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   Table of Contents - Current issue
July-December 2022
Volume 1 | Issue 2
Page Nos. 47-75

Online since Wednesday, February 15, 2023

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2023 updates on the closed or open after-source control for severe complicated intraabdominal sepsis (COOL) trial p. 47
Jinjian Huang, Jianan Ren, Jessica L McKee, Andrew W Kirkpatrick
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Antimicrobial use and other risk factors for infections with antimicrobial-resistant bacteria and fungi bacteria and fungi in an intensive care unit p. 50
Abigail W Cheng, Jesse Chou, Robert G Sawyer
Introduction: Resistant infections are especially problematic in the intensive care unit (ICU), but risk factors remain unclear. We hypothesized that the risk factors for resistant Gram-negative rods (rGNR), resistant Gram-positive cocci (rGPC), and secondary fungal infections differed. Materials and Methods: A single-center cohort study of patients with ICU-acquired infections from 1997 to 2017 was performed. Inclusion was conditioned on the presence of rGNR, rGPC, or fungi. Risk factors studied included demographics, medical comorbidities, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and previous antimicrobial exposure. Results: Four thousand three hundred and nineteen ICU-acquired infections were identified. One thousand nine hundred and ninety-eight were considered resistant and 2321 were considered nonresistant. Identification of any resistant organism was significantly associated with female sex, nontrauma diagnosis, APACHE II score, liver disease, chronic steroid use, history of any prior infection, and history of a resistant infection, but not days of prior antimicrobial use. Infections with rGNR were associated with days of therapeutic antimicrobials given for a previous infection, but not total prior antimicrobial days during hospitalization. rGPC infections were associated with both previous infections treated with antimicrobials and total prior antimicrobial days during hospitalization. Fungal infections were not associated with any measure of prior antimicrobial exposure. Controlling for the severity of illness and demographics, resistant infections were not associated with mortality compared to nonresistant infections. Conclusions: The likelihood of rGNR infection is closely linked to recent antimicrobial exposure, while rGPC infection appears to be associated with prior antimicrobial exposure. Fungal infections may not be associated with prior antimicrobial exposure. These findings suggest disparate mechanisms of dysbiosis for different classes of resistant pathogens.
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Characterizing the prognostic utility of isolating yeast in surgical site infections and subsequent use of antifungal therapies p. 58
Jesse Chou, Graham McLaren, Abigail W Cheng, Robert G Sawyer
Background: Whether the isolation of yeast from surgical site infections (SSIs) affects outcomes is unclear. We hypothesized that for SSI, yeasts are nonpathogenic and that neither the isolation of yeast nor the use of antifungal agents affects outcomes. Methods: Incisional SSIs from general surgery patients at a single institution between 1997 and 2017 with positive cultures were analyzed, categorized by the presence of yeast. Demographics and in-hospital mortality were compared by Student's t-test and Chi-square analysis. Independent predictors of isolation of yeast and in-hospital mortality were determined by multivariate logistic regression analysis (MV). Results: In total, 977 infections with positive cultures were identified: 190 (19.4%) with yeast and 787 (80.6%) without. By univariate analysis, cultures positive for yeast were associated with a higher severity of illness/APACHE II score (15.6 ± 0.5 versus 11.6 ± 0.2; P < 0.0001), diagnosis in the ICU (83/190, 43.6% versus 154/787, 19.5%; P < 0.0001), age (55.2 ± 1.1 versus 52.4 ± 0.5; P = 0.015), and female sex (105/190, 55.3% versus 362/787, 46.0%; P = 0.027). Independent predictors of isolation of yeast included sex, APACHE II Score, and diagnosis after discharge from index procedure, and for mortality, age, APACHE II, diagnosis after discharge, and receiving antifungal treatment. Isolation of yeast was not associated with mortality (P = 0.12). For fungal SSI, antifungal treatment was not associated with decreased mortality. Conclusion: Isolation of yeast from incisional SSI is not associated with mortality, and the use of antifungal agent is associated with higher mortality. Routine fungal cultures of SSI are not warranted.
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A counterculture movement: Characterizing the prognostic utility of obtaining wound cultures for incisional surgical site infections p. 62
Graham McLaren, Jesse Chou, Robert G Sawyer
Background: Surgical site infections (SSIs) account for 15% of all healthcare-associated infections, yet, the utility of cultures remains controversial. We hypothesized that obtaining cultures would not affect outcomes from incisional SSI. Methods: All incisional SSI from general surgery patients treated as inpatients at a single institution between 1997 and 2017 were included. Patient variables were compared by Student's t-test and Chi-square analysis. Predictors of in-hospital mortality, duration of therapy, and hospital length of stay, including the acquisition of wound cultures, were determined by multivariate (MV) logistic regression analysis. Results: In total, 2054 SSIs were identified: 1077 (52.4%) with cultures and 977 (47.6%) without. Obtaining cultures were associated with higher severity of illness/Acute Physiology and Chronic Health Evaluation (APACHE-II) score (12.4 ± 0.2 vs. 8.8 ± 0.2; P < 0.0001) and multiple comorbidities, as well as a longer antimicrobial course (13.8 ± 0.3 days vs. 9.1 ± 0.2 days; P < 0.0001), length of stay (17.4 ± 0.8 days vs. 9.7 ± 0.5 days; P < 0.0001), and mortality (8.6% vs. 4.2%; P < 0.0001). Factors independently predicting mortality included age in years (odds ratio [OR] 1.03 [95% confidence interval [CI] 1.02–1.05], P < 0.0001), APACHE-II (OR 1.17 [95% CI 1.14–1.21], P < 0.0001), days from operation to diagnosis (OR 1.01 [95% CI 1.01–1.02], P < 0.0001), and diagnosis of SSI after discharge (OR 4.98 [95% CI 2.18–11.35], P < 0.0001). Obtaining cultures (OR 1.04 [95% CI 0.65–1.64], P = 0.88) were not associated with mortality. Acquisition of cultures was independently associated with longer antimicrobial duration and length of stay. Conclusion: Routinely obtaining cultures from infected surgical incisions does not change the overall outcome and should be reserved for special circumstances, such as critical illness.
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Investing in surgical site infection control toward safe surgery and universal health coverage p. 67
Justina O Seyi-Olajide, Emmanuel Adoyi Ameh
Surgical site infection (SSI) is a common but preventable complication after surgery and is a major cause of postoperative morbidity and mortality in low-and middle-income countries. Antimicrobial resistance (AMR) rates are also high in the setting. To scale up access to surgical care toward achieving the goals of universal health coverage, several countries in the setting have created surgical plans. These plans aim to significantly increase surgical volumes. These countries must scale up infection prevention and control programs at the same pace to avoid uncontrollable increases in SSI and AMR rates. Implementation of the safe surgery checklist needs to be scaled up to support SSI prevention and control programs.
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Colonic anastomotic fistula treated by endoscopic over-the-scope clip with fibrin glue p. 71
Jinpeng Zhang, Yitian Teng, Ruixia Tian, Huajian Ren
Enterocutaneous fistula is a severe complication of gastrointestinal surgery, often associated with abdominal infection, bleeding, malnutrition, and multiple organ dysfunction. Among the early stages of enterocutaneous fistula, the active promotion of spontaneous healing of enterocutaneous fistula is crucial for the treatment of enterocutaneous fistula. Herein, we present a case of enterocutaneous fistula occurring in a 55-year-old Chinese male patient. The patient was operated on by sigmoid diverticulum perforation and underwent partial sigmoid resection and colostomy. Four months later and stoma reversal was done, after which the incision went through repeat infection. He presented to the outpatient department with a sinus tract within the median abdominal incision and pus in abdominal drainage. He was then diagnosed with a colonic anastomotic fistula after computer tomography and fistulography. The successful closure of the fistula confirmed by colonogram was achieved within 2 weeks by the treatment of over-the-scope clip (OTSC) combined with fibrin glue. Our case shows that the approaches of OTSC and fibrin glue are expected to be a promising and novel strategy for treating enterocutaneous fistulas.
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