Risk factors for gram-negative bacterial surgical site infection: do allergies to antibiotics increase risk?

OBJECTIVE: To determine the relationship between inadequate antimicrobial prophylaxis and development of gram-negative bacterial (GNB) surgical site infection (SSI). DESIGN: Retrospective case-control study. SETTING: A 369-bed acute care community hospital in Durham, North Carolina. PATIENTS: Case patients were defined as patients who developed a GNB SSI after undergoing a surgical procedure during the period from January 1, 1998, through January 1, 2007. Control patients were uninfected patients who underwent surgery during the same study period and were matched to case patients by surgeon and type of procedure. Both patient groups were selected on the basis of prospectively collected data on patients who underwent surgery. METHODS: Patient data were collected from patient medical records. Multivariable analysis was performed using logistic regression with backward selection, to identify variables independently associated with GNB SSI. RESULTS: Case patients were similar to control patients with respect to demographics and comorbid conditions, but were older (P = .04), more obese (P = .03), and more likely to have diabetes mellitus (P = .03). Inappropriate timing of antimicrobial prophylaxis was the predominant reason that prophylaxis was deemed inadequate for both patient groups (59.1% of case patients vs 64.0% of control patients; P = .56). Case patients who had a history of allergic reactions to antimicrobial prophylaxis were significantly less likely to receive antimicrobial prophylaxis in a timely manner (P = .03). Variables independently associated with GNB SSI in multivariable analysis included urinary catheterization before surgery (odds ratio [OR], 3.74 [95% confidence interval {CI}, 1.11-12.62), diabetes mellitus (OR, 2.25 [95% CI, 1.02-4.94]), and an American Society of Anesthesiologists score greater than 2 (OR, 2.14 [95% CI, 1.13-4.06]). CONCLUSIONS: A beta-lactam allergy was not associated with increased risk for GNB SSI. Further studies, using patient data from larger hospital databases, are needed to examine the relationship between use of urinary catheter before surgery and risk of GNB SSI.

Mortality and time to extubation in severe hospital-acquired pneumonia.

BACKGROUND: This study examined predictors of in-hospital mortality and time to extubation among patients with acute, severe hospital-acquired pneumonia (HAP) managed in the intensive care unit (ICU). METHODS: Patients with HAP prospectively identified between June 2001 and May 2003 were included in the study if they (1) met the Centers for Disease Control and Prevention's definition for HAP, (2) were treated in the ICU within 1 day of the HAP diagnosis, and (3) required intubation acutely or had a bloodstream infection within 48 hours of the HAP diagnosis. RESULTS: The cohort included 219 patients, 83 of whom died (37.9%). Independent predictors of mortality included cancer (odds ratio [OR] = 4.2; 95% confidence interval [CI] = 1.7 to 10.5), age over 60 years (OR = 2.7; 95% CI = 1.3 to 5.6), APACHE-II score >15 (OR = 2.0; 95% CI = 1.0 to 4.1), and receiving care in the medical ICU (OR = 3.0; 95% CI = 1.1 to 8.2). The following predictors were associated with an increased time to extubation: receipt of vancomycin (1.81-fold increase; P = .001), immunocompromised status (1.92-fold increase; P = .07), and treatment in the surgical or neurosurgical ICU (1.95-fold increase, P = .01; 1.83-fold increase, P = .03). CONCLUSION: Vancomycin was associated with increased time to extubation. Alternatives to vancomycin for treating patients with acute, severe HAP should be studied.

Cerebral phaeohyphomycosis in an immunodeficient child treated medically with combination antifungal therapy.

Cerebral phaeohyphomycosis is a rare fungal infection with a poor prognosis when using conventional antifungal therapy in the absence of neurosurgical intervention. We present a case of a pediatric patient with inoperable Cladophialophora bantiana cerebral abscesses. To our knowledge, this child's case is the first reported to be treated with the combination of the newer triazole voriconazole and the new echinocandin caspofungin. Although our patient subsequently died, the natural rapid progression of the disease seemed to be altered by the antifungal combination alone, in the absence of surgery. Despite the fatal outcome for our patient, we encourage other clinicians to try unique medical approaches for this historically life-threatening infection when adjunctive surgery is impossible.