Nonantibiotic strategies to decrease the postbiopsy hospitalization rates because of infectious complications after transrectal prostate biopsy

OBJECTIVES

To compare the effect of biopsy needle disinfection with 10% formalin solution alone and with povidone-iodine rectal cleaning on preventing infectious complications requiring hospitalization.

METHODS

The data of 902 patients who underwent prostate biopsy by transrectal route were retrospectively analyzed. Inclusion criteria were prophylactic antibiotic use and negative urine culture before the biopsy. Three groups occurred according to the methods used during the biopsy procedure. In Group 1, 501 patients, biopsy needle disinfection was made using 10% formalin solution during the biopsy procedure. Group 2, 164 patients, applied only prophylactic antibiotics. Group 3, 237 patients, applied both 10% formalin disinfection of the biopsy needle and prebiopsy povidone-iodine rectal cleansing. Hospitalized patients because of infectious complications a month after the biopsy were our outcome measures.

RESULTS

Hospitalization rates because of biopsy-related infectious complications, according to Groups 1, 2, and 3, were 2.7%, 8.5%, and 0%, respectively. The best results were observed in Group 3 and the worst in Group 2.

CONCLUSIONS

The two nonantibiotic strategies, biopsy needle disinfection with formalin solution and rectal cleaning with povidone-iodine, look more effective when applied together. However, further prospective studies are required to confirm our analysis.

Postoperative infectious complications worsen oncologic outcomes following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

BACKGROUND

Pancreaticoduodenectomy (PD) remains the only curative option for patients with pancreatic adenocarcinoma (PDAC). Infectious complications (IC) can negatively impact patient outcomes and delay adjuvant therapy in most patients. This study aims to determine IC effect on overall survival (OS) following PD for PDAC.

STUDY DESIGN

Patients who underwent PD for PDAC between 2010 and 2020 were identified from a single institutional database. Patients were categorized into two groups based on whether they experienced IC or not. The relationship between postoperative IC and OS was investigated using Kaplan-Meier and Cox-regression multivariate analysis.

RESULTS

Among 655 patients who underwent PD for PDAC, 197 (30%) experienced a postoperative IC. Superficial wound infection was the most common type of infectious complication (n = 125, 63.4%). Patients with IC had significantly more minor complications (Clavien-Dindo [CD] < 3; [59.4% vs. 40.2%, p < 0.001]), major complications (CD ≥ 3; [37.6% vs. 18.8%, p < 0.001]), prolonged LOS (47.2% vs 20.3%, p < 0.001), biochemical leak (6.1% vs. 2.8%, p = 0.046), postoperative bleeding (4.1% vs. 1.3%, p = 0.026) and reoperation (9.6% vs. 2.2%, p < 0.001). Time to adjuvant chemotherapy was delayed in patients with IC versus those without (10 vs. 8 weeks, p < 0.001). Median OS for patients who experienced no complication, noninfectious complication, and infectious complication was 33.3 months, 29.06 months, and 27.58 months respectively (p = 0.023). On multivariate analysis, postoperative IC were an independent predictor of worse OS (HR 1.32, p = 0.049).

CONCLUSIONS

IC following PD for PDAC independently predict worse oncologic outcomes. Thus, efforts to prevent and manage IC should be a priority in the care of patients undergoing PD for PDAC.

COVID-19 antibody titers after tixagevimab-cilgavimab injection in patients with hematologic diseases; a single-center, prospective study

Knowledge of the SARS-CoV-2 antibody titers induced by tixagevimab-cilgavimab in patients with hematologic diseases remains insufficient. Here, we performed a single-center, prospective study to reveal the changes in antibody titer after administration of tixagevimab-cilgavimab in 78 patients with hematologic diseases. The median peak titer was 155.4 U/mL, and the median AUC was 46556 days·U/mL. First, we compared several characteristics between patients with low titers (peak titer ≤ 155.4 U/mL) and high titers (peak titer > 155.4 U/mL). We extracted 6 factors (patient age, sex, ECOG-PS, serum albumin level, and cross-sectional area and computed tomographic number of the psoas major muscle) as candidates influencing the antibody titers. Multiple regression analysis revealed that antibody titer was closely associated with these 6 factors (contribution rate = 0.76, p = 0.02). Our data support the inability of tixagevimab-cilgavimab to induce sufficient antibody titers against SARS-CoV-2, especially in older, frailer, female patients.

Infectious Complications in Patients with Myelodysplastic Syndromes: A Report from the Düsseldorf MDS Registry

Despite notable advancements in infection prevention and treatment, individuals with hematologic malignancies still face the persistent threat of frequent and life-threatening complications. Those undergoing chemotherapy or other disease-modifying therapies are particularly vulnerable to developing infectious complications, increasing the risk of mortality. Myelodysplastic syndromes (MDS) predominantly affect the elderly, with the incidence rising with age and peaking at around 70 years. Patients with MDS commonly present with unexplained low blood-cell counts, primarily anemia, and often experience varying degrees of neutropenia as the disease progresses. In our subsequent retrospective study involving 1593 patients from the Düsseldorf MDS Registry, we aimed at outlining the incidence of infections in MDS patients and identifying factors contributing to heightened susceptibility to infectious complications in this population.

Infectious Complications in Laparoscopic Gynecologic Oncology Surgery within an ERAS-Compliant Setting

Minimally Invasive Surgery (MIS) represents a safe and feasible option for the surgical treatment of gynecologic malignancies, offering benefits, including reduced blood loss, lower complications, and faster recovery, without compromising oncological outcomes in selected patients. MIS is widely accepted in early-stage gynecologic malignancies, including endometrial cancer, cervical tumors measuring 2 cm or less, and early-stage ovarian cancer, considering the risk of surgical spillage. Despite its advantages, MIS does not rule out the possibility of adverse events such as postoperative infections. This retrospective study on 260 patients undergoing laparoscopic surgery at Parma University Hospital for gynecologic malignancies explores the incidence and risk factors of postoperative infectious complications. The Clavien-Dindo classification was used to rank postoperative surgical complications occurring 30 days after surgery and Enhanced Recovery After Surgery (ERAS) recommendations put into practice. In our population, 15 (5.8%) patients developed infectious complications, predominantly urinary tract infections (9, 3.5%). Longer surgical procedures were independently associated with higher postoperative infection risk (p = 0.045). Furthermore, C1 radical hysterectomy correlated significantly with infectious complications (p = 0.001, OR 3.977, 95% CI 1.370-11.544). In conclusion, compared to prior research, our study reported a lower rate of infectious complications occurrence and highlights the importance of adopting infection prevention measures.

[Prospective analysis of inflammatory markers and perioperative clinical data in children with craniosynostosis undergoing reconstructive surgery]

BACKGROUND

Craniosynostosis (CS) is a group of skull malformations manifested by congenital absence or premature closure of cranial sutures. Reconstructive surgery in the second half of life is traditional approach for CS. The issues of surgical stress response after reconstructive surgery for CS in children are still unclear.

OBJECTIVE

To evaluate clinical and laboratory parameters in children undergoing traumatic reconstructive surgery for CS.

MATERIAL AND METHODS

Inclusion criteria were CS, reconstructive surgery, age <24 months, no comorbidities and available laboratory diagnostic protocol including complete blood count, biochemical blood test with analysis of C-reactive protein, procalcitonin, ferritin and presepsin. The study included 32 patients (24 (75%) boys and 8 (25%) girls) aged 10.29±4.99 months after surgery between October 2021 and June 2022. Non-syndromic and syndromic forms of CS were observed in 25 (78.1%) and 7 (21.9%) cases, respectively.

RESULTS

There were no infectious complications. We analyzed postoperative clinical data, fever, clinical and biochemical markers of inflammation.

CONCLUSION

Early postoperative period after reconstructive surgery for CS in children is accompanied by significant increase of inflammatory markers (C-reactive protein, procalcitonin, ferritin). However, these findings do not indicate infectious complications. This is a manifestation of nonspecific systemic reaction. Severity of systemic inflammatory response syndrome with increase in acute phase proteins indicates highly traumatic reconstructive surgery for CS in children. Analysis of serum presepsin allows for differential diagnosis between infectious complication and uncomplicated course of early postoperative period.

Comparison of enteral immunonutrition and enteral nutrition in patients undergoing gastric cancer surgery: a systematic review and meta-analysis of randomized, controlled trials

OBJECTIVE

Enteral immunonutrition is a nutritional intervention that has been studied in postoperative patients with gastric cancer, but its effectiveness is controversial. This study aimed to investigate the effects of enteral immunonutrition and enteral nutrition on immune function in patients who undergo gastric cancer surgery.

METHODS

We performed a systematic review and meta-analysis. A comprehensive search was conducted in PubMed, Embase, Cochrane, Web of Knowledge, and ClinicalTrials.gov from the inception of the review until 10 March 2023. Twelve studies were included for qualitative and quantitative analyses.

RESULTS

We studied 1124 patients, including 565 patients in the enteral immunonutrition group and 559 in the enteral nutrition (controls) group. All included randomized, controlled trials were high quality. CD4+ levels, lymphocytes, transferrin concentrations, and systemic inflammatory response syndrome were not significantly different between the enteral immunonutrition and enteral nutrition groups. However, CD8+, immunoglobulins G and M, and proalbumin concentrations, CD4+/CD8+, and infectious complications were significantly higher in the enteral immunonutrition group than in the enteral nutrition group. A sensitivity analysis showed consistent results after excluding each study. Begg's test showed no publication bias.

CONCLUSIONS

Enteral immunonutrition is an effective nutritional intervention that improves immune function in patients who have undergone gastric cancer surgery.

Diagnostic efficacy of serum presepsin for postoperative infectious complications: a meta-analysis

Background

Postoperative infectious complications (PICs) are major concerns. Early and accurate diagnosis is critical for timely treatment and improved outcomes. Presepsin is an emerging biomarker for bacterial infections. However, its diagnostic efficacy for PICs across surgical specialties remains unclear.

Methods

In this study, a systematic search on MEDLINE, Embase, Google Scholar, and Cochrane Library was performed on September 30, 2023, to identify studies that evaluated presepsin for diagnosing PICs. PIC is defined as the development of surgical site infection or remote infection. Pooled sensitivity, specificity, and hierarchical summary receiver operating characteristic (HSROC) curves were calculated. The primary outcome was the assessment of the efficacy of presepsin for PIC diagnosis, and the secondary outcome was the investigation of the reliability of procalcitonin or C-reactive protein (CRP) in the diagnosis of PICs.

Results

This meta-analysis included eight studies (n = 984) and revealed that the pooled sensitivity and specificity of presepsin for PIC diagnosis were 76% (95% confidence interval [CI] 68%-82%) and 83% (95% CI 75%-89%), respectively. The HSROC curve yielded an area under the curve (AUC) of 0.77 (95% CI 0.73-0.81). Analysis of six studies on procalcitonin showed a combined sensitivity of 78% and specificity of 77%, with an AUC of 0.83 derived from the HSROC. Meanwhile, data from five studies on CRP indicated pooled sensitivity of 84% and specificity of 79%, with the HSROC curve yielding an AUC of 0.89.

Conclusion

Presepsin exhibits moderate diagnostic accuracy for PIC across surgical disciplines. Based on the HSROC-derived AUC, CRP has the highest diagnostic efficacy for PICs, followed by procalcitonin and presepsin. Nonetheless, presepsin demonstrated greater specificity than the other biomarkers. Further study is warranted to validate the utility of and optimize the cutoff values for presepsin.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023468358.

Acute respiratory infections among individuals seeking outpatient care in the states of Washington and Michigan by pregnancy status, 2011-2016

Background

Acute respiratory infections (ARIs) during pregnancy are associated with poor maternal and fetal outcomes.

Methods

Using U.S. Flu Vaccine Effectiveness Network data (2011-2016) from Washington and Michigan, we tested for respiratory viruses among pregnant and non-pregnant outpatients matched on age, site, and season (n = 191).

Results

Among all participants, detection of human coronaviruses and rhinovirus was common. We also observed differences in virus detection by pregnancy status; human coronaviruses and respiratory syncytial virus (RSV) were detected more frequently among pregnant and non-pregnant participants, respectively.

Conclusions

The role of respiratory viruses in maternal ARI morbidity should be further characterized to inform implementation of prevention interventions including maternal vaccines.

Recommendations on prevention of infections in patients with T-cell lymphomas: a narrative review and synthesis

T/Natural killer (NK) cell lymphomas (TCL) represent a heterogenous subgroup of non-Hodgkin lymphoma, associated with poorer prognosis and higher treatment toxicity. A cohesive synthesis of infection outcomes among TCL patients is lacking. International guidelines offer no specific recommendations regarding prophylaxis or supportive infection care for TCL patients. This systematic narrative review highlights infection outcomes in TCL patients treated with conventional, and novel therapies. Recommendations for infection screening, antimicrobial prophylaxis and vaccination strategies are outined.

Burden of Social and Behavioral Determinants of Health on Infectious Complications in Emergency General Surgery

Background: Infectious complications lead to worse post-operative outcomes and are used to compare hospital performance in pay-for-performance programs. However, the impact of social and behavioral determinants of health on infectious complication rates after emergency general surgery (EGS) remains unclear. Patients and Methods: All patients undergoing EGS in the 2019 Nationwide Readmissions Database were included. The primary outcome of the study was the rate of infectious complications within 30 days, defined as a composite outcome including all infectious complications occurring during the index hospitalization or 30-day re-admission. Secondary outcomes included specific infectious complication rates. Multivariable regression analyses were used to study the impact of patient characteristics, social determinants of health (insurance status, median household income in the patient's residential zip code), and behavioral determinants of health (substance use disorders, neuropsychiatric comorbidities) on post-operative infection rates. Results: Of 367,917 patients included in this study, 20.53% had infectious complications. Medicare (adjusted odds ratio [aOR], 1.3; 95% confidence interval [CI], 1.26-1.34; p < 0.001), Medicaid (aOR, 1.24; 95% CI,1.19-1.29; p < 0.001), lowest zip code income quartile (aOR, 1.17; 95% CI, 1.13-1.22; p < 0.001), opioid use disorder (aOR,1.18; 95% CI,1.10-1.29; p < 0.001), and neurodevelopmental disorders (aOR, 2.16; 95% CI, 1.90-2.45; p < 0.001) were identified as independent predictors of 30-day infectious complications. A similar association between determinants of health and infectious complications was also seen for pneumonia, urinary tract infection (UTI), methicillin-resistant Staphylococcus aureus (MRSA) sepsis, and catheter-association urinary tract infection (CAUTI). Conclusions: Social and behavioral determinants of health are associated with a higher risk of developing post-operative infectious complications in EGS. Accounting for these factors in pay-for-performance programs and public reporting could promote fairer comparisons of hospital performance.

Lessons learned from COVID-19 pandemic: outcomes after SARS-CoV-2 infection in hematopoietic cell transplant and cell therapy recipients

We investigated the outcomes after Coronavirus disease 2019 (COVID) in hematopoietic cell transplant (HCT) or chimeric antigen receptor-T cell (CART) therapy recipients in a single-centre study including all (n = 261)HCT/CART recipients (allogeneic-HCT 49%, autologous-HCT 40%, CART 11%). The median age was 60 (22-80) years. COVID severity was mild (74%), moderate (11%), and severe/critical (16%) with a mortality rate of 7% and a median duration of infection of 5.7 weeks. Significant predictors of COVID severe disease or mortality included concurrent infection (HR 14.9, 95% CI 2.2-5.6) and immunosuppressive therapy (OR 4.8, 95% CI 1.2-3.4).HCT/CART recipients have a higher risk of mortality with COVID and warrant vigilant interventions.

Infectious complications among CD19 CAR-T cell therapy recipients: A single-center experience

BACKGROUND

CD19 chimeric antigen receptor (CAR)-T cell therapy has emerged as an effective treatment in those with refractory or relapsed lymphoma. CD19 CAR-T cell therapy can cause direct and indirect toxic adverse effects and increased risk for infection. Infectious complications and optimal antimicrobial prophylaxis strategies are an ongoing area of investigation.

METHODS

A single-center retrospective cohort study was conducted to review recipients of CD19 CAR-T cell therapy between April 2018 and December 2020. Patient characteristics and clinical outcomes were extracted from the electronic health records.

RESULTS

Infectious complications were identified in 18/50 (36%) recipients with 31 episodes of infection. The median time to infection was 225 days (range 0-614). Bacterial infections were most common with bloodstream infection followed by sinusitis and skin and soft tissue infection. Eight viral infections were identified, most being respiratory viral illnesses. Two fungal infections were identified: Pneumocystis jirovecii pneumonia (PJP) and disseminated fusariosis. Seventeen infections (54.8%) were classified as severe: leading to death, requiring hospitalization, need for empiric intravenous antibiotics, or significant alteration in hospital course. No characteristics were found to be statistically significant risks for infection, although a trend toward significance was seen in prior autologous stem cell transplant recipients (p = .12) and those with recurrent neutropenia (p = .14). Three patients (6%) died from infection.

CONCLUSION

Infections were common after CD19 CAR-T cell therapy and occurred beyond the first year. Further multicenter studies are needed to define infectious risks and optimize antimicrobial prophylaxis recommendations in recipients of CD19 CAR-T cell therapy.

Serum Interleukin-6 as a Biomarker for Early Prediction of Post-Operative Infectious Complications After Elective Pancreatectomy

Background: To investigate whether interleukin (IL)-6 could predict the post-operative complications of elective pancreatectomy early. Patients and Methods: Overall, 122 patients who underwent elective pancreatectomy from June 2020 to May 2021 in our hospital were enrolled. Interleukin-6 was measured on the day before and at six hours after surgery, and on post-operative day one, three, and five. The associations between IL-6 level and post-operative complications were analyzed, and the predictive value of IL-6 for complications was assessed. Results: Sixty-three patients developed post-operative complications. Higher IL-6 was observed in patients with post-operative complications on post-operative day one, post-operative day three, and post-operative day five, with odd ratios of 1.43, 1.68, and 2.54 (p = 0.01, p = 0.01, and p = 0.01), respectively. These trends were also observed in patients with infectious complications preoperatively, on post-operative day one, post-operative day three, and post-operative day five, with ORs of 2.46, 1.95, 2.01, and 2.49 (p = 0.00, 0.00, 0.01, 0.00) respectively. Multivariate regression revealed that IL-6 is the only predictor for infectious complications on post-operative day one (p = 0.016). Based on the optimal cutoffs, pre-operative IL-6, IL-6 on post-operative day one and post-operative day three for predicting infectious complications yielded area under the curve (AUC) of 0.73, 0.70, and 0.70, with high negative predictive value of 82.7%, 92.2%, and of 91.3%, respectively. Conclusions: This study validated the early predictive value of IL-6 on infectious complications after pancreatectomy. Because of the performance of serum IL-6 in predicting infectious complications and high NPV, we endorse that IL-6 could be a potential biomarker for early prediction and antibiotic optimization after pancreatectomy.

The effect of probiotics on surgical outcomes in patients with gastric cancer: a meta-analysis of randomized controlled trials

The effect of probiotics on postoperative infectious complications and nutritional status in patients with gastric cancer is still controversial, and a comprehensive search and analysis of the current relevant evidence is necessary. Our study aimed to define the effects of probiotics on surgical outcomes in gastric cancer patients undergoing surgery. Up to June 20, 2023, Embase, PubMed, Web of Science, and Cochrane databases were searched for randomized controlled trials of probiotics in gastric cancer patients undergoing surgery. Relative risk (RR) or mean difference (MD) was used to calculate the effect sizes using RevMan 5.3. A total of nine studies reporting on 861 participants were included. Perioperative supplementation with probiotics did not improve weight loss (MD 0.73 kg; 95% CI: -0.56, 2.02) or serum prealbumin levels (MD 9.48 mg/L 95% CI: -3.43, 22.40), but did reduce the incidence of postoperative infectious complications (RR 0.46, 95% CI 0.28, 0.77), shorten the time to first exhaust (MD -11.27 h; 95% CI: -16.83, -5.70), the time to first defecation (MD -15.71 h; 95% CI: -25.62, -5.79), and the length of hospital stay (MD -0.94 days; 95% CI: -1.33, -0.55), and increase serum albumin levels (MD 0.73 g/L; 95% CI: 0.01, 1.46) in gastric cancer patients undergoing surgery. Probiotics are effective in preventing postoperative infectious complications, promoting postoperative recovery, and improving nutritional status in gastric cancer patients undergoing surgery. Our study highlights the importance of probiotics for healthcare systems and offers a potential strategy to improve the prognosis and reduce the medical burden of gastric cancer patients undergoing surgery.

[Infectious factor in transuretral surgery of benign prostate hyperplasia: a systematic review and meta-analysis]

PURPOSE

To assess postoperative bacteriuria and infectious complications in terms of antibiotic prophylaxis (ABP) regimens, preoperative urine bacterial status and total prostate-specific antigen (PSA) level in patients with benign prostate hyperplasia (BPH) undergoing transurethral prostate surgery.

MATERIALS AND METHODS

The PubMed, ClinicalKey, Google Scholar and the Cochrane bibliographic databases were searched from 1992 to 2022. The Mantel-Haenszel method was used to calculate the odds ratio (OR) and inverse variance method was used to calculate mean difference (MD) with 95% confidence interval (CI). Primary outcome was the development of asymptomatic bacteriuria, secondary - development of infectious complications.

RESULTS

This meta-analysis showed that ABP significantly decreased level of postoperative bacteriuria and infection complications. This meta-analysis was in favour of prolonged ABP ( more or equal 3 days) in lowering postoperative infectious complications rate compared to short regimens ( less or equal 24 hours). Preoperative bacteriuria was not significantly associated with postoperative bacteriuria level and infectious complications. Mean preoperative PSA level significantly differed in patients with and without postoperative bacteriuria.

CONCLUSION

This meta-analysis demonstrated significant gaps in the knowledge of perioperative bacterial status and antibiotic prophylaxis strategies efficacy in the group of patients undergoing transurethral prostate surgery. There is no consensus on optimal ABP regimen. Most of included studies had significant heterogeneity. Further studies are required.

Infectious complications of induction treatment for acute myeloid leukaemia using the "7 + 3" protocol without antibiotic prophylaxis - 15 years of experience of one clinical site

BACKGROUND

Infectious complications during induction chemotherapy of acute myeloid leukaemia are very common. Prophylactic use of antibiotics however is an ongoing challenge in this situation due to bacterial multi-drug resistance. The aim of this study was to provide a comprehensive overview of the incidence of infectious complications in patients with AML undergoing induction therapy using the "7+3" protocol without routine antibiotic prophylaxis at one clinical site providing specialised haematological care in the Czech Republic, over a period of 15 years. The study also evaluates the aetiological spectrum of causative agents and the development of antibiotic resistance in the context of the use of the various classes of antibiotics. The analysis includes evaluation of the importance of risk factors for infectious complications and their impact on treatment of the underlying disease. The data are compared with published figures for similar cohorts of patients.

PATIENTS AND METHODS

This study presents a retrospective analysis of infectious complications in 242 patients with acute myeloid leukaemia undergoing the first cycle of induction therapy without routine antibiotic prophylaxis in one clinical site in Czech Republic during years 2006-2020.

RESULTS

A total of 363 febrile episodes (FE) were recorded. At least 1 FE during the induction was detected in 229 (94.6%) patients. Clinically defined infection was the cause in 96 (26.4%) FEs and blood stream infection in 69 (19.0%) FEs. Both complications occurred simultaneously in 29 (8.0%) FEs. 169 (46.6%) FEs were evaluated as fever of unknown origin (FUO). The achievement of complete remission had a significant effect on the duration of the FE (6 vs. 9 days, P=0.0005) and on the overall survival duration (79.3 vs. 6.5 months, P<0.0001). Patients diagnosed with infection or FUO at diagnosis were significantly more likely to suffer from colonisation by multi-drug resistant bacterial strains at discharge (29.2% vs. 16.3%, P=0.022). This group of patients used antibiotic therapy for a significantly longer time (35 vs. 23 days, P<0.0001). Infection was a contributing cause of death in 18 (7.4%) patients. Mortality was significantly related to the failure to achieve complete remission (P<0.0001).

CONCLUSION

Infectious mortality during induction treatment without routine antibiotic prophylaxis was comparable to the published cohorts with prophylaxis. Regular microbiology surveillance with adequate initial antibiotic treatment can compensate routine antibiotic prophylaxis with slower development of antibiotic resistance.

Does mechanical bowel preparation really prevent complications after colorectal surgery depending on the lesion localization? A myth or fact?

Objectives

Despite being routinely used before elective colorectal surgery in most surgical clinics, mechanical bowel preparation (MBP) remains controversial. This study aimed to investigate postoperative complications and outcomes of right, left, or rectosigmoid resection without MBP.

Material and Methods

Patients who underwent elective colorectal surgery without mechanical bowel preparation and oral antibiotics between January 2011 and December 2021 were included in the study. Patients were categorized according to the side of resection, and these subgroups were compared for anastomotic leakage, surgical site infections (SSI), and overall morbidity measured using the Clavien-Dindo complication grade.

Results

Data of 422 patients were analyzed. Overall anastomotic leakage was found in 14 patients (3.3%), SSI in 46 (10.9%), collection in 14 (3.3%), mortality in 18 (4.3%), and reoperation in 17 (%4) patients. Anastomotic leakage was observed in six (3.9%) in right colectomy, two (1.9%) in left colectomy, and in six (3.7%) patients in the rectosigmoid resection group when the groups were evaluated separately. There was no statistical difference between the groups (p= 0.630). Furthermore, there was no statistical difference between the groups regarding collection and reoperation (p values were p= 0.31, and p= 0.251, respectively).

Conclusion

Study results showed that anastomotic leakage, surgical site infection, intra-abdominal collection, reoperation, and mortality rates were similar to the current literature obtained from the studies with mechanical bowel preparation. In addition, these results were found to be similar according to the resection site.

A Systematic Review and Meta-analysis of Rituximab-Associated Infections Among Children and Adolescents With Glomerular Disease: Focus on the Risk of Infections

OBJECTIVE

This systematic review and meta-analysis aimed to explore rituximab (RTX) associated infectious complications in children with glomerular disease.

METHODS

We performed an electronic search of PubMed, International Scientific Information (ISI), Scopus, and EMBASE between January 2010 and July 2021. Infection rates and total drug-related adverse events were the outcomes. Statistical heterogeneity was evaluated by using the I2 statistic. When there was statistical evidence of heterogeneity (I2 > 50%, p > 0.1), a random-effect model was adopted. Data analysis was performed with Stata17.0 software.

RESULTS

A total of 7 studies with 668 patients (136 with lupus nephritis [LN] and 532 with nephrotic syndrome were included in the meta-analysis. The pooled risk ratio showed that the administration of RTX was significantly associated with lower risk of infectious complications in patients with LN and nephrotic syndrome (0.72 [95% CI 0.58, 0.85]) when compared with population data of patients without glomerular disease (p = 0.2). There was no significant difference between the LN and nephrotic syndrome groups in terms of total serious adverse events or the occurrence of infections. There was significant heterogeneity among the reported studies (Q = 42.39, p < 0.001, I2 = 81%).

CONCLUSION

Administration of RTX in children with glomerular disease is associated with a lower rate of infections when compared with population data of patients without LN or nephrotic syndrome. Additional high-quality randomized controlled trials with long-term follow-up are needed to identify the long-term potential complications. Trial registration PROPERO ID: CRD42021274869 (https://www.crd.york.ac/prospero/display_record.php?).

The results of the modified St Jude Total Therapy XV Protocol in the treatment of low- and middle-income children with acute lymphoblastic leukemia

The St Jude Total Therapy Study XV was the first clinical trial to prospectively use minimal residual disease levels during and after remission induction therapy to guide risk-directed treatment. We used the Total Therapy XV protocol with minimal modification in treating 115 newly diagnosed pediatric acute lymphoblastic leukemia patients from low- and middle-income groups from January 2011 to December 2017. The mean age at diagnosis was 5.97 ± 3.96 years. The median follow-up period was 88 months. Three (2.6%) patients had bone marrow relapse, and one (0.87%) had an isolated central nervous system relapse. Nineteen of the patients (16.52%) died due to infection-related complications, three (2.61%) died due to progressive disease, and one (0.87%) died due to hematopoietic stem cell transplant complications. Five-year overall survival was 80%, and event-free survival was 78.3%. Our results showed that the Total XV treatment protocol could be used successfully in patients with ALL from low- and middle-income populations. However, infection-related deaths remain a significant problem.

Microbiota Metabolism Failure as a Risk Factor for Postoperative Complications after Aortic Prosthetics

Postoperative complications in cardiovascular surgery remain an important unresolved problem, in particular in patients with aortic aneurysm. The role of the altered microbiota in such patients is of great interest. The aim of this pilot study was to determine whether the development of postoperative complications in patients with aortic aneurysm is related with initial or acquired disorders of microbiota metabolism by monitoring the level of some aromatic microbial metabolites (AMMs) circulating in the blood before the surgery and in the early postoperative period. The study comprised patients with aortic aneurysm (n = 79), including patients without complications (n = 36) and patients with all types of complications (n = 43). The serum samples from the patients were collected before and 6 h after the end of the surgery. The most significant results were obtained for the sum of three sepsis-associated AMMs. This level was higher before the surgery in comparison with that of healthy volunteers (n = 48), p < 0.001, and it was also higher in the early postoperative period in patients with all types of complications compared to those without complications, p = 0.001; the area under the ROC curve, the cut-off value, and the odds ratio were 0.7; 2.9 µmol/L, and 5.5, respectively. Impaired microbiota metabolism is important in the development of complications after complex reconstructive aortic surgery, which is the basis for the search for a new prevention strategy.

Therapeutic efficacy and infectious complications of CD19-targeted chimeric antigen receptor-modified T cell immunotherapy

Lymphocyte depletion chemotherapy CD19-targeted chimeric antigen receptor-modified T (CAR-T) cell immunotherapy is an innovative approach for the treatment of refractory or relapsed B-cell malignancies. This method also has the occurrence of infection, and there has been no systematic analysis of infectious complications. In our study, we intend to analyze the infection in patients between day 0 and day 90 by analyzing the data of 40 patients who received CD19 CAR-T cell therapy collected in our hospital. We assessed risk factors for infection before and after treatment using Poisson and Cox regression, respectively. A cohort study was used, including patients with acute lymphocytic leukemia, chronic lymphocytic leukemia and non-Hodgkin's lymphoma. 40 patients were infected for the first time occurred at a median of 6 days after CAR-T cell infusion, and 8 (20%) had 10 infections within 28 days after CAR-T cell infusion, on days 29 and 29. The infection density between 90 days was lower at 0.67. This resulted in an infection density of 1.19 infections per 100 days. Two patients (5%) developed invasive fungal infections and two patients (5%) developed life-threatening or fatal infections. In an adjusted model for baseline characteristics, patients with ALL, ≥4 prior antitumor regimens, and receiving the highest CAR-T cell dose had higher infection densities at 28 days. The incidence of infection was comparable to that observed in clinical trials of salvage associated with infection after CAR-T cell infusion.

Infection-related mortality after HLA-identical and haploidentical hematopoietic cell transplantation using reduced-intensity conditioning in an outpatient setting

BACKGROUND

Despite the improvements in supportive care for allogeneic-hematopoietic cell transplantation (allo-HCT) recipients, infectious complications and infection-related mortality (IRM) continue to be a major issue for transplantation centers.

METHODS

We herein report the infectious complications and IRM of 107 and 89 patients that underwent haploidentical (haplo-HCT) or HLA-identical HCT at a tertiary referral center during 2013-2020. Patients in the haplo-HCT group received post-transplant cyclophosphamide (PT-Cy), and all received reduced-intensity conditioning regimens.

RESULTS

More haplo-HCT recipients presented severe infections in the pre-engraftment period (22.4% vs. 6.7%, p = 0.003). Viral (14.9% vs. 4.5%, p = 0.016) and fungal (12.1% vs. 1.1%, p = 0.003) etiologies were more common in this period in this group. The 100-day and 2-year cumulative incidence of IRM was 15% and 21% for the haplo-HCT and 5.6% and 17% for the HLA-identical group; no significant differences were observed between the groups. Fungal pathogens mainly contributed to IRM (33.3%). Infections were the most common cause of mortality (40/81, 49.4%). There were significant differences in donor/recipient CMV serostatus between transplant groups (0.002).

CONCLUSIONS

No differences in IRM were observed based on allo-HCT type, with more haplo-HCT patients suffering from severe infections in the pre-engraftment period. Studies to assess future prevention, diagnostic, and treatment strategies to reduce IRM are warranted.

Does concurrent gynaecological surgery affect infectious complications rate after mastectomy with implant-based reconstruction?

BACKGROUND

Women who undergo breast cancer surgery often have an indication for gynaecological procedure. The aim of our study was to compare infectious complications rate after mastectomy with implant-based reconstruction in patients with and without concurrent gynaecological procedure.

PATIENTS AND METHODS

We retrospectively reviewed clinical records of 159 consecutively operated patients after mastectomy with implant-based reconstruction. The patients were divided in 2 groups: 102 patients without (Group1) and 57 with (Group 2) concurrent gynaecological procedure. Infectious complications rates between the groups were compared using χ²-test. Logistic regression was performed to test for association of different variables with infectious complications.

RESULTS

There were 240 breast reconstructions performed. Median follow-up time was 297 days (10-1061 days). Mean patient age was 47.2 years (95% CI 32.8-65.9); 48.2 years (95% CI 46.1-50.3) in Group 1 and 45.8 years (95% CI 43.2-48.3) in Group 2; p = 0.002). Infectious complications rate was 17.6% (17.6% vs. 17.5%, p = 0.987), implant loss occurred in 5.7% (4.9% vs. 7.0%, p = 0.58). Obesity (body mass index [BMI] > 30 kg/m²), age, previous breast conserving treatment (BCT) with radiotherapy (RT) were identified as risk factors for infectious complications in univariate analysis. Obesity (adjusted odds ratio [aOR] 3.319, 95% CI 1.085-10.157, p = 0.036) and BCT with RT (aOR 7.481, 95% CI 2.230-25.101, p = 0.001) were independently associated with infectious complications in multivariate model.

CONCLUSIONS

Concurrent gynaecological procedure for patients undergoing mastectomy with implant-based reconstruction did not carry an increased risk for infectious complications.

The effect of povidone-iodine rectal cleansing on post-biopsy infectious complications

OBJECTIVE

To evaluate the effect of pre-biopsy povidone-iodine rectal cleansing on post-biopsy hospitalization rates due to prostate biopsy-related infectious complications.

MATERIAL AND METHODS

In this retrospective study, we reviewed 552 patients who underwent ultrasonography-guided transrectal prostate biopsy between 2014 and 2022. Group 1, 361 patients (January 2014-October 2020) were not applied povidone-iodine rectal cleansing, and group 2, 191 patients (November 2020-January 2022) were applied povidone-iodine rectal cleansing since we changed our biopsy protocol. All patients were given the same antibiotic prophylaxis, ciprofloxacin 500 mg, and ornidazole 500 mg twice daily starting 24 h before the biopsy and lasting a total of 5 days. Sodium phosphate enema was applied to all patients in the biopsy morning. The outcome was the hospitalization rates of patients because of infectious complications a month after the biopsy.

RESULTS

No patients were hospitalized in the povidone-iodine rectal cleansing group because of biopsy related complications. The hospitalization rate of group 1 was 3% and there was a statistical difference between groups.

CONCLUSION

The povidone-iodine solution is cheap, safe and easy to apply. The povidone-iodine rectal cleansing method seems to decrease infectious complications related to prostate biopsy procedure, but we need a randomized controlled trial to confirm our study.

TRIAL REGISTRATION

We got permission for this retrospective study from the Karabuk university ethics council with the number 2021/649 on 1 October 2021.

DEMOGRAPHICS TO DEFINE PEDIATRIC BURN PATIENTS AT RISK OF ADVERSE OUTCOMES

ABSTRACT

Background: There is currently no standard definition of a severe burn in the pediatric patient population to identify those at higher risk of infectious complications. Our aim was to correlate total burn surface area (TBSA), burn depth, and type of burn injury to nosocomial infection rates and systemic immune system responses to better define risk factors associated with adverse outcomes. Methods: A prospective observational study at a single-center, quaternary-care, American Burn Association-verified pediatric burn center was conducted from 2016 to 2021. Blood was collected within 72 h of injury from 103 pediatric patients. Whole blood was incubated with lipopolysaccharide or phytohemagglutinin stimulation reagent to measure innate and adaptive immune response, respectively. Flow cytometry was performed on whole blood samples to measure both innate and adaptive immune cells. Unstimulated plasma was also extracted, and IL-6 and IL-10 as well as soluble proteins B- and T-lymphocyte attenuator, CD27, and T-cell immunoglobulin mucin 3 were quantified. Results: There was a significant increased risk for nosocomial infection in pediatric patients with TBSA burns of ≥20%, full-thickness burn injuries ≥5%, or flame burn injuries. There was an overall decrease in both innate and adaptive immune function in patients with TBSA burns ≥20% or full-thickness burn injuries ≥5%. Both burn injury characteristics were also associated with a significant increase in unstimulated IL-6 and IL-10 and soluble immunoregulatory checkpoint proteins. We observed a significant decrease in soluble B- and T-lymphocyte attenuator for those with a flame injury, but there were no other differences between flame injury and scald/contact burns in terms of innate and adaptive immune function. Conclusion: Burns with ≥20% TBSA or ≥5% full thickness in pediatric patients are associated with systemic immune dysfunction and increased risk of nosocomial infections.

Elevated serum total IgE is associated with eczema exacerbation in children hospitalized for atopic dermatitis

BACKGROUND/OBJECTIVES

Atopic dermatitis (AD) can be a debilitating skin condition, often leading to hospitalization due to severe AD exacerbations or infectious complications. As both AD exacerbations and infectious complications can present similarly, it can be difficult to distinguish the two conditions. Thus, we aimed to evaluate if there is any difference in serum IgE levels in children with AD who were hospitalized for AD exacerbation and for AD-associated infectious complications.

METHODS

A retrospective chart review was performed on hospitalized children with AD exacerbations and AD-associated infectious complications over a 17-year span. Data including length of stay, primary diagnosis, systemic antibiotics, laboratory, and bacterial culture results were collected. Serum total immunoglobulin E (IgE) levels were adjusted by age. Age, length of stay, total IgE levels, and age-adjusted IgE levels were compared using t-test. Logistic regression was used for age-adjusted IgE levels.

RESULTS

The mean serum total IgE level in subjects with AD exacerbation was 9603 ± 15,873 kU/L, which was significantly higher than that of subjects with infectious complications at 3167 ± 5486 kU/L (p = .029). Logistic regression revealed that subjects with an age-adjusted IgE of >4 had more than 3-fold odds of having AD exacerbation than infectious complications.

CONCLUSIONS

Our results suggest that total IgE levels are higher in children who were hospitalized for AD exacerbation than those with AD-associated infectious complications.

Kidney Transplantation in a Patient Affected by Sickle Cell Trait: A Case Report and State-of-the-Art Review

Chronic kidney disease (CKD) is a common feature of sickle cell disease (SCD). The awareness of the clinical presentation and renal involvement in patients affected by hemoglobinopathies is greatly needed. Patient management is particularly complex, especially with kidney transplantation. We, therefore, report the case of a 56-year-old patient affected by sickle cell trait who underwent kidney transplantation. This case will underline all the various challenges the nephrologist must face in this clinical setting and their management.

[Surgical management of tracheal anastomosis failure and risk of arterial bleeding]

OBJECTIVE

To determine the optimal algorithm for tracheal anastomotic insufficiency and prevention of arterial bleeding.

MATERIAL AND METHODS

We present 2 patients with defects of tracheal anastomosis after tracheal resection and divergence of tracheal edges. We primarily analyzed appropriate emergency care and prevention of subsequent severe complications such as arterial bleeding and respiratory insufficiency.

CONCLUSION

Tracheostomy may be preferable for complete late tracheal anastomotic insufficiency to restore breathing. However, surgery should be accompanied by prevention of arterial bleeding. Isolation of damaged area, particularly tracheostomy tube, from the mediastinum by well-vascularized tissues can prevent bleeding from major vessels (for example, innominate artery). Follow-up is unreasonable due to worsening of clinical situation, risk of hemorrhagic complications and fatal outcomes. General satisfactory clinical status of the patient is not of matter. Repeated tracheal anastomosis is justified only for early insufficiency, i.e. within 2-3 days when postoperative inflammation is mild.

EBUS-TBNA-INDUCED PURULENT PERICARDITIS: A RARE COMPLICATION OF A COMMON PROCEDURE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a diagnostic tool used to investigate mediastinal lesions. It has a good safety profile, but there are rare accounts of potentially deadly complications. The present article describes one such complication: pericardial empyema. A 70-year-old man underwent EBUS-TBNA for the differential diagnosis of a pulmonary mass with multiple mediastinal adenopathies. Two weeks after the procedure he developed chest pain, shortness of breath and fever, with rapid progression to hypotension, tachycardia and low peripheral saturation. He was diagnosed with purulent pericarditis with cardiac tamponade. Pericardial drainage and antibiotic therapy were employed with successful recovery from obstructive disease and septic shock.

LEARNING POINTS

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has a good safety profile and is used to investigate peritracheal and peribronchial lesions, but severe complications have occurred so prophylactic measures should be implemented.Risk factors for infections due to EBUS-TBNA have not been properly established, but the presence of necrotic or cystic lesions and an elevated number of punctures during TBNA seem to be relevant.Although severe complications are rare, awareness of their existence may allow faster diagnosis and, consequently, a better prognosis.

[On the issue of forensic evaluation of mandibular fractures complicated with infections]

The analysis of 387 cases of mandibular fractures complicated by posttraumatic infections is presented. These infections were quite diverse - from local suppuration of soft tissues surrounding the fracture to widespread processes affecting fatty tissue planes, including the anterior and posterior mediastinum. Infectious complications determine the injury outcome in each case - recovery, disability, or death. Two clinical observations with lethal outcomes are described.

Effect of Perioperative Blood Transfusions and Infectious Complications on Inflammatory Activation and Long-Term Survival Following Gastric Cancer Resection

Background: The aim of this study was to evaluate the impact of perioperative blood transfusion and infectious complications on postoperative changes of inflammatory markers, as well as on disease-free survival (DFS) in patients undergoing curative gastric cancer resection. Methods: Multicenter cohort study in all patients undergoing gastric cancer resection with curative intent. Patients were classified into four groups based on their perioperative course: one, no blood transfusion and no infectious complication; two, blood transfusion; three, infectious complication; four, both transfusion and infectious complication. Neutrophil-to-lymphocyte ratio (NLR) was determined at diagnosis, immediately before surgery, and 10 days after surgery. A multivariate Cox regression model was used to analyze the relationship of perioperative group and dynamic changes of NLR with disease-free survival. Results: 282 patients were included, 181 in group one, 23 in group two, 55 in group three, and 23 in group four. Postoperative NLR changes showed progressive increase in the four groups. Univariate analysis showed that NLR change > 2.6 had a significant association with DFS (HR 1.55; 95% CI 1.06−2.26; p = 0.025), which was maintained in multivariate analysis (HR 1.67; 95% CI 1.14−2.46; p = 0.009). Perioperative classification was an independent predictor of DFS, with a progressive difference from group one: group two, HR 0.80 (95% CI: 0.40−1.61; p = 0.540); group three, HR 1.42 (95% CI: 0.88−2.30; p = 0.148), group four, HR 2.85 (95% CI: 1.64−4.95; p = 0.046). Conclusions: Combination of perioperative blood transfusion and infectious complications following gastric cancer surgery was related to greater NLR increase and poorer DFS. These findings suggest that perioperative blood transfusion and infectious complications may have a synergic effect creating a pro-inflammatory activation that favors tumor recurrence.

Infection Risk in Patients with Dermatomyositis Associated with Anti-MDA5 Antibodies: A Historical Cohort Study

Objective: Dermatomyositis associated with anti-MDA5 autoantibodies (DM-MDA5+) is a rare autoimmune disease usually characterized by skin involvement, often-severe lung involvement, and general features. Several reports of infections have been described, sometimes early after the introduction of immunosuppressive therapy. We studied the infection risk in a DM-MDA5+ population. Methods: A retrospective cohort study comparing the number and type of infections during the follow-up of 19 patients with DM-MDA5+ and 37 patients with another type of inflammatory myopathy was analyzed. Patients in both groups were matched on initial immunosuppressive therapy. We described and compared significant infectious complications (SIC) in each group. Results: Patients DM-MDA5+ had more SIC: 27 events in the DM-MDA5+ group versus 6 in the controls (HR 7.08, 95% CI 2.50−20.04, p < 0.0001). The number of SIC per patient was higher in DM-MDA5+ (1.4 ± 1.57 vs. 0.16 ± 0.44, p < 0.001). These were mainly lung (n = 13, 48%) and skin infections (n = 6, 22%), more often infections of an undetermined infectious agent (n = 11, 41%) or of bacterial origin (n = 9, 33%). A few cases of opportunistic infections were reported. The median duration of follow-up without SIC event in the DM-MDA5+ cohort was 3.5 months. Conclusion: Patients with DM-MDA5+ have an increased infection risk compared to others inflammatory myopathies irrespective of immunosuppressive therapy exposure. These results highlight the importance of monitoring for infection during patient follow-up.

Therapeutic Options in Refractory Evans Syndrome: A Case Report

Evans syndrome is a rare autoimmune disease, characterized by at least two immune cytopenias, most frequently anemia and thrombocytopenia and rarely immune neutropenia. It has a variable clinical presentation and is rarely diagnosed in adults. It can be idiopathic or secondary to lymphoproliferative disease, infections, autoimmune diseases, drugs, and immunodeficiencies in about 50% of cases. It is characterized by a chronic, relapsing, potentially fatal course due to its hemorrhagic complications as well as complications associated with the long-term immunosuppressive treatment required to control the disease, such as infectious diseases, and cardiovascular and renal complications. Its prognosis depends on the underlying cause. Because of its rarity, the treatment is empirical, based mostly on case series and recommendations for the treatment of other immune cytopenias. The underlying disease and demographic characteristics also play an important role in choosing the treatment, which should be adapted individually to each patient. We present a case of an elderly patient with idiopathic autoimmune hemolytic anemia and thrombocytopenia, refractory to various treatment options.

Complications of Percutaneous Peritoneal Dialysis Catheter

A functional peritoneal dialysis (PD) catheter is the cornerstone for the success of renal replacement therapy. This success is largely dependent on adhering to best practices during catheter insertion, which starts with a comprehensive preoperative evaluation that helps in determining the catheter configuration type and both entry and exit sites. Additionally, following the best practice guidelines during PD catheter insertion minimizes undesirable complications and provides a durable functional access for dialysis. However, adverse complications are still encountered despite abiding with these clinical guidelines. These complications are categorized into mechanical and infectious groups. The description and management of these adverse events are discussed in detail in this article with particular attention to the technical pitfalls that can occur during catheter insertion. Avoiding these pitfalls can minimize PD catheter complications and potentially improve clinical outcomes.

Anaesthesia for non-cardiac surgical procedures in patients after heart transplantation

Over the last 5 years, around 75 heart transplantations a year have been performed in the Czech Republic. According to these data and longer survival of these patients, it is obvious that non-cardiac surgical procedures in this particular group of patients are not rare. In the patients after heart transplantation, there is a significantly higher risk of undergoing elective and emergency surgical procedures due to various reasons. Appropriate anaesthesia and perioperative care are fundamentally affected by the knowledge of pathophysiological and pharmacological differences of transplanted heart. An equally important aspect is a lifetime immunosuppressive therapy in these patients.

Antibiotic therapy of postoperative bronchopneumonia in patients after lung resections - single-site experience

INTRODUCTION

Infectious complications after lung surgery are the most important factor that affects mortality and morbidity, prolongs hospital stays and increases financial costs. According to various sources, 30-day mortality after lung resections reaches 123%. Infectious complications account for 2075% of overall mortality. The infections most often present as postoperative pneumonia (POP), and their treatment is based on empirical and targeted antibiotic therapy. Any time lag in initiating effective antibiotic therapy significantly increases morbidity and mortality. Postoperative pneumonia is defined according to current guidelines of the American Thoracic Society of 2016 as nosocomial or ventilator pneumonia in patients after surgery.

METHODS

Evaluation of risk factors, infectious agents, morbidity and mortality in patients after lung resections at a single site in the period from 1 January 2018 to 31 December 2019.

RESULTS

Of our group of 190 patients, 21 (11.1%) patients had POP which was severe in 6 (33% with POP) patients, and 11 patients with POP required artificial oxygenation for saturation below 92%. Two patients with POP had to be intubated for respiratory failure, and 3 patients required noradrenaline circulatory support. One patient with severe POP died of multiorgan failure after developing refractory sepsis.

CONCLUSION

Early identification of lung infection and early initiation of POP therapy are critical points for reducing morbidity and mortality after lung resections. Advanced antibiotic regimens for POP stratify the risk of mortality and infection with multidrug-resistant bacterial strains. However, the regimes require modification according to the epidemiological situation at the site with individualization of the specific procedure. Other research tasks include identification of valid markers of the initial stages of infection, and targeting of antibiotic therapy according to risk stratification and the relationship with physiological flora.

Perioperative antimicrobial prophylaxis in patients undergoing pancreatoduodenectomy: retrospective analysis of bacteriological profile and susceptibility

BACKGROUND

Pancreatic tumours are frequently associated with obstructive jaundice requiring preoperative biliary drainage (PBD) before pancreatoduodenectomy (PD), exposing patients to infectious complications. This study aims to compare postoperative complications after PD with or without PBD and to analyse bile bacteriology and antibiotic susceptibility.

METHODS

All patients undergoing PD between 2014 and 2019 were retrospectively evaluated, and postoperative outcomes were compared according to PBD use. Prophylactic narrow-spectrum antibiotic therapy was given for 24 h, then adapted according to bacteriologic profile. Intraoperative bile cultures and antibiograms were collected.

RESULTS

Among 164 patients with intraoperative bile culture during PD (75 PBD+, 89 PBD-), an infected bile was observed in 95% and 70% of PBD + and PBD- groups, respectively (p < 0.001). Postoperative mortality and severe morbidity including infectious complications were similar between groups (5% and 15%). The median duration of antibiotherapy was longer in PBD + compared to PBD- groups (9 vs. 2 days, p = 0.009). Malignant indication and PBD were associated with bile contamination using univariate analysis, and PBD was significantly relevant at multivariate analysis. Most common pathogens identified in bile cultures were Escherichia coli, Klebsiella spp. and Enterobacter spp. Overall antibiotic susceptibility to commonly used antibiotics was decreased, including those used in our local guidelines.

CONCLUSIONS

PBD exposes nearly 100% of patients undergoing PD to bile infection and an increased duration of postoperative antimicrobial therapy, without increasing infectious complications in this study. Adaptation of antimicrobial prophylaxis should be further evaluated according to performance of PBD and local epidemiology, in order to avoid overuse of antibiotics.

Complications after appendectomy in patients with treated appendicitis: results from a retrospective study

BACKGROUND

This study was designed to provide additional insights into the incidence of appendectomy complications in patients with appendicitis.

METHODS

A total of 619 patients who underwent appendectomy for appendicitis between 2014 and 2020 were recruited. Preoperative patient data and details of postoperative complications were collected. Comparisons between simple and complex appendicitis were obtained via univariate and multivariate analyses of the outcomes.

RESULTS

Simple and complex appendicitis was diagnosed in 192 and 427 patients, respectively. Twenty-eight patients with simple appendicitis developed complications, and 14 of these were infectious complications. In patients with complex appendicitis, 65 patients developed complications, and 55 of these were infectious complications. Infectious complications were identified as the largest proportion of complications. The significant risk factor for infectious complications in simple appendicitis was American Society of Anesthesiologists (ASA) grade [odds ratio (OR) =7.843, 95% confidence interval (CI): 1.987-30.955, P=0.003]. ASA grade (OR =1.992, P=0.032) and positive bacterial culture (OR =4.019, 95% CI: 1.809-8.933, P=0.001) were significantly related to infectious complication in complex appendicitis.

CONCLUSIONS

This study showed that appendectomy is not always a routine operation with few complications. There was a relatively high rate of complications in patients with appendicitis, which were mostly infectious complications. A higher ASA grade correlated with infectious complication. In some cases of complex appendicitis, patients with positive bacterial culture may have had a greater risk of infectious complications.

Infections in secondary immunodeficiency patients treated with Privigen® or Hizentra®: a retrospective US administrative claims study in patients with hematological malignancies

B cell-derived lymphoproliferative disorders are associated with secondary immunodeficiency (SID); some patients require immunoglobulin replacement therapy (IgRT) to mitigate infections. Using IQVIA's PharMetrics^® Plus database, patients with SID who received IgPro10/IgPro20 in the 12 months post-diagnosis (IgRT users) were matched to patients with SID not receiving IgRT (non-IgRT users). The risk of severe infection was compared using within-patient change from baseline to follow-up as well as between cohorts. Overall, 277 IgRT users were matched to 1019 non-IgRT users. Before IgRT, more IgRT users experienced any bacterial infection (88.4% vs. 72.9%; p<.0001) or ≥1 severe bacterial infection (SBI) (42.2% vs. 31.8%; p=.0011) vs. non-IgRT users. During follow-up, risk of SBI among IgRT users (21.7%) reached parity with non-IgRT users (21.2%). IgRT was associated with a reduction in SBIs to levels comparable with the lower 'baseline infection risk' of non-IgRT users. These criteria help define SID patients who may benefit from IgRT.

Pulmonary Complications After Pediatric Stem Cell Transplant

The number of disorders that benefit from hematopoietic stem cell transplantation (HSCT) has increased, causing the overall number of HSCT to increase accordingly. Disorders treated by HSCT include malignancy, benign hematologic disorders, bone marrow failure syndromes, and certain genetic diagnoses. Thus, understanding the complications, diagnostic workup of complications, and subsequent treatments has become increasingly important. One such category of complications includes the pulmonary system. While the overall incidence of pulmonary complications has decreased, the morbidity and mortality of these complications remain high. Therefore, having a clear differential diagnosis and diagnostic workup is imperative. Pulmonary complications can be subdivided by time of onset and whether the complication is infectious or non-infectious. While most infectious complications have clear diagnostic criteria and treatment courses, the non-infectious complications are more varied and not always well understood. This review article discusses pulmonary complications of HSCT recipients and outlines current knowledge, gaps in knowledge, and current treatment of each complication. This article includes some adult studies, as there is a significant paucity of pediatric data.

Modified Frailty Index-5 Score and Post-Operative Infectious Complications in Patients Undergoing Surgery for Intestinal-Cutaneous Fistula: A Nationwide Retrospective Cohort Analysis

Background: Post-operative infectious complications after repair of intestinal-cutaneous fistulas (ICF) represent a substantial burden and these outcomes vary widely in the literature. We aimed to evaluate the use of the modified frailty index-5 (mFI-5) to account for physiologic reserve to predict infectious complications in patients with ICF undergoing operative repair. Methods: We used the American College of Surgeon National Surgical Quality Improvement Program (ACS-NSQIP) 2006-2017 dataset to include patients who underwent ICF repair. The main outcome measure was 30-day infectious complications (surgical site infection [SSI], sepsis, pneumonia, and urinary tract infection [UTI]). The risk of 30-day post-operative infectious complications was assessed based on mFI-5 score. We performed multivariable logistic regression analyses to evaluate the association between infectious complications and mFI-5. Results: We identified 4,197 patients who underwent an ICF repair. The median age (interquartile range [IQR]) was 57 (46, 67) years, and the majority of patients were female (2,260; 53.9%); white (3,348; 79.8%); and 1,586 (38.3%) were obese. After adjustment for relevant confounders such as baseline patient characteristics, and operative details, mFI-5 was independently associated with infectious complications (odds ratio [OR], 2.00; 95% confidence interval [CI], 1.25-3.21), particularly SSI (OR, 2.16; 95% CI, 1.28-3.63) and pneumonia (OR, 5.31; 95% CI, 2.29-12.35), but not UTI or sepsis. Conclusions: We showed that the mFI-5 is a strong predictor of infectious complications after ICF repair. It can be utilized to account for physiologic reserve, therefore reducing the variability of outcomes reported for ICF repair.

Impact of Type of Postoperative Complications on Long-Term Survival of Gastric Cancer Patients: Results From a High-Volume Institution in China

BACKGROUND

This study aimed to evaluate the impact of postoperative complication and its etiology on long-term survival for gastric cancer (GC) patients with curative resection.

METHODS

From January 2009 to December 2014, a total of 1,667 GC patients who had undergone curative gastrectomy were analyzed. Patients with severe complications (SCs) (Clavien-Dindo grade III or higher complications or those causing a hospital stay of 15 days or longer) were separated into a "complication group." Univariate and multivariate analyses were performed to reveal the relationship between postoperative complications and long-term survival. A 2:1 propensity score matching (PSM) was used to balance baseline parameters between the two groups.

RESULTS

SCs were diagnosed in 168 (10.08%) patients, including different etiology: infectious complications (ICs) in 111 (6.66%) and non-infectious complications (NICs) in 71 (4.26%) patients. Multivariate analysis showed that presence of SCs (P=0.001) was an independent prognostic factor for overall survival, and further analysis by complication type demonstrated that the deteriorated overall survival was mainly caused by ICs (P=0.004) rather than NICs (P=0.068). After PSM, patients with SCs (p=0.002) still had a significantly decreased overall survival, and the presence of ICs (P=0.002) rather than NICs (P=0.067) showed a negative impact on long-term survival.

CONCLUSION

Serious complications, particularly of an infectious type, may have a negative impact on overall survival of GC patients. However, additional multicenter prospective studies with larger sample size are required to verify this issue.

[Prosthetic repair of the aorta with a cadaveric homograft for infection of bifurcated synthetic vascular prosthesis]

Infection of arterial vascular grafts is a rare but utterly severe complication in vascular surgery. Therapeutic policy in patients with graft infection has not been standardized, to be determined individually. One of the variants of surgical treatment is considered to be repeat aortic repair using a cadaveric graft. Presented in the article is a clinical case report concerning a 60-year-old male patient previously subjected to aortofemoral bifurcation bypass grafting with stage IV ischaemia of lower limbs according to the Pokrovsky-Fontaine classification. In the early postoperative period the events of critical ischaemia were not arrested. Due to the presence of a block of the femoropopliteal segment, as the second stage 3 days after the primary operation, the patient underwent autovenous femoropopliteal bypass grafting with a reversed autovein above the knee-joint fissure. The clinical course of critical ischaemia of the limb was relieved. During subsequent 8 months of follow up his state remained stable. Eight months after the primary operation he developed purulent discharge from the postoperative scar on the left femur. In the setting of the Purulent Surgery Department, the patient was emergently subjected to opening and drainage of the abscess of the postoperative scar. On the bottom of the wound there was a freely lying branch of a synthetic vascular prosthesis. Computed tomography revealed infection of the entire synthetic prosthesis and aneurysms of distal anastomoses. Given extremely high risk for the development of arrosive haemorrhage, a decision was made on operative treatment - repeat prosthetic repair of the abdominal aorta with a cadaveric allograft. At the Vascular Department of the Clinic of Faculty Surgery, laparotomy was performed, with removal of the infected graft, followed by debridement of the retroperitoneal space and repeat aortofemoral bifurcation prosthetic repair of the abdominal aorta with a cadaveric allograft. The wound healed with first intention. There was no evidence of infectious process relapse. The patient was discharged on postoperative day 15 in a satisfactory condition. The duration of follow up amounted to 6 months. The control examination showed that the pain-free walking distance was 500 m. Doppler ultrasonography demonstrated that the graft was functioning, with no signs of either anastomotic aneurysms or suppuration of the retroperitoneal space.

Perioperative Immunonutrition in Elderly Patients Undergoing Total Hip and Knee Arthroplasty: Impact on Postoperative Outcomes

BACKGROUND

Arthroplasties in elderly patients are surgeries performed to ensure their quality of life. Perioperative care with specific nutrients can improve nutrition status and metabolic response to orthopedic surgeries, such as total knee arthroplasty (TKA) and total hip arthroplasty (THA).

METHODS

Retrospective study with elderly patients divided into 2 groups: control and immunonutrition. The immunonutrition group was instructed to start oral intake of the nutrition supplement 5 days before and to resume it 5 days after arthroplasty (200 mL, 3 times per day). The following were analyzed as primary and secondary outcomes: length of stay (LOS), infectious and noninfectious complications, need for intensive care unit (ICU), transfusion requirement, and C-reactive protein.

RESULTS

A total of 3015 elderly patients met the inclusion criteria: control group (n = 1398) and immunonutrition group (n = 1617). Overall, 81.2% were women and mean age was 72.6 ± 6.9 years. Immunonutrition group had a shorter LOS in hours (32.0 ± 19.4 vs 56.0 ± 26.4; P < .001) and lower rates of infectious complications (2.2% vs 4.6%; P < .001). Noninfectious complications and need for ICU also had lower rates in the immunonutrition group. In the logistic regression analysis, immunonutrition reduced the chance of infectious complications by 55% (odds ratio [OR], 0.45; 95% CI, 0.30-0.68; P < .001) even after adjusting for variables (OR, 0.45; 95% CI, 0.28-0.71; P < .001).

CONCLUSION

Perioperative immunonutrition in elderly patients undergoing THA or TKA may shorten postoperative LOS and reduce infectious and noninfectious complications and transfusion requirement.

Infectious complications of CAR T-cell therapy: a clinical update

Chimeric antigen receptor (CAR) T-cell therapy is a revolutionary treatment modality used to treat haematological malignancies. Lymphocytes are engineered to produce CARs directed towards tumour cell antigens. Clinical trials have demonstrated impressive malignancy-related outcomes. Unfortunately, numerous off-target effects can cause toxicity-related adverse events in this population, the main being cytokine release syndrome and immune effector cell neurotoxicity syndrome. This causes significant patient morbidity and poor outcomes. Patients who receive CAR T-cell therapy are also profoundly immunosuppressed and often cytopenic, which is caused by a multitude of patient- and treatment-related factors. Thus, infection-related complications are also common in this group. Indeed, up to one third of patients will suffer a serious bacterial infection in the first 30 days after therapy. Viral respiratory tract infection appears to be the most common during the late phase and can be severe; one patient has died of influenza A infection. Fungal infection and cytomegalovirus (CMV) reactivation appear to be uncommon. Although institutional guidelines on infection-prevention strategies are available, there is a dearth of evidence to support their approach. Future research needs to target important unanswered questions that remain in this patient population in order to improve their short- and long-term outcomes.

Combination therapy of Tocilizumab and steroid for management of COVID-19 associated cytokine release syndrome: A single center experience from Pune, Western India

Cytokine release syndrome (CRS) or cytokine storm is thought to be the cause of inflammatory lung damage, worsening pneumonia and death in patients with COVID-19. Steroids (Methylprednislone or Dexamethasone) and Tocilizumab (TCZ), an interleukin-6 receptor antagonist, are approved for treatment of CRS in India. The aim of this study was to evaluate the efficacy and safety of combination therapy of TCZ and steroid in COVID-19 associated CRS.This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India between April 2 and November 2, 2020. All patients administered TCZ and steroids during this period were included. The primary endpoint was incidence of all cause mortality. Secondary outcomes studied were need for mechanical ventilation and incidence of systemic and infectious complications. Baseline and time dependent risk factors significantly associated with death were identified by Relative risk estimation.Out of 2831 admitted patients, 515 (24.3% females) were administered TCZ and steroids. There were 135 deaths (26.2%), while 380 patients (73.8%) had clinical improvement. Mechanical ventilation was required in 242 (47%) patients. Of these, 44.2% (107/242) recovered and were weaned off the ventilator. Thirty seven percent patients were managed in wards and did not need intensive care unit (ICU) admission. Infectious complications like hospital acquired pneumonia, blood stream bacterial and fungal infections were observed in 2.13%, 2.13% and 0.06% patients respectively. Age ≥ 60 years (P = .014), presence of co-morbidities like hypertension (P = .011), IL-6 ≥ 100 pg/ml (P = .002), D-dimer ≥ 1000 ng/ml (P < .0001), CT severity index ≥ 18 (P < .0001) and systemic complications like lung fibrosis (P = .019), cardiac arrhythmia (P < .0001), hypotension (P < .0001) and encephalopathy (P < .0001) were associated with increased risk of death.Combination therapy of TCZ and steroids is likely to be safe and effective in management of COVID-19 associated cytokine release syndrome. Efficacy of this anti-inflammatory combination therapy needs to be validated in randomized controlled trials.

Cyclophosphamide induction dose and outcomes in ANCA-associated vasculitis with renal involvement: A comparative cohort study

ABSTRACT

Treatment of ANCA-associated vasculitis (AAV) improved over the last decades but disease-unspecific agents such as cyclophosphamide are still associated with serious adverse events, including high rates of infectious complications and malignancy with increased mortality.In this comparative cohort study, we included 121 AAV patients with renal involvement from 2 German vasculitis centers. Patients were separated into subsequent groups: 2.5 to 3 g vs >3 g cumulative cyclophosphamide induction dose. We investigated if a cyclophosphamide induction dose of 2.5 to 3 g could maintain efficacy while minimizing adverse events in AAV patients with renal involvement.Patients with 2.5 to 3 g vs >3 g cumulative cyclophosphamide (median 3.0 g vs 5.5 g, P < .001) had a comparable time to remission (median 4.0 vs 3.8 months, log-rank P = .87) with 90.6% and 91.5% achieving remission after 12 months. Refractory disease was low in both groups (median 3.6% vs 6.2%, P = .68) and relapse rate did not differ (median 36% vs 42%, log-rank P = .51). Kidney function was comparable at disease onset in both groups (eGFR, mean ± SD 29 ± 20 mL/min/1.73 m2 vs 35 ± 26 mL/min/1.73 m2, P = .34) and improved after 2 years irrespective of the cyclophosphamide dose (ΔeGFR, mean ± SD +8.9 ± 1.4 mL/min/1.73 m2 vs +6.0 ± 1.1 mL/min/1.73 m2, P = .33). The 2.5-3 g group had a lower rate of leukopenia (HR = 2.73 [95% CI, 1.2-6.3], P = .014) and less infectious episodes per patient (median 1.2 vs 0.7, P = .012), especially urinary tract infections (HR = 2.15 [95% CI, 1.1-4.5], P = .032).A cyclophosphamide induction dose of 2.5 to 3 g was able to induce remission and prevent from relapses with fewer cases of leukopenia and less infectious episodes during follow-up. Especially elderly AAV patients who are particularly susceptible to infectious complications could benefit from minimizing dosing regimens with maintained efficacy to control disease activity.

Impacts of single nucleotide polymorphisms in Fc gamma receptor IIA (rs1801274) on lung transplant outcomes among Japanese lung transplant recipients

This study aimed to analyze the influences of single nucleotide polymorphisms (SNPs) in Fc gamma receptor IIA (FCGR2A) on postoperative outcomes after lung transplantation (LTx). We enrolled 191 lung transplant recipients (80 undergoing living-donor lobar lung transplants [LDLLTs] and 111 undergoing deceased-donor lung transplants [DDLTs]) in this study. We identified SNPs in FCGR2A (131 histidine [H] or arginine [R]; rs1801274) and reviewed the infectious complication-free survival after ICU discharge. The SNPs in FCGR2A comprised H/H (n=53), H/R (n=24), and R/R (n=3) in LDLLT, and H/H (n=67), H/R (n=42), and R/R (n=2) in DDLT. Recipients with H/H (H/H group) and those with H/R or R/R (R group) were compared in the analyses of infectious complications. In multivariate analyses, the R group of SNPs in FCGR2A was associated with pneumonia-free survival (HR: 2.52 [95% confidence interval {CI}: 1.35-4.71], p=0.004), fungal infection-free survival (HR: 2.50 [95% CI: 1.07-5.84], p=0.035), and cytomegalovirus infection-free survival (HR: 2.24 [95% CI: 1.07-4.69], p=0.032) in LDLLT but it was not associated with infectious complication-free survival in DDLT. Therefore, in LDLLT, more attention to infectious complications might need to be paid for LTx recipients with H/R or R/R than for those with H/H.