A proposal for a comprehensive approach to infections across the surgical pathway.

Despite evidence supporting the effectiveness of best practices in infection prevention and management, many healthcare workers fail to implement them and evidence-based practices tend to be underused in routine practice. Prevention and management of infections across the surgical pathway should always focus on collaboration among all healthcare workers sharing knowledge of best practices. To clarify key issues in the prevention and management of infections across the surgical pathway, a multidisciplinary task force of experts convened in Ancona, Italy, on May 31, 2019, for a national meeting. This document represents the executive summary of the final statements approved by the expert panel.

Non-Restrictive Antimicrobial Stewardship Program in a General and Emergency Surgery Unit.

BACKGROUND: The goal of an antimicrobial stewardship program (ASP) is to prevent the emergence of antimicrobial drug resistance and reduce adverse drug events, optimizing the selection, dosing, and duration of therapy in individual patients. METHODS: This retrospective study evaluated changes in antimicrobial agent use associated with implementation of an ASP in a general and emergency unit. The pre-intervention and post-intervention periods were defined as July 1, 2013, to December 31, 2013 (pre-intervention) and January 1, 2014, to June 30, 2014 (post-intervention). RESULTS: The mean total monthly antimicrobial use decreased by 18.8%, from 1,074.9 defined daily doses (DDD) per 1,000 patient-days to 873.0 DDD per 1,000 patient-days after the intervention. There was a significant reduction in the use of piperacillin-tazobactam, by 33.7% (p < 0.05), in imipenem/cilastatin, by 63.9% (p < 0.05), in meropenem by 68.0% (p < 0.05), and in levofloxacin by 45.0% (p < 0.05) without any negative effect on patient susceptibility to infections. Indeed, patient outcomes, including deaths, length of stay in the hospital, and re-admission within 30 days were not affected. CONCLUSIONS: The implementation of an education-based ASP achieved a significant improvement in all antimicrobial agent prescriptions in the surgical unit and a reduction in antimicrobial drug consumption, even when no restrictive measures were implemented.

Risk of clinical progression among patients with immunological nonresponse despite virological suppression after combination antiretroviral treatment.

BACKGROUND: It is unclear whether lack of immunological response despite viral suppression and relatively preserved CD4 T-cell count is associated with increased risk of AIDS or severe non-AIDS events. METHODS: Patients initiating first combination antiretroviral therapy (cART) were studied from first viral load 80  copies/ml or less up to AIDS, serious non-AIDS events (malignancies, severe infections, acute kidney injury, cardiovascular events, liver decompensation) or death. Follow-up was right censored if viral load was more than 500. Immunological nonresponse (INR) was defined as current CD4 cell count less than 120% pre-cART. A Poisson regression analysis was used to investigate the association between INR and the outcome. RESULTS: Three thousand, three hundred and seventy-eight patients were followed for a median of 32 months (interquartile range: 15-67). Two hundred and twenty-two events (32 deaths, 39 AIDS-defining events, 48 malignancies, 32 severe infections, 47 acute kidney injuries, 12 cardiovascular events, 12 other nonfatal events) were observed. The rate of clinical events among INR and immunological responders was 4.41 [95% confidence interval (CI) 3.38-5.74] and 1.84 (95% CI 1.58-2.15) per 100 person years of follow-up, respectively, accounting for a crude rate ratio of 2.39 (95% CI 1.77-3.25; P < 0.001). INR remained an independent predictor of clinical progression after adjusting for baseline characteristics, including pre-cART CD4 cell count (adjusted rate ratio 2.93; 95% CI 2.06-4.16, P < 0.001) or current CD4 cell count (adjusted rate ratio 1.94; 95% CI 1.39-2.72, P < 0.001). The association did not vary by pre-cART CD4 cell counts (P for interaction = 0.93) CONCLUSION: INR are at higher risk of severe clinical events than responders. The association was consistent across different CD4 cell counts at cART initiation and was only partially explained by current CD4 cell count. INR could be a marker of immune system malfunctioning, not completely captured by absolute CD4 cell count.