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1.
Article in English | MEDLINE | ID: mdl-38990709

ABSTRACT

Background: The Surgical Infection Society (SIS) published evidence-based guidelines for the management of intra-abdominal infection (IAI) in 1992, 2002, 2010, and 2017. Here, we present the most recent guideline update based on a systematic review of current literature. Methods: The writing group, including current and former members of the SIS Therapeutics and Guidelines Committee and other individuals with content or guideline expertise within the SIS, working with a professional librarian, performed a systematic review using PubMed/Medline, the Cochrane Library, Embase, and Web of Science from 2016 until February 2024. Keyword descriptors combined "surgical site infections" or "intra-abdominal infections" in adults limited to randomized controlled trials, systematic reviews, and meta-analyses. Additional relevant publications not in the initial search but identified during literature review were included. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system was utilized to evaluate the evidence. The strength of each recommendation was rated strong (1) or weak (2). The quality of the evidence was rated high (A), moderate (B), or weak (C). The guideline contains new recommendations and updates to recommendations from previous IAI guideline versions. Final recommendations were developed by an iterative process. All writing group members voted to accept or reject each recommendation. Results: This updated evidence-based guideline contains recommendations from the SIS for the treatment of adult patients with IAI. Evidence-based recommendations were developed for antimicrobial agent selection, timing, route of administration, duration, and de-escalation; timing of source control; treatment of specific pathogens; treatment of specific intra-abdominal disease processes; and implementation of hospital-based antimicrobial agent stewardship programs. Summary: This document contains the most up-to-date recommendations from the SIS on the prevention and management of IAI in adult patients.

2.
World J Emerg Surg ; 19(1): 22, 2024 Jun 08.
Article in English | MEDLINE | ID: mdl-38851700

ABSTRACT

Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs.


Subject(s)
Intraabdominal Infections , Humans , Intraabdominal Infections/drug therapy , Risk Factors , Anti-Bacterial Agents/therapeutic use
3.
Curr Opin Infect Dis ; 35(4): 363-369, 2022 08 01.
Article in English | MEDLINE | ID: mdl-35849527

ABSTRACT

PURPOSE OF REVIEW: To review recent medical literature addressing antimicrobial stewardship in solid organ transplant (SOT) recipients. RECENT FINDINGS: Few studies with a strict focus on SOT patients have been published to date. Team-based antimicrobial stewardship interventions in SOT populations do have beneficial impacts on antimicrobial stewardship-relevant outcomes. Several studies have compared SOT-specific antibiograms to widely accepted hospital antibiograms; these studies all have found important differences in resistance rates among bacterial pathogens. Novel biomarkers like virome monitoring for assessing the net state of immunosuppression hold promise for individualized antimicrobial stewardship interventions. SUMMARY: SOT patients are an understudied population with respect to antimicrobial stewardship interventions. Current antimicrobial stewardship interventions for SOT patients are largely extrapolated from studies in general patient populations and may not accurately reflect SOT-specific infection risks or outcomes. Antimicrobial stewardship interventions do impact SOT-relevant care goals but require significantly more research to achieve the depth and reach of antimicrobial stewardship interventions developed for general populations.


Subject(s)
Antimicrobial Stewardship , Infections , Organ Transplantation , Antimicrobial Stewardship/methods , Humans , Microbial Sensitivity Tests , Organ Transplantation/adverse effects , Organ Transplantation/methods , Transplant Recipients
4.
Surg Infect (Larchmt) ; 23(2): 97-104, 2022 Mar.
Article in English | MEDLINE | ID: mdl-34619068

ABSTRACT

Background: Clostridioides difficile infection (CDI) can result in life-threatening illness requiring surgery. Surgical options for managing severe or fulminant, non-perforated C. difficile colitis include total abdominal colectomy with end ileostomy or creation of a diverting loop ileostomy with antegrade vancomycin lavage. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for summarizing the current SIS recommendations for total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for severe or fulminant, non-perforated C. difficile colitis. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Severe infection was defined as laboratory diagnosis of C. difficile infection with leukocytosis (white blood cell count of ≥15,000 cells/mL) or elevated creatinine (serum creatinine level >1.5 mg/dL). Fulminant infection was defined as laboratory diagnosis of C. difficile infection with hypotension or shock, ileus, or megacolon. Perforation was defined as complete disruption of the colon wall. Total abdominal colectomy was defined as resection of the ascending, transverse, descending, and sigmoid colon with end ileostomy. For the purpose of the guideline, the terms subtotal colectomy, total abdominal colectomy, and rectal-sparing total colectomy were used interchangeably. Diverting loop ileostomy with antegrade enema was defined as creation of both a diverting loop ileostomy with intra-operative colonic lavage and post-operative antegrade vancomycin unless otherwise specified. Evaluation of the published evidence was performed using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: We recommend that total abdominal colectomy be the procedure of choice for definitive therapy of severe or fulminant, non-perforated C. difficile colitis. In select patients, colon preservation using diverting loop ileostomy with intra-colonic vancomycin may be associated with higher rates of ostomy reversal and restoration of gastrointestinal continuity but may lead to development of recurrent C. difficile colitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations regarding use of total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for adults with severe or fulminant, non-perforated C. difficile infection.


Subject(s)
Clostridioides difficile , Colitis , Clostridioides , Colectomy/adverse effects , Colectomy/methods , Colitis/surgery , Humans , Ileostomy/adverse effects , Ileostomy/methods , Therapeutic Irrigation/methods
5.
Surg Infect (Larchmt) ; 22(4): 383-399, 2021 May.
Article in English | MEDLINE | ID: mdl-33646051

ABSTRACT

Background: The Surgical Infection Society (SIS) Guidelines for the treatment of complicated skin and soft tissue infections (SSTIs) were published in October 2009 in Surgical Infections. The purpose of this project was to provide a succinct update on the earlier guidelines based on an additional decade of data. Methods: We reviewed the previous guidelines eliminating bite wounds and diabetic foot infections including their associated references. Relevant articles on the topic of complicated SSTIs from 2008-2020 were reviewed and graded individually. Comparisons were then made between the old and the new graded recommendations with review of the older references by two authors when there was disparity between the grades. Results: The majority of new studies addressed antimicrobial options and duration of therapy particularly in complicated abscesses. There were fewer updated studies on diagnosis and specific operative interventions. Many of the topics addressed in the original guidelines had no new literature to evaluate. Conclusions: Most recommendations remain unchanged from the original guidelines with the exception of increased support for adjuvant antimicrobial therapy after drainage of complex abscess and increased data for the use of alternative antimicrobial agents.


Subject(s)
Anti-Infective Agents , Skin Diseases, Bacterial , Soft Tissue Infections , Anti-Bacterial Agents/therapeutic use , Drainage , Humans , Skin Diseases, Bacterial/drug therapy , Soft Tissue Infections/drug therapy
7.
Surg Infect (Larchmt) ; 21(2): 81-93, 2020 Mar.
Article in English | MEDLINE | ID: mdl-31584343

ABSTRACT

Background: Necrotizing fasciitis is a major health problem throughout the world. The purpose of this review is to assist providers with the care of these patients through a better understanding of the pathophysiology and management options. Methods: This is a collaborative review of the literature between members of the Surgical Infection Society of North America and World Society of Emergency Surgery. Results: Necrotizing fasciitis continues to be difficult to manage with the mainstay being early diagnosis and surgical intervention. Recognition of at-risk populations assists with the initiation of treatment, thereby impacting outcomes. Conclusions: Although there are some additional treatment strategies available, surgical debridement and antimicrobial therapy are central to the successful eradication of the disease process.


Subject(s)
Fasciitis, Necrotizing/physiopathology , Fasciitis, Necrotizing/therapy , Soft Tissue Infections/therapy , Anti-Bacterial Agents/therapeutic use , Clostridium Infections/physiopathology , Clostridium Infections/therapy , Debridement/methods , Fasciitis, Necrotizing/blood , Fasciitis, Necrotizing/diagnosis , Humans , Risk Assessment , Risk Factors , Soft Tissue Infections/blood , Soft Tissue Infections/diagnosis , Soft Tissue Infections/physiopathology , Staphylococcal Infections/physiopathology , Staphylococcal Infections/therapy , Staphylococcus aureus , Streptococcal Infections/physiopathology , Streptococcal Infections/therapy , Streptococcus pyogenes
8.
Surg Infect (Larchmt) ; 20(5): 431-433, 2019 Jul.
Article in English | MEDLINE | ID: mdl-30789313

ABSTRACT

Background: Necrotizing soft-tissue infections are a devastating infection that is rarely caused by Actinomyces spp. Case Report: A 45-year-old obese previously healthy male presented to the emergency department with diabetic ketoacidosis. The patient developed systemic signs of infections and right medial thigh pain subsequently diagnosed as a necrotizing soft-tissue infection. Successful treatment included prompt surgical intervention and initiation of broad-spectrum antimicrobial drugs. Conclusion: Actinomyces turicensis may be the pathogen causing certain necrotizing soft-tissue infections. Clinicians should consider the possibility that this organism represents a true pathogen and not colonization/contamination.


Subject(s)
Actinomyces/isolation & purification , Actinomycosis/diagnosis , Actinomycosis/pathology , Diabetes Complications , Soft Tissue Infections/diagnosis , Soft Tissue Infections/pathology , Thigh/pathology , Actinomyces/classification , Actinomycosis/microbiology , Actinomycosis/therapy , Anti-Infective Agents/administration & dosage , Debridement , Humans , Male , Middle Aged , Soft Tissue Infections/microbiology , Soft Tissue Infections/therapy , Treatment Outcome
9.
Surg Infect (Larchmt) ; 19(7): 655-660, 2018 Oct.
Article in English | MEDLINE | ID: mdl-30179571

ABSTRACT

BACKGROUND: Diverticulitis remains a common disease encountered in the acute care setting. Management strategies have been developed to guide treatment decisions based on imaging. By using a multi-faceted clinical pathway approach, a standardized method of diagnosing and categorizing disease severity can be performed in order to guide appropriate management. This study evaluated provider compliance with an institutional clinical pathway designed to guide management of diverticulitis. METHODS: An institutional clinical pathway was developed to manage diverticulitis, including radiologic classification, primary service line assignment, interventional strategies, and antimicrobial treatment. To assess provider compliance with the algorithm, we queried the institutional acute diverticulitis database for patients admitted from May 19, 2016 to February 8, 2017, which identified 83 patients. Provider compliance with the pathway was assessed using subgroup analysis of radiologic documentation (modified Neff [mNeff] classification), primary service assignment, and interventions (i.e., interventional radiology [IR] and antimicrobial agents). RESULTS: The cohort represented a diverse group of mNeff classifications, predominantly Stage 0. Surgical interventions occurred in 10.8% of the cohort. Antimicrobial agents were administered to 88.0% and 78.3% of the outpatients and inpatients, respectively. Patients received a total duration of antimicrobial therapy (mean ± standard deviation [SD]) of 10.2 ± 5.1 days. Overall compliance occurred in 10% of the patients. Compliance with radiologic documentation, antimicrobial choice, and antimicrobial duration were 90.4%, 20.5%, and 69.9%, respectively. CONCLUSIONS: Overall compliance with the clinical pathway was poor, except as it related to compliance with radiologic documentation, appropriate assignment to surgical service line, and antimicrobial duration. These results suggest areas for future improvement to augment compliance with the clinical pathway.


Subject(s)
Anti-Bacterial Agents/therapeutic use , Critical Pathways/statistics & numerical data , Diverticulitis/diagnostic imaging , Guideline Adherence/statistics & numerical data , Anti-Bacterial Agents/administration & dosage , Diverticulitis/classification , Diverticulitis/pathology , Diverticulitis/therapy , Female , Humans , Male , Middle Aged , Radiography
10.
Surg Infect (Larchmt) ; 18(8): 879-885, 2017.
Article in English | MEDLINE | ID: mdl-28994635

ABSTRACT

BACKGROUND: Enterococci are isolated frequently as pathogens in patients with intra-abdominal infections (IAIs) and may predict poor clinical outcomes. It remains controversial whether enterococci warrant an altered treatment approach with regard to antimicrobial treatment. PATIENTS AND METHODS: The study population was derived from the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial database. Through post hoc analysis subjects were stratified into two groups based on isolation of Enterococcus. Fifty subjects of the cohort (n = 518) had Enterococcus isolated. Uni-variable and multi-variable analyses were conducted to determine whether isolation of Enterococcus constituted an independent predictor of the pre-defined STOP-IT composite outcome (surgical site infection, recurrent IAI, or death) and the individual components of the composite outcome. RESULTS: From the cohort of 50 subjects, we identified 52 isolates of Enterococcus spp. with a predominance of Enterococcus faecalis (40%) followed by other Enterococcus spp. (37%) and Enterococcus faecium (17%). Baseline demographic characteristics were statistically similar between the two groups. Antibiotic utilization distribution remained balanced between the Enterococcus and no Enterococcus groups with the majority receiving piperacillin-tazobactam (62% and 54%, respectively). The groups had comparable infection characteristics including setting of acquisition (>50% community acquired) and origin of infection (predominantly colon or rectum). Individual and composite clinical outcomes were not different statistically between the Enterococcus and no Enterococcus groups: surgical site infection (10% vs. 7.5%; p = 0.53), recurrent IAI (20% vs. 14.1%; p = 0.26), death (2% vs. 1%; p = 0.40), and composite of all three (30% vs. 20.9%; p = 0.14], respectively. Multi-variable analysis revealed that isolation of Enterococcus did not predict independently the incidence of the composite outcome (odds ratio [OR] 1.53 [95% confidence interval {CI} = 0.78-3.01]; p = 0.22; c-statistic = 0.65; goodness of fit, p = 0.71). CONCLUSIONS: Enterococcus was not a more common pathogen in health-care-associated IAIs and was not an independent risk factor for the composite outcome. The isolation of Enterococcus from IAIs may not warrant an alternative treatment approach but larger studies are needed to validate these findings.


Subject(s)
Enterococcus/isolation & purification , Intraabdominal Infections/microbiology , Surgical Wound Infection/microbiology , Anti-Bacterial Agents/therapeutic use , Cross Infection/drug therapy , Cross Infection/microbiology , Female , Humans , Intraabdominal Infections/drug therapy , Male , Middle Aged , Surgical Wound Infection/drug therapy , Treatment Outcome
11.
Surg Infect (Larchmt) ; 18(5): 527-535, 2017 Jul.
Article in English | MEDLINE | ID: mdl-28614043

ABSTRACT

BACKGROUND: Acute appendicitis is the most common abdominal surgical emergency in the United States, with a lifetime risk of 7%-8%. The treatment paradigm for complicated appendicitis has evolved over the past decade, and many cases now are managed by broad-spectrum antibiotics. We determined the role of non-operative and operative management in adult patients with uncomplicated appendicitis. METHODS: Several meta-analyses have attempted to clarify the debate. Arguably the most influential is the Appendicitis Acuta (APPAC) Trial. RESULTS: According to the non-inferiority analysis and a pre-specified non-inferiority margin of -24%, the APPAC did not demonstrate non-inferiority of antibiotics vs. appendectomy. Significantly, however, the operations were nearly always open, whereas the majority of appendectomies in the United States are done laparoscopically; and laparoscopic and open appendectomies are not equivalent operations. Treatment with antibiotics is efficacious more than 70% of the time. However, a switch to an antimicrobial-only approach may result in a greater probability of antimicrobial-associated collateral damage, both to the host patient and to antibiotic susceptibility patterns. A surgery-only approach would result in a reduction in antibiotic exposure, a consideration in these days of focus on antimicrobial stewardship. CONCLUSION: Future studies should focus on isolating the characteristics of appendicitis most susceptible to antibiotics, using laparoscopic operations as controls and identifying long-term side effects such as antibiotic resistance or Clostridium difficile colitis.


Subject(s)
Anti-Bacterial Agents , Appendicitis/drug therapy , Appendicitis/surgery , Drug Utilization , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/adverse effects , Anti-Bacterial Agents/therapeutic use , Drug Resistance, Bacterial , Drug Utilization/standards , Drug Utilization/statistics & numerical data , Humans , Practice Guidelines as Topic
13.
Surg Infect (Larchmt) ; 18(1): 1-76, 2017 Jan.
Article in English | MEDLINE | ID: mdl-28085573

ABSTRACT

BACKGROUND: Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS: Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS: This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY: The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.


Subject(s)
Intraabdominal Infections/therapy , Surgical Wound Infection/therapy , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/therapeutic use , Humans , Laparotomy , Risk
14.
Med Mycol ; 55(3): 278-284, 2017 Apr 01.
Article in English | MEDLINE | ID: mdl-27601609

ABSTRACT

Characteristics of cirrhosis-associated cryptococcosis first diagnosed after death are not fully known. In a multicenter study, data generated as standard of care was systematically collected in 113 consecutive patients with cirrhosis and cryptococcosis followed for 80 patient-years. The diagnosis of cryptococcosis was first established after death in 15.9% (18/113) of the patients. Compared to cases diagnosed while alive, these patients had higher MELD score (33 vs. 22, P = .029) and higher rate of cryptococcemia (75.0% vs. 41.9%, P = .027). Cases diagnosed after death, in comparison to those diagnosed during life were more likely to present with shock (OR 3.42, 95% CI 1.18-9.90, P = .023), require mechanical ventilation at admission (OR 8.5, 95% CI 2.74-26.38, P = .001), less likely to undergo testing for serum cryptococcal antigen (OR 0.07, 95% CI 0.02-0.21, P < .001) and have positive antigen when the test was performed (OR 0.07, 95% CI 0.01-0.60, P = .016). In a subset of cirrhotic patients with advanced liver disease cryptococcosis was first recognized after death. These patients had the characteristics of presenting with fulminant fungemia, were less likely to have positive serum cryptococcal antigen and posed a diagnostic challenge for care providers.


Subject(s)
Cryptococcosis/pathology , Fungemia/pathology , Liver Cirrhosis/complications , Female , Humans , Male , Middle Aged , Prognosis , Severity of Illness Index
15.
Surg Infect (Larchmt) ; 18(2): 77-82, 2017.
Article in English | MEDLINE | ID: mdl-28005468

ABSTRACT

BACKGROUND: Age has been shown to play a significant role in the etiology of complicated intra-abdominal infections (cIAIs), but the correlation between age and outcomes after therapy was not investigated in the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial. PATIENTS AND METHODS: Data were obtained by post hoc analysis of the STOP-IT trial database. Patients were stratified by age <65 or ≥65 years. Primary outcomes were surgical site infection (SSI), recurrent IAI (recIAI), and death. Multivariable analysis was performed to identify independent predictors of outcomes. RESULTS: There were 398 subjects <65 and 120 ≥ 65 years. Overall baseline characteristics of the two groups were similar. The site of infection was similar between groups except: Colon or rectum (48.3% vs. 29.9%, p = 0.0002) and biliary tree (16.7% vs. 9.1%, p = 0.02), which were more common in the older group, whereas small intestine (6.7% vs. 16.3%, p = 0.008) and appendix (4.2% vs.17.1%, p = 0.0004) were more common in the younger group. Among the primary outcomes, only death was significantly different between the age groups and was more prevalent in the ≥65 years group (4 [3.3%] vs. 1 [0.3%], p = 0.01). Surgical site infection (9.2% vs. 7.3%, p = 0.50), recIAI (15.8% vs. 14.4%, p = 0.69), and a composite outcome (26.7% vs. 20.4%, p = 0.14) were statistically similar between the age groups, and this remained true when controlling for other co-variables. Multivariable analyses did not reveal age as an independent predictor of the composite or individual outcomes. CONCLUSION: Patients with a more advanced age demonstrated variable sources of infection relative to the younger cohort, yet received similar treatments. Patient age was not an independent predictor of the undesired cIAI outcomes. These findings suggest that advanced age itself does not play a significant role in predicting these adverse outcomes for cIAIs and does not necessitate an altered treatment tactic.


Subject(s)
Intraabdominal Infections/epidemiology , Surgical Wound Infection/epidemiology , Adolescent , Adult , Age Factors , Aged , Aged, 80 and over , Anti-Bacterial Agents/therapeutic use , Drainage , Female , Humans , Intraabdominal Infections/microbiology , Intraabdominal Infections/therapy , Male , Middle Aged , Randomized Controlled Trials as Topic , Retrospective Studies , Surgical Wound Infection/microbiology , Surgical Wound Infection/therapy , Young Adult
16.
Surg Infect (Larchmt) ; 17(6): 625-631, 2016 Dec.
Article in English | MEDLINE | ID: mdl-27828764

ABSTRACT

Despite current antimicrobial stewardship programs (ASPs) being advocated by infectious disease specialists and discussed by national and international policy makers, ASPs coverage remains limited to only certain hospitals as well as specific service lines within hospitals. The ASPs incorporate a variety of strategies to optimize antimicrobial agent use in the hospital, yet the exact set of interventions essential to ASP success remains unknown. Promotion of ASPs across clinical practice is crucial to their success to ensure standardization of antimicrobial agent use within an institution. To effectively accomplish this standardization, providers who actively engage in antimicrobial agent prescribing should participate in the establishment and support of these programs. Hence, surgeons need to play a major role in these collaborations. Surgeons must be aware that judicious antibiotic utilization is an integral part of any stewardship program and necessary to maximize clinical cure and minimize emergence of antimicrobial resistance. The battle against antibiotic resistance should be fought by all healthcare professionals. If surgeons around the world participate in this global fight and demonstrate awareness of the major problem of antimicrobial resistance, they will be pivotal leaders. If surgeons fail to actively engage and use antibiotics judiciously, they will find themselves deprived of the autonomy to treat their patients.


Subject(s)
Anti-Infective Agents , Antibiotic Prophylaxis , Drug Resistance, Microbial , Surgical Wound Infection/drug therapy , Anti-Infective Agents/administration & dosage , Anti-Infective Agents/therapeutic use , Drug Utilization , Hospitals , Humans , Intraabdominal Infections/drug therapy , Practice Patterns, Physicians' , Prescription Drug Overuse , Surgeons
17.
Surg Infect (Larchmt) ; 17(6): 694-699, 2016 Dec.
Article in English | MEDLINE | ID: mdl-27483362

ABSTRACT

BACKGROUND: Management of complicated intra-abdominal infections (cIAIs) includes broad-spectrum antimicrobial coverage and commonly includes vancomycin for the empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA). Ideally, culture-guided de-escalation follows to promote robust antimicrobial stewardship. This study assessed the impact and necessity of vancomycin in cIAI treatment regimens. PATIENTS AND METHODS: A post hoc analysis of the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial was performed. Patients receiving piperacillin-tazobactam (P/T) and/or a carbapenem were included with categorization based on use of vancomycin. Univariate and multivariable analyses evaluated effects of including vancomycin on individual and the composite of undesirable outcomes (recurrent IAI, surgical site infection [SSI], or death). RESULTS: The study cohort included 344 patients with 110 (32%) patients receiving vancomycin. Isolation of MRSA occurred in only eight (2.3%) patients. Vancomycin use was associated with a similar composite outcome, 29.1%, vs. no vancomycin, 22.2% (p = 0.17). Patients receiving vancomycin had (mean [standard deviation]) higher Acute Physiology and Chronic Health Evaluation II scores (13.1 [6.6] vs. 9.4 [5.7], p < 0.0001), extended length of stay (12.6 [10.2] vs. 8.6 [8.0] d, p < 0.001), and prolonged antibiotic courses (9.1 [8.0] vs. 7.1 [4.9] d, p = 0.02). After risk adjustment in a multivariate model, no significant difference existed for the measured outcomes. CONCLUSIONS: This post hoc analysis reveals that addition of vancomycin occurred in nearly one third of patients and more often in sicker patients. Despite this selection bias, no appreciable differences in undesired outcomes were demonstrated, suggesting limited utility for adding vancomycin to cIAI treatment regimens.


Subject(s)
Anti-Bacterial Agents/therapeutic use , Intraabdominal Infections/drug therapy , Intraabdominal Infections/epidemiology , Methicillin-Resistant Staphylococcus aureus , Staphylococcal Infections/drug therapy , Staphylococcal Infections/epidemiology , Vancomycin/therapeutic use , Adult , Aged , Anti-Bacterial Agents/administration & dosage , Comorbidity , Female , Humans , Intraabdominal Infections/mortality , Male , Middle Aged , Staphylococcal Infections/mortality , Treatment Outcome , Vancomycin/administration & dosage
18.
Surg Infect (Larchmt) ; 17(6): 720-723, 2016 Dec.
Article in English | MEDLINE | ID: mdl-27500970

ABSTRACT

BACKGROUND: Data on antimicrobial prophylaxis for open fractures is limited, with many protocols based on expert recommendations. These protocols include aminoglycosides (AGs) for fractures with significant soft tissue injury, but these drugs are associated with acute kidney injury (AKI) in other settings; this risk has not been defined for open fracture prophylaxis. METHODS: We performed a retrospective study from May 2012 to October 2014 at our Level 1 trauma center. Patients with open fractures were evaluated for demographics, location/type of fracture, injury severity, and receipt of an AG. Outcomes included rates of AKI, infection, and mortality. RESULTS: There were 167 patients with open fractures during the study period (119 males, mean age 42 ± 17 [standard deviation] years), with 80 (48%) receiving prophylactic gentamicin (AG+ group). The AG+ and AG- patients had similar fracture sites and Injury Severity Scores (ISSs) (12.6 ± 9.9 AG+ vs. 15.9 ± 13.2 AG-) but were more likely to have sustained blunt trauma (96% AG+ vs. 77%; p < 0.001) or received intravenous contrast medium ≤48 h from admission (75% AG+ vs. 56% AG-; p = 0.01). Gentamicin was not associated with AKI (odds ratio [OR] 0.22; 95% confidence interval [CI] 0.020-2.44; p = 0.22), whereas hypotension on admission (OR 10.7; 95% CI 1.42-80.93; p = 0.02) and ISS (OR 1.1; 95% CI 1.01-1.20; p = 0.02) were both associated with AKI. Only four fracture site infections were identified, three in the AG+ group and one in the AG- group (3.8% vs. 1.1%; p = 0.27). The mortality rate was greater in the AG- group (3.8% vs. 12.6%; p = 0.04). CONCLUSIONS: Prophylactic gentamicin is not associated with AKI, whereas hypotension on admission and higher ISS were. The use of nephrotoxic agents, including aminoglycosides, should be restricted in open fracture patients presenting with hypotension or a high ISS.


Subject(s)
Acute Kidney Injury/epidemiology , Acute Kidney Injury/etiology , Anti-Bacterial Agents/therapeutic use , Antibiotic Prophylaxis/statistics & numerical data , Fractures, Open/epidemiology , Gentamicins/therapeutic use , Acute Kidney Injury/mortality , Adult , Female , Humans , Male , Middle Aged , Retrospective Studies
19.
Surg Infect (Larchmt) ; 17(3): 323-8, 2016 Jun.
Article in English | MEDLINE | ID: mdl-27206239

ABSTRACT

BACKGROUND: Discoveries regarding the basic mechanisms underlying malignant disease, rheumatologic disorders, and autoimmune diseases have led to the development of many new therapeutic modalities that target components of the immune system. Most of these are antibodies or fusion proteins that interfere with components of the immune response that are playing both pathological and protective roles, resulting in variable degrees of immune suppression and a higher risk of infectious complications. METHODS: Review of the English-language literature. RESULTS: As these modalities are often used in combination with more traditional methods of immune suppression (e.g., corticosteroids), an increasing spectrum of infection is being encountered by clinicians. Febrile neutropenia requires rapid assessment and initiation of empiric broad-spectrum antimicrobial therapy. Persistence despite this therapy should prompt further investigation for drug-resistant bacteria and invasive fungal disease. Important pathogens to consider in patients with neutropenia, chronic steroid exposure, or underlying gastrointestinal malignant diseases include fungi (Candida, Aspergillus) and atypical bacteria (Nocardia, Clostridium septicum). CONCLUSIONS: This review focuses on observations regarding the greater risk of infections associated with many of these new biological modalities, as well as some specific infectious complications that may be encountered more commonly by the surgical consultant.


Subject(s)
Immunocompromised Host , Immunosuppressive Agents/adverse effects , Infections/immunology , Antibodies, Monoclonal/adverse effects , Humans , Infections/diagnosis , Infections/therapy
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