It is time to define an organizational model for the prevention and management of infections along the surgical pathway: a worldwide cross-sectional survey

BACKGROUND

The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness.

METHODS

A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days.

RESULTS

Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations.

CONCLUSION

Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened.

How to Predict Postoperative Complications After Early Laparoscopic Cholecystectomy for Acute Cholecystitis: the Chole-Risk Score

BACKGROUND

Early laparoscopic cholecystectomy (ELC) is the gold standard treatment for patients with acute calculous cholecystitis (ACC); however, it is still related to significant postoperative complications. The aim of this study is to identify factors associated with an increased risk of postoperative complications and develop a preoperative score able to predict them.

METHODS

Multicentric retrospective analysis of 1868 patients with ACC submitted to ELC. Included patients were divided into two groups according to the presentation of increased postoperative complications defined as postoperative complications ≥ Clavien-Dindo IIIa, length of stay greater than 10 days and readmissions within 30 days of discharge. Variables that were independently predictive of increased postoperative complications were combined determining the Chole-Risk Score, which was validated through a correlation analysis.

RESULTS

We included 282 (15.1%) patients with postoperative complications. The multivariate analysis predictors of increased morbidity were previous percutaneous cholecystostomy (OR 2.95, p=0.001), previous abdominal surgery (OR 1.57, p=0.031) and diabetes (OR 1.62, p=0.005); Charlson Comorbidity Index >6 (OR 2.48, p=0.003), increased total bilirubin > 2 mg/dL (OR 1.88, p=0.002), dilated bile duct (OR 1.79, p=0.027), perforated gallbladder (OR 2.62, p<0.001) and severity grade (OR 1.93, p=0.001). The Chole-Risk Score was generated by grouping these variables into four categories, with scores ranging from 0 to 4. It presented a progressive increase in postoperative complications ranging from 5.8% of patients scoring 0 to 47.8% of patients scoring 4 (p<0.001).

CONCLUSION

The Chole-Risk Score represents an intuitive tool capable of predicting postoperative complications in patients with ACC.

Risk Factors for Intra-Abdominal Infections Caused by Carbapenemase-Producing Enterobacteriaceae in a Surgical Setting

Background: The aim of this study was to identify risk factors for acquisition of intra-abdominal infections (IAI) caused by carbapenemase-producing Enterobacteriaceae (CPE) in surgical patients. Methods: A matched case-control study was performed. We included all cases with CPE-related IAI acquired during admission to a general surgery department from January 2013 to December 2018, and they were matched with control subjects with IAI caused by non-resistant bacteria (ratio 1:3). Independent risk factors were obtained by logistic regression. Results: Forty patients with IAI-CPE were matched with 120 control subjects. Independent risk factors for acquisition of IAI-CPE were previous hospitalization (odds ratio [OR] 2.56; 95% confidence interval [CI] l 1.01-6.49; p = 0.047), digestive endoscopy (OR 4.11; 95% CI 1.40-12.07; p = 0.010), carbapenem therapy (OR 9.54; 95% CI 3.33-27.30; p < 0.001), and aminoglycoside use (OR 45.41; 95% CI 7.90-261.06; p < 0.001). Conclusions: Four clinical factors can identify patients at high-risk of IAI-CPE.

[Infections by OXA-48 carbapenemase-producing Enterobacteriaceae in surgical patients: antibiotic consumption and susceptibility patterns]

Objetivos

Analizar la administración de antibióticos, la evolución temporal de sensibilidades y el tratamiento dirigido de las infecciones asociadas a enterobacterias productoras de carbapenemasas (EPC) OXA-48 en un servicio de Cirugía General y Digestivo.

Material y métodos

Estudio observacional retrospectivo, incluyendo pacientes con cultivo positivo de OXA-48 y datos clínicos de infección activa, hospitalizados en un servicio de Cirugía General y Digestivo entre enero 2013 y diciembre 2018.

Resultados

Se incluyeron 65 pacientes, con 66 aislamientos de OXA-48: Klebsiella pneumoniae, 57 (86,5%); Enterobacter cloacae, 5 (7,6%); Escherichia coli, 3 (4,5%); Morganella morganii, 1 (1,5%). La infección intraabdominal fue la más común (n=39, 60%), y el consumo previo de antibióticos fue: piperacilina-tazobactam (48%), meropenem (45%), ciprofloxacino (25,5%), ertapenem (16,5%), imipenem (12%), amikacina (12%), tigeciclina (12%). La evolución temporal (2013/14, 2015/16 y 2017/18) de las sensibilidades (porcentajes) según antibiograma fue: ceftazidima-avibactam X-X-100; amikacina 100-96-84 (p=0,518); tigeciclina 100-92-80 (p=0,437); colistina 100-67-66 (p<0,001); meropenem 37-64-72 (p=0,214); imipenem 51-41-77 (p=0,109); gentamicina 13-19-18 (p=0,879); ertapenem 35-0-0 (p<0,001). El tratamiento dirigido tuvo una mediana de duración de 14 [RIQ 9-20] días, destacando en frecuencia: tigeciclina (57%); meropenem (40,5%); amikacina (37,5%); ceftazidima-avibactam (9%); imipenem (7,5%); colistina (7,5%). La mortalidad global a 30 días fue del 12% (8 individuos). El tratamiento dirigido fue adecuado según antibiograma en el 87,7%, utilizando un régimen de terapia combinada en el 76,9%, régimen que incluyó algún carbapenémico en el 49,2%.

Conclusiones

En Cirugía General y Digestivo destaca la infección intraabdominal asociada a OXA-48, con elevado consumo previo de antibióticos de amplio espectro. El tratamiento dirigido con mayor sensibilidad de cepas productoras de OXA-48 incluye ceftazidima-avibactam, amikacina, tigeciclina, meropenem e imipenem.

Laparoscopic Cholecystectomy for Acute Cholecystitis: Is the Surgery Still Safe beyond the 7-Day Barrier?

BACKGROUND

The optimal timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. The aim of this study was to assess the outcomes of ELC in patients with delayed presentation.

METHODS

Retrospective analysis of 381 patients who underwent ELC for ACC between January 2010 and September 2018. Included patients were classified into two groups according to the timing of surgery from the onset of symptoms: group 1 (G1) within the first 7 days and group 2 (G2) beyond 7 days.

RESULTS

There were no significant differences regarding conversion rate (G1 8.6% vs. G2 11.8%; p = 0.527), operative time (G1 100 min [75-120] vs. G2 120 min [71-150]; p = 0.060), bile duct injuries (G1 0.3% vs. G2 0%; p = 1), major postoperative complications (G1 11% vs. G2 5.9%; p = 0.557), reoperation rates (G1 1.4% vs. G2 0%; p = 1), length of stay (G1 4 days [3-7] vs. G2 5 days [3-7]; p = 0.539), readmissions (G1 3.7% vs. G2 5.9%; p = 0.633) and costs (G1 6035 € [3693-8330] vs. G2 7243 € [4921-11,336]; p = 0.395).

CONCLUSION

ELC may be considered for patients with ACC who can tolerate surgery with more than 1 week of symptom duration.

Intra-Abdominal Infections by Carbapenemase-Producing Enterobacteriaceae in a Surgical Unit: Counting Mortality, Stay, and Costs

Background: Carbapenemase-producing Enterobacteriaceae (CPE)-related infections are a problem in public health at present, including intra-abdominal infections (IAI) and surgical populations. The aim of this study was to determine mortality and related risk factors, length of stay (LOS,) and costs for CPE-IAI in surgical patients. Patients and Methods: Review of CPE-related IAI acquired during admission in a general surgery department from January 2013 to December 2018. A mortality analysis was performed specifically in patients with CPE-IAI, and a global analysis of IAI including patients with CPE-IAI (cases) and matched patients with IAI by non-resistant bacteria (controls). Results: Forty patients with CPE-IAI were included, OXA-48-producing Klebsiella pneumoniae was present in 85%. Global mortality rate at 30 days for CPE-IAI was 17.5%; mortality-related factors were: solid tumor (p = 0.009), metastatic disease (p = 0.005), immunodeficiency (p = 0.039), blood transfusion (p = 0.009), and septic shock (p = 0.011). Predictors related to mortality for IAI in the global analysis included age (p = 0.046), Charlson index (p = 0.036), CPE isolation (p = 0.003), and septic shock (p < 0.001). Median global LOS was 43 days (IQR 27-64) in patients with CPE-IAI, and 27 days (IQR 18-35) in controls (p < 0.001). Median global cost of admission was $31,671 (IQR 14,006-55,745) for patients with CPE-IAI and $20,306 (IQR 11,974-27,947) for controls (p = 0.064). The most relevant locations of underlying disease for CPE-IAI were: colorectal (32.5%) with 57-day LOS (IQR 34-65) and cost of $42,877 (IQR 18,780-92,607), and pancreas (25%) with 60-day LOS (IQR 32-99) and cost of $56,371 (IQR 32,590-113,979). Conclusion: Carbapenemase-producing Enterobacteriaceae-related IAI is associated with substantial mortality, LOS, and costs. Factors related to CPE-IAI mortality are solid tumor, metastatic disease, immunodeficiency, blood transfusion, and septic shock. Carbapenemase-producing Enterobacteriaceae isolation in IAI implies higher risk of mortality.

Perforated emphysematous cholecystitis and Streptococcus bovis

Streptococcus bovis is an uncommon cause of biliary tract infection, being acute cholecystitis including this microorganism extremely rare. This entity is more frequent in older patients with cardiovascular disease, diabetes, hepatitis, or neoplasms as colon cancer.

Meckel's diverticulum in the adult: surgical treatment

Introduction: Management of asymptomatic Meckel's diverticulum (MD) incidentally discovered in adults remains controversial. The aim of this study was to determine if incidental diverticula should be removed. Materials and methods: We reviewed a consecutive series of patients surgically managed from January 1994 to December 2016. Patients were divided into two groups according to symptomatic or asymptomatic diverticula, and characteristics were compared. Results: The study included 66 patients: 30 in the symptomatic group (45%) and 36 in the incidental group (55%). We found 12 females (18.2%), and the ratio male:female was higher in the symptomatic group (14:1 vs. 2.6:1). Patients in the symptomatic group were significantly younger: 41.7 ± 18.1 vs. 54.7 ± 19.8 years (p = .007). MD in the symptomatic group tended to be longer (3.8 ± 1.9 vs. 2.6 ± 0.9 cm; p = .003). A MD-associated malignancy was present in three patients (4.5%), all neuroendocrine tumours. Major postoperative complications occurred in 6.6% of symptomatic patients and 0% within the incidental group, without specific morbidity related to prophylactic surgery. No mortality was observed. Conclusion: Resection of incidentally found Meckel's diverticulum can be made because of benefits outweigh the risks in this high-risk area for cancer.

Conservative Management of Gallstone Disease in the Elderly Population: Outcomes and Recurrence

BACKGROUND & AIMS

The prevalence of gallstone disease increases with age, being early cholecystectomy the most accepted treatment in the vast majority of patients in order to prevent complications and recurrence. The aim of this study is to determine the recurrence rate and its possible predictors after initial non-operative management.

MATERIALS AND METHODS

We reviewed a consecutive series of patients, older than 65 years, admitted for a gallstone-related disease and treated with a non-operative management between January 2010 and December 2013. We analyzed comorbidities, clinical data, diagnosis, management, recurrence, and its treatment. Median follow-up after the discharge was 2 years. Recurrence was analyzed by a Kaplan-Meier survival curve. Possible recurrence's predictors were analyzed.

RESULTS

The study included 226 patients. Mean age was 80.4 ± 7.2 years, 127 (56%) were female. The main causes of index hospitalization were acute cholecystitis (58%) and biliary pancreatitis (18.1%). After 2 years of follow-up, the recurrence rate was 39.8%; mean time to recurrence was 255.2 ± 42.1 days, 81% of patients recurred within 1 year. Bile duct disease implied a higher recurrence rate than the gallbladder disease group (52% vs 33%, p < 0.001). Subjects with two or more diagnoses during index admission presented higher recurrence rate (32% vs 49%, p < 0.001).

CONCLUSION

More than a third of elderly patients could present a recurrence within 2 years after initial non-operative management. Early cholecystectomy should be considered at index admission in order to prevent recurrence.

Abdominal compartment syndrome secondary to acute necrotizing pancreatitis

Severe acute pancreatitis occurs in around 20% of patients and is associated with mortality rates between 8-40%. Abdominal compartment syndrome is a fatal complication that is associated with new organ failure or acute worsening of existing organ failure and has an associated mortality of around 60%. Intra-abdominal pressure measurements are recommended in patients with risk factors for intra-abdominal hypertension or abdominal compartment syndrome. Management should be based on a step-up method and surgical intervention may be indicated when conservative treatment fails.

Efficiency of the Bethesda System for Thyroid Cytopathology

INTRODUCTION

Fine-needle aspiration biopsies are a key tool for preoperative assessment of thyroid nodules, and the Bethesda system is the preferred method to report cytological analysis. The purpose of this study is to assess the efficiency of the Bethesda system to identify the malignancy risk of thyroid nodules.

METHODS

Patients who underwent thyroid surgery between June 2010 and June 2017 were included. Samples were classified into 6categories according to rates of malignancy associated with each diagnostic category. In order to investigate the correlation between categories, a statistical analysis compared the categories with pathology reports. Diagnostic indicators were calculated as a screening test (categories IV, V, VI as true-positive) and as a method to identify malignancy (V, VI as true-positive).

RESULTS

In a series of 522 patients, we found 184 (35.2%) malignant tumours, papillary carcinoma being the most prevalent with 155 cases (84.2%). Malignant rates for diagnostic categories were: I, 0%; II, 1.5%; III, 6.4%; IV, 31%; V, 86.5%; VI, 100%. A robust correlation was identified between categories on statistical analysis. For the «screening test» analysis, sensitivity was 98.9%, specificity 84.4%, positive predictive value 69.6%, negative predictive value 99.5%, and diagnostic accuracy 88.2%. Analysing the accuracy to detect malignancy, values were: sensitivity 98.6%, specificity 97.6%, positive predictive value 93.5%, negative predictive value 99.5%, diagnostic accuracy 97.9%.

CONCLUSION

The Bethesda system is a clear and reliable approach to report thyroid cytology and therefore is an effective tool to identify malignancy risk and guide clinical management.

Neuroendocrine tumours within a Meckel's diverticulum

A Meckel's diverticulum is a common anomaly of the gastrointestinal tract. Although the majority of patients do not have any symptoms, malignancies can develop inside these diverticula, with neuroendocrine tumours being the most common. Diverticulectomy is the best option for complicated diverticula but prophylactic resection of asymptomatic diverticula in adults remains controversial. We present a case series of three patients with a neuroendocrine tumour found in a Meckel's diverticulum. Given the number of asymptomatic diverticula not resected, it seems likely that incidental neuroendocrine tumours are more prevalent than thought previously. With the minimally invasive techniques now available and the low complication rate for incidental diverticulectomy, we believe that the benefits of resection of this high risk area for cancer outweigh the risks of surgery.

Neuroendocrine tumours within a Meckel's diverticulum

A Meckel's diverticulum is a common anomaly of the gastrointestinal tract. Although the majority of patients do not have any symptoms, malignancies can develop inside these diverticula, with neuroendocrine tumours being the most common. Diverticulectomy is the best option for complicated diverticula but prophylactic resection of asymptomatic diverticula in adults remains controversial. We present a case series of three patients with a neuroendocrine tumour found in a Meckel's diverticulum. Given the number of asymptomatic diverticula not resected, it seems likely that incidental neuroendocrine tumours are more prevalent than thought previously. With the minimally invasive techniques now available and the low complication rate for incidental diverticulectomy, we believe that the benefits of resection of this high risk area for cancer outweigh the risks of surgery.

A giant hiatal hernia and intrathoracic pancreas

Transhiatal herniation of the pancreas is an extremely rare condition, with only a few more than ten cases reported. Most patients are symptomatic at initial presentation and multi-detector computed tomography allows a detailed visualization of the anatomy and size of the diaphragmatic defect. Surgical repair is recommended for symptomatic cases.

Surgery in late melanoma adrenal metastasis

Metastatic melanoma to adrenal gland are very infrequent, being generally associated with additional evidence of systemic disease and, consequently, with short-term survival. However, the prognosis and the therapeutic management vary depending on some important oncological features. Long-term survival rates have been described after complete resection of metastatic disease. Here, we report the case of a woman aged 41 years diagnosed with a cutaneous melanoma on the right side of her paravertebral region, level III of Clark, in 2002, who underwent surgical excision of the tumour with negative margins and a negative sentinel node. She posteriorly developed pulmonary metastasis in 2006 and 2009, both resected with curative intention and in 2013, she was diagnosed with an adrenal metastasis. Therefore, she was submitted to an uneventful right laparoscopic adrenalectomy. The pathology report described metastasis of a cutaneous melanoma, negative for BRAF mutation. The patient is actually disease-free after 30 months of follow-up.

An unusual enterolith ileus

The duodenum is an uncommon location of diverticula in the digestive tract, and they are often asymptomatic. Formation of an enterolith inside diverticula has been previously described, although it is a rare condition. In this context, intestinal obstruction due to distal migration of foreign bodies is extremely rare. We report a case of an 86-year-old woman with obstructive symptoms due to a jejunal foreign body that had migrated from a duodenal diverticulum. An emergency laparotomy was performed to extract a phytobezoar. Enterolith ileus secondary to duodenal diverticula is an exceptional entity. Diagnosis and management are usually delayed because of a non-specific presentation, and early surgical exploration is required for bowel disimpaction. This condition should be considered in elderly patients with prolonged immobilization or neurodegenerative diseases.

Neuroendocrine tumour arising inside a tailgut cyst

Tailgut cysts are rare benign retrorectal cysts arising from persistent remnants of an embryonic hindgut. Malignant transformation inside this lesion is very uncommon and occurrence of neuroendocrine tumours in this context is extremely rare. We report the case of a 56-year-old woman who underwent surgical excision of a presacral tailgut cyst, which was found incidentally to include a neuroendocrine tumour.