Clinical Impact of Vancomycin MIC on Outcomes in Patients With Coagulase-negative Staphylococcal Bacteremia.

PURPOSE: Coagulase-negative staphylococci (CoNS) are Gram-positive organisms that are a known component of normal skin flora and the most common cause of nosocomial bacteremia. For CoNS species, the vancomycin MIC breakpoint for susceptibility set by the Clinical and Laboratory Standards Institute is ≤4 µg/mL. There has been published reports of vancomycin heteroresistance in CoNS with vancomycin MICs of 2 to 4 µg/mL. The aim of this retrospective cohort analysis was to assess the clinical impact of vancomycin MICs <2 µg/mL versus ≥2 µg/mL in adult patients with CoNS bloodstream infections. METHODS: Adult patients admitted to University Medical Center New Orleans with a blood culture positive for CoNS were assessed. The primary outcome was difference in 30-day mortality. Secondary outcomes were in-hospital, all-cause mortality; duration of bacteremia; hospital length of stay; and percentage of oxacillin-resistant CoNS. FINDINGS: There was no difference in mortality in the vancomycin MIC <2 µg/mL group versus the vancomycin MIC ≥2 µg/mL group at 30 days (15.4% vs 17.4%; P = 1). In-hospital, all-cause mortality was also not different between groups (11.5% vs 13%; P = 1). Hospital length of stay between groups was 28.2 days versus 21 days (P = 0.692). Median duration of bacteremia was 1 day in both groups (P = 0.975), and median scheduled duration of antibiotic therapy was 14.9 days and 19.5 days (P = 0.385). The source and mode of acquisition of CoNS were similar between groups. Of all CoNS isolates, 58.7% (44 of 75) were oxacillin resistant. Staphylococcus epidermidis was the most common CoNS species at 66.7% (50 of 75). Of all isolates, 30.7% (23 of 75) had a vancomycin MIC ≥2 µg/mL, and 87% (20 of 23) of these were S. epidermidis. There was a higher percentage of S. epidermidis in the vancomycin MIC ≥2 µg/mL group than in the MIC <2 µg/mL group (87% vs 57.7%; P = 0.012). CoNS with a vancomycin MIC ≥2 µg/mL were also more likely to be oxacillin resistant (78.3% vs 50%; P = 0.005). IMPLICATIONS: There was no difference in clinical outcomes in adult patients with a CoNS bloodstream infection with a vancomycin MIC <2 µg/mL versus ≥2 µg/mL. At present, vancomycin remains appropriate empiric therapy for CoNS bloodstream infection. Further research is needed to determine if there is a true clinical impact of a vancomycin MIC ≥2 µg/mL in CoNS infections.

Do Antibiotics Prevent Infectious Complications in Critically Injured Patients With Blunt Nonoperative Midfacial Trauma?

BACKGROUND: While recent literature suggests antibiotics are not needed in patients with nonoperative facial fractures involving sinuses, the existing studies do not focus on critically injured patients who are known to be at higher risk for sinusitis and ventilator-associated pneumonia, which could be exacerbated by facial fractures. PURPOSE: The purpose of this study was to determine if antibiotics reduce the rate of infectious complications in critically injured patients who have blunt midfacial trauma treated nonoperatively. STUDY DESIGN, SETTING, SAMPLE: The authors conducted a retrospective cohort study consisting of patients admitted to the trauma intensive care unit who sustained blunt midfacial injuries managed nonoperatively at an urban Level 1 trauma center from August 13th, 2012, to July 30th, 2020. Adults who were critically injured on admission and sustained a midfacial fracture involving a sinus were included in the study. Patients who underwent operative repair of any facial fracture were excluded. PREDICTOR VARIABLE: The predictor variable was the use of antibiotics. MAIN OUTCOME VARIABLE: The primary outcome variable was the development of infectious complications, such as sinusitis, soft tissue infection, or any type of pneumonia, including ventilator-associated pneumonia (VAP). ANALYSES: The data were analyzed using Wilcoxon rank sum tests, Fisher exact tests, and multivariable logistic regression as appropriate for analysis type with significance level set at <0.05. RESULTS: The study included 307 patients, with a mean age of 40.6 years. Men accounted for 85.0% of the study population. Antibiotics were administered to 229 (74.6%) of the study population. Complications developed in 13.6% of the patients, which included sinusitis (0.3%), VAP (7.5%), and other types of pneumonia (5.9%). Clostridioides difficile colitis developed in 2 patients (0.6%). Antibiotics were not associated with a decrease in infectious complications in either the unadjusted analysis (13.1% in antibiotic group, 15.4% in no antibiotic group, RR = 0.85 [95% confidence interval = 0.5 to 1.6], P = .7) or the adjusted analysis (odds ratio 0.74 [0.34 to 1.62]). CONCLUSIONS AND RELEVANCE: Even in this critically injured patient population thought to be at elevated risk for infectious complications from their midfacial fractures, the rates of infectious complications in those who received antibiotics and those who did not were no different. These results suggest that consideration of more judicious use of antibiotics is warranted in critically ill patients with nonoperative midface fractures.

Perioperative Fluid Management in Surgical Patients: A Review.

Intravenous (IV) fluids are one of the most widely prescribed medications. Despite their frequent usage, IV fluids are often not used appropriately. High-quality evidence to guide the surgeon in the perioperative period is sparse. A plethora of choices for IV fluids exists with limited evidence to help guide the surgeon in specific patient populations and situations. To address this, the authors have set out to provide a critical review of commonly used IV fluids to treat surgical patients. Gaps in the existing literature for the surgical population will also be discussed as potential target areas for future research.

A Propensity-Matched Analysis of Tranexamic Acid and Acute Respiratory Distress Syndrome in Trauma Patients.

INTRODUCTION: Tranexamic acid (TXA) protects the vasculature endothelium after hemorrhage, resulting in a decreased capillary leak. These properties may protect patients receiving TXA from acute respiratory distress syndrome (ARDS), however, clinical studies have yet to examine this topic. We hypothesized that trauma patients receiving TXA would have lower incidence of ARDS. METHODS: This was a retrospective review of adult (18+ y) patients who presented to a large Level I trauma center with an injury severity score ≥ 16 from admit years 2012-2020. Propensity matching was employed to examine how TXA administration is associated with ARDS. RESULTS: There were a total of 2751 patients meeting study criteria, with 162 (5.9%) received TXA. Of the 162 patients that received TXA, only 12 (7.4%) received pre-hospital TXA, while 4 (2.5%) received TXA both pre-hospital and in hospital. Of the 63 patients developing ARDS, 62 (98.4%) did not receive TXA. After propensity matching, 304 patients remained, with 152 in each cohort. The incidence of ARDS (P = 0.08), pneumonia (P = 0.68), any pulmonary complication (P = 0.33), and mortality (P = 0.37) were not different in patients receiving TXA on propensity matching. CONCLUSIONS: TXA did not protect trauma patients from pulmonary complications; however, nearly all patients developing ARDS did not receive TXA. Larger studies should examine this relationship to improve understanding of therapies that may prevent ARDS.

Impact of Increased Enoxaparin Dosing on Anti-Xa Levels for Venous Thromboembolism Prophylaxis in Trauma Patients.

INTRODUCTION: Venous thromboembolism (VTE) contributes to significant morbidity in trauma patients while increasing hospital costs and length of stay. Standard trauma prophylaxis dosing with enoxaparin 30 mg twice daily may be inadequate to prevent VTEs. The objective of this study was to compare standard dosing of enoxaparin to an increased dose of enoxaparin 40 mg twice daily for trauma patients. We hypothesized that increasing thromboprophylaxis dosing leads to an increase in therapeutic anti-Xa levels and reduced VTE rates. METHODS: A retrospective study was performed from January 2020 to June 2021 at a Level I trauma center, following implementation of an increased enoxaparin dosing strategy. Patients with increased enoxaparin dosing were compared with those who received standard dosing. The primary outcome evaluated was the incidence of subtherapeutic anti-Xa levels. Secondary outcomes evaluated VTE rates and clinically significant bleed. RESULTS: A total of 204 trauma patients were identified. Ninety-one patients received an increased enoxaparin dose compared to 113 who received standard dosing. The baseline demographics of both groups were similar (P > .05). Subtherapeutic levels were higher with standard dosing compared to the increased dose (50 vs 22%, P = .003). Higher VTE rates were observed with standard dosing compared to higher dosing (6.2 vs 3.3%) but with a lower incidence of major bleed (1.8 vs 4.4%). Overall annual VTE rates decreased from 1.6 to 1.3% after implementation of the increased dosing regimen. CONCLUSIONS: This study demonstrated that an increased dosing strategy decreased rates of subtherapeutic anti-Xa levels and trended toward lower overall VTE rates in trauma.

The effect of study design biases on the diagnostic accuracy of magnetic resonance imaging for detecting silicone breast implant ruptures: a meta-analysis.

BACKGROUND: The U.S. Food and Drug Administration has recommended that all silicone breast implant recipients undergo serial screening to detect implant rupture with magnetic resonance imaging. The authors performed a systematic review and meta-analysis to examine the effect of study design biases on the estimation of magnetic resonance imaging diagnostic accuracy measures. METHODS: Studies were identified using the MEDLINE, EMBASE, ISI Web of Science, and Cochrane library databases. Two reviewers independently screened potential studies for inclusion and extracted data. Study design biases were assessed using the Quality of Diagnostic Accuracy Studies tool and the Standards for Reporting of Diagnostic Accuracy Studies checklist. Meta-analyses estimated the influence of biases on diagnostic odds ratios. RESULTS: Among 1175 identified articles, 21 met the inclusion criteria. Most studies using magnetic resonance imaging (10 of 16) and ultrasound (10 of 13) examined symptomatic subjects. Magnetic resonance imaging studies evaluating symptomatic subjects had 14-fold higher diagnostic accuracy estimates compared with studies using an asymptomatic sample (relative diagnostic odds ratio, 13.8; 95 percent confidence interval, 1.83 to 104.6) and 2-fold higher diagnostic accuracy estimates compared with studies using a screening sample (relative diagnostic odds ratio, 1.89; 95 percent confidence interval, 0.05 to 75.7). CONCLUSIONS: Many of the published studies using magnetic resonance imaging or ultrasound to detect silicone breast implant rupture are flawed with methodologic biases. These methodologic shortcomings may result in overestimated magnetic resonance imaging diagnostic accuracy measures and should be interpreted with caution when applying the data to a screening population.

A systematic review of outcomes of toe-to-thumb transfers for isolated traumatic thumb amputation.

BACKGROUND: Toe-to-thumb transfer is an established procedure for reconstruction of traumatic thumb amputations. The four types of toe-to-thumb transfers are the second toe, the great toe, the wrap-around great toe and the trimmed great toe transfers. The purpose of this study is to conduct a systematic review of the literature to compare outcomes amongst different methods of toe-to-thumb transfers. METHODS: A literature search using 'toe-to-thumb transfer' combined with 'thumb injury' and 'thumb reconstruction' as keywords and limited to humans and the English language identified 633 studies. Studies were included in the review if they: (1) present primary data, (2) report three or more toe-to-thumb transfers for isolated complete traumatic thumb amputation between the metacarpophalangeal joint and the interphalangeal joint (both excluded) and (3) present functional outcome data. RESULTS: Twenty-five studies representing 450 toe-to-thumb transfers met the inclusion criteria. They included 101 second toe transfers, 196 great toe transfers, 122 wrap-around transfers and 31 trimmed toe transfers. The mean survival rate was 96.4%. No statistically significant differences could be detected between the four transfers with regards to survival, arc of motion, total active motion, grip and pinch strength and static two-point discrimination. CONCLUSIONS: All four types of toe transfer procedures have predictably high survival rates and good patient satisfaction scores. The current data are inadequate to make any comments with regards to donor site morbidity. Till such data are available, an evidence-based recommendation for the superiority of a specific type of toe-to-thumb transfer cannot be made.

A systematic review of ethical principles in the plastic surgery literature.

BACKGROUND: This purpose of this study was to perform a systematic review to identify articles that discuss ethical issues relating to the field of plastic and reconstructive surgery and to evaluate whether ethical issues are underrepresented in the plastic surgery literature. METHODS: Four medical databases were selected to search through the medical literature with specific inclusion criteria to disqualify irrelevant articles from the study. Appropriate articles were extracted, and their quality and validity were assessed by multiple investigators to maximize reproducibility. The data were then synthesized and analyzed for associations among the ethical principles. RESULTS: Of a total library search of more than 100,000 plastic surgery-oriented articles, only 110 clearly focused on ethical principles. Autonomy (53 percent) was the most common major theme, whereas distributive justice (15 percent) represented the least frequently emphasized ethical principle. The proportions of each ethical principle were tested against each other for equality using Cochran's Q test; the Q test reached statistical significance (Q = 67.04, df = 3, p < 0.0001), indicating that the ethical principles were not discussed equally in plastic surgery literature, which was expected because autonomy represented 53 percent of the articles, whereas distributive justice represented only 15 percent of articles. When examining both major and minor themes, more than half of the articles (61 percent) addressed two or more ethical principles. Beneficence and nonmaleficence were strongly associated (Pearson's chi = 55.38, df = 1,p < 0.0001). CONCLUSION: Despite the extensive number of ethical issues that plastic surgeons face, a relatively small proportion of plastic surgery literature was dedicated to discussing ethical principles.