[Perioperative antibiotic prophylaxis]

Identifying patients at high risk for antibiotic treatment following hospital admission: a predictive score to improve antimicrobial stewardship measures

PURPOSE

Identifying patients for clinical studies evaluating strategies to reduce unnecessary antibiotic usage in hospitals is challenging. This study aimed to develop a predictive score to identify newly hospitalized patients with high likelihood of receiving antibiotics, thus improving patient inclusion in future studies focusing on antimicrobial stewardship (AMS) programs.

METHODS

This retrospective analysis used data from the PILGRIM study (NCT03765528), which included 1,600 patients across ten international sites. Predictive variables for antibiotic treatment during hospitalization were computed, and an additive score model was developed using logistic regression and 10-fold cross-validation. The PILGRIM score was validated in an independent cohort (validation cohort), with performance metrics assessed.

RESULTS

Data from 1,258 patients was included. In the development cohort 52.8% (n = 445) and in the validation cohort 42.4% (n = 134) of patients received antibiotics. Key predictors included hematologic malignancies, immunosuppressive medication, and past hospitalization. The logistic regression model demonstrated an area under the curve of 0.74 in the validation. The final additive score incorporated these predictors plus "planned elective surgery" achieving a specificity of 92%, a positive predictive value of 78%, a sensitivity of 41%, and a negative predictive value (NPV) of 69%in validation set.

CONCLUSION

The PILGRIM score effectively identifies newly hospitalized patients likely to receive antibiotics, demonstrating high specificity and PPV. Its application can improve future AMS programs and trial recruitment by facilitating targeted inclusion of patients, especially in the hematological and oncological setting. Further -external and prospective- validation is needed to broaden the model's applicability.

Mechanical bowel preparation combined with oral antibiotics reduces infectious complications and anastomotic leak in elective colorectal surgery: a pooled-analysis with trial sequential analysis

OBJECTIVE

A pooled analysis combined with trial sequential analysis (TSA) was conducted in order to explore the effect of mechanical bowel preparation (MBP) combined with oral antibiotic bowel decontamination (OAB) versus MBP alone on patients who have undergone colorectal resection.

METHODS

Comprehensive and systematic searches of PubMed, Embase, Cochrane Library, Web of Knowledge, and Clinical Trials.gov databases were conducted. The quality of literature was evaluated using Cochrane risk bias assessment tool as well as Newcastle-Ottawa Scale (NOS) score. A pooled analysis of randomized controlled trials (RCTs) and prospective studies was performed comparing patients who underwent colorectal resection and received MBP plus OAB or MBP alone. The outcome endpoints were the incidence of anastomotic leak (AL) and surgical site infection (SSI). TSA is a tool used to assess the reliability of currently available evidence to determine further clinical trial validation.

RESULTS

The analysis included a total of 22 studies involving 8852 patients, including 3016 patients in the MBP + OAB group and 4415 patients exposed to MBP alone. The pooled analysis showed that the incidence of postoperative anastomotic leak was significantly lower in the group treated with MBP plus OAB compared with MBP alone (OR = 0.43, 95% CI: 0.23-0.81, P = 0.009, I2 = 73%). The incidence of postoperative surgical site infections was significantly lower in the group exposed to the combination of MBP and OAB compared with MBP alone (OR = 0.38, 95% CI: 0.32-0.46, P < 0.0001, I2 = 24%). The TSA demonstrated significant benefits of MBP plus OAB intervention in terms of AL and SSI.

CONCLUSION

MBP combined with OAB significantly reduces the incidence of AL and SSI in patients after colorectal resection compared with MBP alone.

Influence of Antibiotic Management on Microbial Selection and Infectious Complications After Trauma

Background: The inflammatory response and post-traumatic complications like infections play an important role in the pathophysiology of severe injuries. This study examines the microbiological aspects in anti-infective treatment of trauma patients and their inflammatory response in post-traumatic infections complications.

Patients and Methods: A retrospective analysis of prospectively collected data in trauma patients (ISS ≥ 16) over a 1-year period (01/2018 to 12/2018) is provided. Patient population was stratified into severely injured patients without post-traumatic infection (inf-PT), and severely injured patients who developed an infection (inf+PT).

Results: Of 114 trauma patients, 45 suffered from post-traumatic infection during the first 10 days of hospitalization. Severely injured patients with concomitant traumatic brain injury (PT+TBI) showed the highest rate of post-traumatic infection. Pro-inflammatory reaction was tracked by levels of Interleukin (IL-)6 (day 3: inf+T 190.8 ± 359.4 pg/dL > inf-PT 56.2 ± 57.7 pg/mL (mean ± SD); p = 0.008) and C-Reactive-Protein (CRP, day 3: inf+PT 15.3 mg/dL > inf-PT 6.7 mg/dL, p = 0.001) which were significantly higher in trauma patients who develop an infectious complication and showed a significant positive correlation with the occurrence of infection. The leading entity of infection was pneumonia followed by infections of the urinary tract mainly caused by gram-negative Enterobacteriaceae. 67.5% of all trauma patients received single-shot antibiosis during initial care in trauma bay. The development of secondary colonization was not relevant positively correlated with single-shot antibiosis (r = 0.013, p = 0.895) and prophylactically calculated antibiotic administration (r = 0.066, p = 0.500).

Conclusion: Severely injured trauma patients have an increased risk for development of infectious complications, which mainly is pneumonia followed by infection of the urinary tract mainly caused by gram-negative Enterobacteriaceae. Based on the data in this study, the one-time antibiotic and prophylactic calculated use of antibiotics, like Cephalosporins must be critically discussed in terms of their role in the development of post-traumatic infections and microbial selection.

Psoas Versus Femoral Blocks: A Registry Analysis of Risks and Benefits

BACKGROUND AND OBJECTIVES

Psoas blocks are an alternative to femoral nerve blocks and have the potential advantage of blocking the entire lumbar plexus. However, the psoas muscle is located deeply, making psoas blocks more difficult than femoral blocks. In contrast, while femoral blocks are generally easy to perform, the inguinal region is prone to infection. We thus tested the hypothesis that psoas blocks are associated with more insertion-related complications than femoral blocks but have fewer catheter-related infections.

METHODS

We extracted 22,434 surgical cases from the German Network for Regional Anesthesia registry (2007-2014) and grouped cases as psoas (n = 7593) and femoral (n = 14,841) blocks. Insertion-related complications (including single-shot blocks and catheter) and infectious complications (including only catheter) in each group were compared with χ tests. The groups were compared with multivariable logistic models, adjusted for potential confounding factors.

RESULTS

After adjustment for potential confounding factors, psoas blocks were associated with more complications than femoral blocks including vascular puncture 6.3% versus 1.1%, with an adjusted odds ratio (aOR) of 3.6 (95% confidence interval [CI], 2.9-4.6; P < 0.001), and multiple skin punctures 12.6% versus 7.7%, with an aOR of 2.6 (95% CI, 2.1-3.3; P <0.001). Psoas blocks were also associated with fewer catheter-related infections: 0.3% versus 0.9% (aOR of 0.4; 95% CI, 0.2-0.8; P = 0.016), and with improved patient satisfaction (mean ± SD 0- to 10-point scale score, 9.6 ± 1.2 vs 8.4 ± 2.9; P < 0.001). Results from a propensity-matched sensitivity analysis were similar.

CONCLUSIONS

Psoas blocks are associated with more insertion-related complications but fewer infectious complications.

CLINICAL TRIAL REGISTRATION

ID NCT02846610.