyses. RESULTS: A total of 5,027 patients underwent infrainguinal open revascularization procedures in the nonelective setting with median age 68 (±11.66 standard deviation), with 1,666 females (33.1%). The 30-day mortality rate was 2.7%. The Emergency Surgery Score correlated with 30-day mortality (area under the curve was 0.738). The Emergency Surgery Score also predicted risk of death/discharge to hospice (area under the curve 0.756), discharge to rehab (area under the curve 0.643), renal failure (area under the curve 0.741), postintervention ventilation requirement (0.684), stroke (0.717), cardiopulmonary arrest (0.657), and septic shock (0.697). A cumulative frequency table of mortality with Emergency Surgery Score was used to partition patients into quartiles of Emergency Surgery Score ≤5, Emergency Surgery Score of 6, Emergency Surgery Score of 7 or 8, and Emergency Surgery Score ≥9. A Cochran-Armitage test showed linear trend toward increased 30-day mortality among the quartiles with increasing Emergency Surgery Score (P < .001), with quartile 4 (Emergency Surgery Score ≥10) having 13 times odds of increased 30-day mortality compared to reference quartile 1 (Emergency Surgery Score ≤4). CONCLUSION: Emergency Surgery Score performance accurately predicts mortality for infrainguinal open revascularization procedures in the nonelective setting procedures. It may be useful for preoperative risk stratification and for national benchmarking after nonelective open lower extremity procedures.

Implementation of Robotic-Assisted Percutaneous Coronary Intervention Into a High-Risk PCI Program.

BACKGROUND: How to implement robotic-assisted PCI safely and when to escalate to more complex cases has not been previously described. We sought to evaluate clinical outcomes in patients undergoing robotic-assisted PCI in the first year of a newly established robotic-assisted PCI program. METHODS: All patients who underwent robotic-assisted PCI in the first 12 months at a single academic center were included in the study. Lesion complexity was characterized as "PRECISE-like", "CORA-PCI-like", or "CORA-PCI excluded" based on established criteria. The primary outcome was clinical success, defined as <30% residual stenosis after stenting with a final TIMI flow grade 2-3 and no procedural complications. Secondary outcomes included robotic success, defined as clinical success with robotic completion, unintentional manual conversion rate, procedure time, and procedural complications. RESULTS: Of the 57 consecutive lesions treated, 12 (22.6%) had a PRECISE-like lesion complexity while 32 (56.1%) had a CORA- PCI-like, and 13 (22.8%) a CORA-PCI excluded lesion complexity. There was no significant difference in clinical success (100.0% vs. 96.7% vs. 100.0%, p = 1.00) among the groups but robotic success was numerically lower as complexity increased (100.0% vs. 80.0% vs. 72.7%, p = 0.15), with an increased frequency of manual conversion. There was no significant difference in procedural complication rates among the groups. The robotic completion rate improved during the study period. CONCLUSION: Robotic-assisted PCI, can be safely implemented in a moderate-sized academic center, with a rapid escalation in patient and lesion complexity.

Totally Robotic Three-Vessel Percutaneous Coronary Intervention With Total Occlusion Using Robotic Automation.

Robotic-assisted percutaneous coronary intervention (PCI) has emerged as an alternative to manual PCI to mitigate the risk of occupational hazards for operators, and to increase precision of device placement. Previous studies have reported the safety and efficacy of robotic-assisted PCI in simpler lesions, and recently the safety and efficacy of robotic-assisted chronic total occlusion PCI have been reported. Herein, we report two cases with three-vessel disease, including total occlusions, successfully treated robotically utilizing newer guidewire and device automation.

Antimicrobial Selection for Transurethral Procedures Across the United States: A State-by-State Antibiogram Evaluation.

OBJECTIVE: To evaluate optimal regimens for perioperative antimicrobial prophylaxis in transurethral procedures by examining antimicrobial susceptibility patterns in the United States. MATERIALS AND METHODS: Through several methods, we attempted to attain an antibiogram for each state. We focused on microbes known to cause infections after transurethral surgeries and antibiotics referred to in current or prior recommendations and compared susceptibility rates across states using Kruskal Walis tests and the Dwass, Steel, Critchlow-Fligner tests. We also examined susceptibility to (non-ceftazidime) third generation cephalosporins. RESULTS: Data is included from 40 states. For each microbe studied, there was significant variability in sensitivity to antibiotics studied. Current first line recommendations for antimicrobial prophylaxis include first generation cephalosporins with 82%, 80%, and 87% mean coverage for E coli, Proteus, and Klebsiella respectively and trimethoprim-sulfamethoxazole with 74%, 80%, and 93% coverage, respectively. Susceptibility to aminoglycosides is 91%, 92%, and 96%, respectively and to third generation cephalosporin, it is 92%, 99%, and 94%. CONCLUSION: Current first line recommended antimicrobials for prophylaxis in transurethral procedures provide overall poor predicted coverage based on our database of antibiograms. Alternatives exist that have higher predicted susceptibility, though clinical significance of this and risk of resultant antimicrobial resistance is unknown. Urologists should consider local patterns when selecting antimicrobial prophylaxis for their patients.