Morbidity and mortality after fragility hip fracture surgery in patients receiving vitamin K antagonists and direct oral anticoagulants.

INTRODUCTION: Early surgical treatment is recommended to reduce morbidity and mortality in patients with fragility hip fractures. Anticoagulation treatment poses a surgical challenge. While the action of vitamin K antagonists (VKAs) can be reversed, for direct oral anticoagulants (DOACs) antidote is only available for dabigatran. We aimed to assess the outcomes of patients treated with VKAs or DOACs undergoing surgical treatment for fragility hip fractures. MATERIALS AND METHODS: A retrospective study of patients presenting with proximal femoral fractures between January 2012 and June 2016. Patients with VKAs received vitamin-K. Primary outcomes were 1-year and in-hospital mortality. Secondary outcomes were time to surgery, in-hospital complications, need for blood transfusions and 1-year readmissions. RESULTS: Seven-hundred seventy-nine patients (796 hips) were included; 103 received VKAs, 47 DOACs and 646 no-anticoagulation. No difference between the 3 groups was noted with respect to patients' demographics or surgery type. Charlson's comorbidity index was higher for the DOACs group. Patients under anticoagulation were delayed to theater (Surgery < 48 h in 51% DOACs and 59% VKAs patients vs. 92% of no-anticoagulation, p < 0.001). Neither in-hospital nor 1-year mortality differed between groups. No other outcome measures differed, except for more wound infections in VKAs patients. CONCLUSIONS: While preoperative anticoagulation delays surgery following fragility hip fractures, this delay was not found to be related to increased morbidity or mortality. DOACs-treated patients did not have adverse outcomes compared to VKAs-treated patients despite the irreversibility of their treatment.

Extended vs Bolus Infusion of Broad-Spectrum ß-Lactams for Febrile Neutropenia: An Unblinded, Randomized Trial.

Background: Febrile neutropenia may be a sign of severe infection and is associated with significant morbidity and mortality in high-risk patients with hematologic malignancies. Extended infusion of ß-lactam antibiotics is associated with greater clinical response than is bolus infusion in nonneutropenic critically ill patients, but data are lacking for febrile neutropenic patients. Methods: We designed a single-center, nonblinded, randomized trial to compare extended infusion (4 hours) and bolus infusion (30 minutes) of piperacillin-tazobactam or ceftazidime in high-risk patients with febrile neutropenia. The primary endpoint was overall response on day 4, defined as the combination of resolution of fever, sterile blood cultures, resolution of clinical signs and symptoms, and no need for a change in the antibiotic regimen. Outcome was adjudicated by investigators blinded to treatment allocation. Results: Of 123 enrolled patients, 105 had febrile neutropenia and were included in the intention-to-treat analysis: 47 in the extended infusion arm and 58 in the bolus infusion arm. Overall response occurred in 35 (74.4%) patients treated with extended infusion and 32 (55.1%) patients treated with bolus infusion (P = .044). The superiority of extended infusion was greatest for patients with clinically documented infections (overall response, 68.4% [13/19] vs 35.7% [10/28]; P = .039) and specifically for those with pneumonia (80% [4/5] vs 0% [0/8]; P = .007). Conclusions: Extended infusion of ß-lactams is associated with superior treatment outcomes compared with bolus infusion for high-risk patients with febrile neutropenia. The benefit of extended ß-lactam infusion may be greatest for patients with pulmonary infections. Clinical Trials Registration: NCT02463747.