Impact of antimicrobial selection for prophylaxis of left ventricular assist device surgical infections

Clinical Characteristics and Predictors of Mortality of Patients with Post-Neurosurgical Meningitis-A 900-Cases Cohort Study

Aim

To express the clinical characteristics of patients with post-neurosurgical meningitis (PNM) and launch a survival analysis to screen mortality predictors.

Methods

A cohort analysis containing more than 70000 patients was evaluated, and all of them received neurosurgical procedure. Clinical and microbial epidemiology, therapy and mortality of PNM patients were reviewed. Multi-variable Cox proportional hazard models were applied to achieve survival analysis.

Results

About 900 PNM patients from 3244 cases were selected for characteristics and survival analysis, the mean age of them was 41 (27-54) years, 516 (57.3%) were men and 384 (42.7%) were women. The 28-day mortality was 12.4% (112 of 900) in patients with PNM. Hypertension, external ventricular drainage (EVD), and lumbar drainage (LD) are mortality predictors for PNM, with a hazard ratio (HR) of 2.641 (95% C.I. 1.563-4.464, P<0.001), 2.196 (95% C.I. 1.317-3.662, P=0.003), and 1.818 (95% C.I. 1.126-2.936, P=0.014). In treatment, the outcome of patients receiving three or more antibiotic combinations is better than that of patients receiving dual-drug combinations.

Conclusion

The mortality of patients with PNM was relatively high, and the risk factors related to 28-days mortality were hypertension, EVD and LD and treatment with three or more antibiotics are much better.

A nurse-driven penicillin allergy risk score in the preoperative setting was associated with increased cefazolin use perioperatively

STUDY OBJECTIVE

To characterize and assess the effects of a preoperative, nurse-driven penicillin allergy risk stratification tool on rates of perioperative cefazolin and second-line antibiotic use.

DESIGN

Quasi-experimental quality improvement study of penicillin-allergic surgical patients undergoing procedures for which cefazolin is indicated.

SETTING

Outpatient Perioperative Care Clinic (PCC) for preoperative surgical patients at a tertiary care center.

PATIENTS

670 and 1371 adult penicillin-allergic PCC attendants and non-attendants, respectively.

INTERVENTION

A paper penicillin allergy risk stratification questionnaire was administered during the PCC visit. Nurses were educated on its use.

MEASUREMENTS

Antibiotic (cefazolin, clindamycin, vancomycin) use rates in the 24 months before and 17 months after intervention implementation in November 2020 (November 2018 - April 2022) were assessed in penicillin-allergic PCC attendants with statistical process control charts. Multivariable logistic regression assessed antibiotic use rates pre- and post-intervention adjusting for age, sex, surgical specialty and penicillin allergy history severity. Similar analyses were done in penicillin-allergic PCC non-attendants.

MAIN RESULTS

Of 670 penicillin-allergic PCC attendants, 451 (median [IQR] age, 66 (Sousa-Pinto et al., 2021 [14])) were analyzed pre-intervention and 219 (median [IQR] age, 66 (Mine et al., 1970 [13])) post-intervention. One month after implementation, process measures demonstrated an upward shift in cefazolin use for PCC attendants versus no shift or other special cause variation for PCC non-attendants. There were increased odds of cefazolin use (aOR 1.67, 95% CI [1.09-2.57], P = 0.019), decreased odds of clindamycin use (aOR 0.61, 95% CI [0.42-0.89], P = 0.010) and decreased odds of vancomycin use (aOR 0.56, 95% CI [0.35-0.88], P = 0.013) in PCC attendants post-intervention. This effect did not occur in PCC non-attendants. There was no increase in perioperative anaphylaxis post-intervention.

CONCLUSIONS

A simple penicillin allergy risk stratification tool implemented in the preoperative setting was associated with increased use of cefazolin and decreased rates of second-line agents post implementation.

Left Ventricular Assist Device: Review of Antimicrobial Prophylaxis Strategies and Incidence of Infections at a Tertiary Care Center 12-Year Experience

Background

Left ventricular assist devices (LVAD) have an associated infection rate of 13%-80% postimplant. An optimal strategy for surgical infection prophylaxis (SIP) at the time of implantation has not been well defined. We aimed to evaluate the different LVAD implantation antibiotic prophylaxis regimens as well as the incidence of LVAD infection at our institution.

Methods

We performed a single-center, retrospective study of patients who underwent LVAD implantation between February 2007 and June 2019. The primary outcome was the incidence of LVAD infection (LVADI), within 3 months and 1 year of placement, between patients who received expanded or narrow-spectrum regimens for SIP. We assessed outcomes using Kaplan-Meier, time-to-first event. We used a noninferiority analysis, which was established if the narrow-spectrum event rate was no more than 5% greater than the expanded-spectrum event rate.

Results

We included 399 patients, 305 (76.4%) patients received narrow-spectrum SIP, whereas the remaining 94 (23.6%) patients received the expanded-spectrum regimen. Statistical noninferiority of the narrow spectrum to the multiple drug regimen was demonstrated at both time points, and statistical superiority of the narrow-spectrum group across 12-month follow up was further evident (P = .037).

Conclusions

We report evidence supporting noninferiority, or even superiority, of the narrow-spectrum over expanded-spectrum antimicrobial prophylaxis strategy with respect to LVADI. These findings support data-driven antimicrobial prophylaxis strategies.