30-day Infection Research Articles

Implementing Change Through an Outpatient Antibiotic Stewardship Program.

We sought to implement a multi-pronged behavioral intervention to reduce and tailor antibiotic use for two common urologic outpatient procedures. This study was a non-blinded intervention study that consisted of a pre-intervention phase (11/2018-1/2019), an intervention phase (1/2020-12/2020) in which a multi-pronged behavioral intervention was implemented, and a post-intervention phase (1/2021-3/2021). We examined antibiotic use for cystoscopy and transrectal prostate biopsy at three separate urologic outpatient clinics. A multi-pronged behavioral intervention consisted of formal physician education, modification of the electronic health order sets, clinic staff education, literature review, development and introduction of patient questionnaires, and individual audit feedback. The primary outcome was 30-day infections. Secondary outcomes were adherence to the recommended antibiotic protocols, questionnaire completion, and Escherichia coli outpatient antibiograms. A total of 2374 patients underwent 3047 cystoscopies and 547 patients underwent 559 prostate biopsies. The proportions of cystoscopy patients receiving antibiotic prophylaxis and prostate biopsy patients receiving augmented antibiotic prophylaxis decreased 33% and 35%, respectively. The odds of post-cystoscopy infection were not different between the pre-intervention and intervention phases and were lower in the post-intervention phase. The odds of post-biopsy infection were not changed between the pre-intervention and intervention or between the pre-intervention and post-intervention phases. Implementing a multi-pronged behavioral intervention reduced and tailored antibiotic use without an increase in 30-day infections. These findings suggest that outpatient antibiotic stewardship and facilitating rapid adoption of guidelines can be accomplished via this approach.

Outcomes of total knee replacement versus unicompartmental knee arthroplasty in an enhanced recovery after surgery protocol

IntroductionUnicompartmental Knee Arthroplasty (UKA) has become popular due to faster recovery and improved range of motion. However, concerns have been made regarding increased risk of early failure. Furthermore, the use of Enhanced Recovery After Surgery (ERAS) protocols have shown to allow faster return to activities, improved satisfaction, and reduced complication rates.This study aims to compare the 6 month functional outcomes of patients undergoing Total Knee Replacement (TKR) versus UKA under the ERAS protocol. MethodsPatient characteristics and comorbidities, 30-day post-operation readmission and infection rates were analyzed. Patient reported outcomes measures namely the Knee Society Function and Knee Score (KSFS, KSKS), Oxford Knee Score (OKS) and both the Physical and Mental component of the Short-Form Health Survey (SF-36) were assessed pre-operatively and 6 months post-operatively.Univariate analysis was used to compare differences in characteristics and comorbidities between the 2 groups. Finally, a multiple linear regression was performed to compare the post-operative outcomes. ResultsUnivariate analysis showed significantly better preoperative and 6 month post-operative KSKS and SF-36 MCS in UKA patients. Multivariate analysis showed no difference in the 6 month post-operative functional outcome scores between UKA and TKR patients. No UKA patients required revision surgery while 4 TKR patients required revision surgery for infection. ConclusionUKA achieves equivalent functional outcomes at 6 months post-operatively as compared to TKR patients and has lower infection rates. UKA is a reasonable option to offer for unicompartmental knee osteoarthritis patients.

Triglyceride-glucose index—A novel metabolism disorder biomarker as a promising indicator for predicting postoperative 30-day infections in elderly patients undergoing gastrointestinal-related abdominal and pelvic surgery

BackgroundThe triglyceride-glucose index, a reliable surrogate biomarker of insulin resistance, has been reported to be associated with cardiovascular events and atherosclerosis. However, few studies have investigated the association of the triglyceride-glucose index with postoperative infections. This study aimed to study the clinical risk values of the preoperative triglyceride-glucose index in postoperative infection complications in elderly patients undergoing gastrointestinal-related abdominal and pelvic surgery. MethodsThis retrospective cohort study included 3,225 older patients who underwent gastrointestinal-related abdominal and pelvic surgery between 2014 and 2019. The patients were divided into groups of triglyceride-glucose index ≤8.268 and triglyceride-glucose index >8.268 according to the optimal triglyceride-glucose index cut-off value. The outcome of interest was postoperative infections within 30 days after surgery. Primary and subgroup analyses were performed to confirm that preoperative triglyceride-glucose index qualifies as a reliable, independent risk indicator. Propensity score matching analysis was further applied to address covariates' potential residual confounding effect and test the robustness of the results. ResultsIn this study, the median age was 71 years (interquartile range, 67, 75 years), the proportion of male patients was 66.3%, and 1,058 (32.8%) were infected within 30 days after surgery. A triglyceride-glucose index >8.268 was associated with an increased risk of postoperative infections in multivariate regression analysis (odds ratio, 1.37; 95% confidence interval, 1.15–1.64; P < .001). The correlation between the triglyceride-glucose index and postoperative infections remained significantly robust (odds ratio, 1.52; 95% confidence interval, 1.21–1.92; P < .001) in the propensity score matching analysis. ConclusionsThe triglyceride-glucose index elevation determined by the optimal cutoff value of 8.268 was an independent risk factor for developing postoperative infections.

Thirty-day outcomes of surgery for hydrocephalus: metrics in a large cohort from the National Surgical Quality Improvement Program-Pediatric.

Hydrocephalus is a lifelong condition punctuated in most cases by unpredictable hospital admissions for surgical maintenance. It occupies more of the attention of the pediatric neurosurgeon than any other condition. Benchmarks for the measurement of outcomes are of interest to patients, their families, and the healthcare system. Compared to other metrics, 30-day outcomes require modest resources to collect, are conceptually transparent, and are responsive to process improvement. The National Surgical Quality Improvement Program-Pediatric of the American College of Surgeons was queried for operations for hydrocephalus in the years 2013 through 2020. Demographic data and data regarding comorbidities were collected. Thirty-day rates of return to the operating room, of shunt infection, and of readmission to hospital were analyzed on a univariate basis and in multivariate models. There were 29,098 surgical procedures in the sample, including 10,135 shunt insertions, 16,420 shunt revisions, and 2543 endoscopic third ventriculostomies. The overall 30-day reoperation rate was 10.3%. The most powerful associations were with the nature of the index procedure and with a history of extreme prematurity. The 30-day shunt infection rate was 1.80%. The major associations were with young age, major cardiac risk factors, nutritional support, and ventilator dependence. The 30-day readmission rate was 17.2%. The nature of the index procedure, current malignancy, nutritional support, and recent steroid administration were major associations. Comorbidities negatively associated with these outcomes were highly prevalent. Precise benchmarks for important 30-day outcomes have been calculated from a very large sample of operations for hydrocephalus in childhood.

541 Development and External Validation of the “Global Surgical-Site Infection” (GloSSI) Predictive Model in Adult Patients Undergoing Abdominal Surgery

Abstract Aim To develop a novel prognostic score to predict 30-day surgical-site infection (SSI) following gastrointestinal surgery, and externally validate in comparison to existing prognostic models. Method This was a secondary analysis of 3 independent prospective international cohort studies conducted on a global basis. This included adults undergoing gastrointestinal surgery. Model development was performed in the GlobalSurg-2 dataset (January-July 2016). The primary outcome was 30-day SSI, with two predictive techniques explored: penalised regression (LASSO) and machine learning (XGBOOST). Final model selection based on prognostic accuracy (Area Under the Curve [AUC], 95% confidence interval) and clinical utility. Novel and previous scores were externally validated in GlobalSurg-1 (July-November 2014), and GlobalSurg-3 (April-October 2018). Results 30,029 patients were eligible: 14,019 (SSI=12.3%) in the derivation cohort, and 8,464 (SSI=11.4%) and 7,546 (SSI=15.7%) in the validation cohorts (GlobalSurg-1 and GlobalSurg-3 respectively). The LASSO model was selected due to similar discrimination to XGBoost in the GlobalSurg-2 dataset (AUC: 0.738, 0.725-0.750 versus 0.737, 0.709-0.765), but greater explainability. The final GloSSI score included six variables: country income, ASA, diabetes, and operative contamination, approach, and duration. Discrimination remained good on external validation in GlobalSurg-1 (AUC: 0.730, 0.715-0.744), but moderate discrimination in GlobalSurg-3 (AUC: 0.606, 95% CI 0.588-0.623). Nonetheless, this demonstrated superior performance to external validation of all previous models evaluated within GlobalSurg or prior datasets. Conclusions The GloSSI score allowed accurate prediction of SSI with 6 simple variables routinely available at surgery across income settings. This can inform use of intraoperative and postoperative interventions to modify the risk of SSI and minimise associated harm.

Evaluation of Practice Changes in Therapy for Stenotrophomonas maltophilia

Background: Stenotrophomonas maltophilia (SM) is a non-fermenting, Gram-negative bacillus. Its intrinsic resistance to many beta-lactams makes for challenging treatment decisions. A preprint of the latest Infectious Diseases Society of America (IDSA) guidance on managing SM infections was published in December 2022 providing a recommendation for combination therapy including trimethoprim/sulfamethoxazole (TMP/SMX) and a second agent. An evaluation of the impact on SM treatment practices following this guidance was conducted at our institution. Methods: A list of 130 patients with non-urine SM cultures from December 2021-August 2023 was generated using a pharmacovigilance platform. Patients were excluded if on comfort measures or discharged to hospice prior to therapy completion, no directed antibiotics were given, or any history of prior SM infection. Twenty-five patients were randomly selected from the pre- and post-guidance periods (before and one month after December 1, 2022) for a total of 50 patients. Data was collected via manual chart review. The primary endpoint was frequency of combination antibiotic therapy in each time period. Secondary endpoints included treatment success (defined as resolution of infection symptoms and lack of infection recurrence), in-hospital mortality, 30-day mortality, and 30-day infection recurrence. Results: Overall, baseline characteristics were similar between groups, the median age was 65 years, 64% of patients were male, 20% were immunocompromised based on prespecified criteria, the median Charlson comorbidity index was 5 (21% estimated 10-Year survival), and 76% of SM cultures were pulmonary isolates. Displayed in figure 1, combination therapy was given in 6 of 25 cases (24%) in the post-guidance group and zero patients in the pre-guidance group. Secondary endpoints of treatment success and all-cause mortality were similar between groups. Duration of therapy was similar between combination and non-combination therapy regimens (median 9 vs 10 days). Among patients who received combination therapy, all had ID consultation, 4 (66.7%) were admitted to the ICU, and 2 (33.3%) had treatment success. Conclusions: Patients treated for SM infection at our institution in the post-IDSA guidance period were more likely to receive combination therapy. A higher rate of treatment success was not observed in the post-IDSA guidance arm for SM infections. Limitations of this study include its small sample size and retrospective design, leading to inability to distinguish colonization from true infection. Additional studies are needed to evaluate the impact of combination antibiotic therapy on outcomes.

Development and external validation of the ‘Global Surgical-Site Infection’ (GloSSI) predictive model in adult patients undergoing gastrointestinal surgery

Abstract Background Identification of patients at high risk of surgical-site infections may allow surgeons to minimize associated morbidity. However, there are significant concerns regarding the methodological quality and transportability of models previously developed. The aim of this study was to develop a novel score to predict 30-day surgical-site infection risk after gastrointestinal surgery across a global context and externally validate against existing models. Methods This was a secondary analysis of two prospective international cohort studies: GlobalSurg-1 (July–November 2014) and GlobalSurg-2 (January–July 2016). Consecutive adults undergoing gastrointestinal surgery were eligible. Model development was performed using GlobalSurg-2 data, with novel and previous scores externally validated using GlobalSurg-1 data. The primary outcome was 30-day surgical-site infections, with two predictive techniques explored: penalized regression (least absolute shrinkage and selection operator (‘LASSO’)) and machine learning (extreme gradient boosting (‘XGBoost’)). Final model selection was based on prognostic accuracy and clinical utility. Results There were 14 019 patients (surgical-site infections = 12.3%) for derivation and 8464 patients (surgical-site infections = 11.4%) for external validation. The LASSO model was selected due to similar discrimination to extreme gradient boosting (AUC 0.738 (95% c.i. 0.725 to 0.750) versus 0.737 (95% c.i. 0.709 to 0.765)), but greater explainability. The final score included six variables: country income, ASA grade, diabetes, and operative contamination, approach, and duration. Model performance remained good on external validation (AUC 0.730 (95% c.i. 0.715 to 0.744); calibration intercept −0.098 and slope 1.008) and demonstrated superior performance to the external validation of all previous models. Conclusion The ‘Global Surgical-Site Infection’ score allows accurate prediction of the risk of surgical-site infections with six simple variables that are routinely available at the time of surgery across global settings. This can inform the use of intraoperative and postoperative interventions to modify the risk of surgical-site infections and minimize associated harm.

Short versus prolonged duration of therapy for Pseudomonas aeruginosa bacteraemia: a systematic review and meta-analysis

The optimal duration of therapy for Pseudomonas aeruginosa bloodstream infection (PSA-BSI) is unknown, with prolonged therapy frequently favored due to severity of infection, patient complexity, risk of multi-drug resistance, and high mortality. We therefore conducted a systematic review and meta-analysis of studies with head-to-head comparison of short versus prolonged therapy for PSA-BSI. A comprehensive search including Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus was performed. We pooled risk ratios using DerSimonian-Laird random effects model and performed subgroup analysis of outcomes including all-cause mortality, recurrent infection, and composite of these outcomes among patients receiving short versus prolonged therapy for PSA-BSI. Heterogeneity was assessed by the I2-index. Risk of bias for cohort studies was assessed using ROBINS-I tool. Of the 908 identified studies, six were included in the systematic review and five studies with head-to-head comparison of treatment duration were assessed in the meta-analysis, totalling 1746 patients. No significant difference in propensity score-weighted composite outcome (30-day all-cause mortality or recurrent infection) was noted between patients receiving short or prolonged therapy, with a pooled RR risk ratio of 0.80 (95% CI confidence interval 0.51-1.25, P=0.32; I2 = 0%). Additionally, duration of therapy did not impact individual outcomes of 30-day all-cause mortality or recurrent/persistent infection. Our meta-analysis demonstrated that short duration of antimicrobial therapy may have similar efficacy to prolonged treatment for PSA-BSI. Future randomized trials will be necessary to definitively determine optimal management of PSA bacteraemia.

Not so Fast: Extended Oral Antibiotic Prophylaxis Does Not Reduce 90-Day Infection Rate Following Joint Arthroplasty

BackgroundPeriprosthetic joint infection (PJI) is a devastating complication following both total hip (THA) and knee (TKA) arthroplasty. Extended oral antibiotic (EOA) prophylaxis has been reported to reduce PJI following TJA in high-risk patients. The purpose of this study was to determine if EOA reduces PJI in all-comers and high-risk THA and TKA populations. MethodsThis is a retrospective cohort study, including 4,576 patients undergoing primary THA or TKA at a single institution from 2018 to 2022. Beginning in 2020, EOA prophylaxis was administered for 10 days following THA or TKA at our institution. Patients were separated into 2 cohorts (1,769 EOA, 2,807 no EOA) based on whether they received postoperative EOA. The 90-day and 1-year outcomes, with a focus on PJI, were then compared between groups. A subgroup analysis of high-risk patients was also performed. ResultsThere was no difference in 90-day PJI rates between cohorts (EOA 1 versus no EOA 0.8%; P = .6). The difference in the rate of PJI remained insignificant at 1 year (EOA 1 versus no EOA 1%; P = .9). Similarly, our subgroup analysis of high-risk patients demonstrated no difference in postoperative PJI between EOA (n = 254) and no EOA (n = 396) (0.8 versus 2.3%, respectively; P = .2). Reassuringly, we also found no differences in the incidence of Clostridium difficile infection (EOA 0.1 versus no EOA 0.1%; P > .9) or in antibiotic resistance among those who developed PJI within 90 days (EOA 59 versus no EOA 83%; P = .2). ConclusionsWith the numbers available for analysis, EOA prophylaxis was not associated with PJI risk reduction following primary TJA when universally deployed. Furthermore, among high-risk patients, there was no statistically significant difference. While we did not identify increased antibiotic resistance or Clostridium difficile infection, we cannot recommend wide-spread adoption of EOA prophylaxis, and clarification regarding the role of EOA, even in high-risk patients, is needed.

Clinical Outcomes of Trimethoprim/Sulfamethoxazole in Critically Ill Patients with Stenotrophomonas maltophilia Bacteremia and Pneumonia Utilizing Renal Replacement Therapies.

Background: The clinical outcomes of usual doses of Trimethoprim-sulfamethoxazole (TMP/SMZ) for treating S. maltophilia in critically ill patients on renal replacement therapies (RRT) have not been established. We sought to assess the clinical outcomes of TMP/SMZ in patients with sepsis utilizing RRT. Methods: A retrospective study was performed on all critically ill adult patients with S. maltophilia infections who received RRT between May 2015 and January 2022. The primary endpoint was clinical cure while the secondary endpoints were microbiologic cure, 30-day infection recurrence, and mortality. Results: Forty-five subjects met the inclusion criteria. The median age was 70.0 [interquartile range (IQR): 63.5-77] years, 57.8% were males, and the median body mass index was 25.7 [IQR: 22-30.2] kg/m2. Clinical success and failure were reported in 18 (40%) and 27 (60%) cases, respectively. There was no significant difference between the 30-day reinfection rates of both groups; however, mortality was significantly higher in the clinical failure group, involving 12 patients (44.4%), versus none in the clinical success group (p = 0.001). The median daily dose of TMP/SMZ upon continuous veno-venous hemofiltration was 1064 [IQR: 776-1380] mg in the clinical cure group vs. 768 [IQR:540-1200] mg in the clinical failure group (p = 0.035). Meanwhile, the median dose for those who received intermittent hemodialysis was 500 [IQR: 320-928] mg in the clinical success group compared to 640 [IQR: 360-1005] mg in the clinical failure group (p = 0.372). A total of 55% experienced thrombocytopenia, 42% hyperkalemia, and 2.2% neutropenia. The multivariable logistic regression analysis showed that the total daily dose at therapy initiation was the only independent factor associated with clinical success after adjusting for different variables including the body mass index [Odds ratio 1.004; 95% confidence interval: (1-1.007), p = 0.044]. Conclusions: Although the S. maltophilia isolates were reported as susceptible, TMP/SMZ with conventional doses to treat bacteremia and pneumonia in critically ill patients utilizing RRT was associated with high rates of clinical and microbiologic failure as well as with mortality. Larger outcomes and pharmacokinetics studies are needed to confirm our findings.

Characterizing antibiotic prophylaxis practices in pediatric deformity spinal surgery and impact on 30-day postoperative infection: an NSQIP pediatric database study.

The aim of this study was to characterize antibiotic prophylaxis practices in pediatric patients who have received posterior arthrodesis for spinal deformity and understand how these practices impact 30-day postoperative infection rates. This was a retrospective cohort study using the National Surgical Quality Improvement Program Pediatric database for year 2021. Patients 18years of age or younger who received posterior arthrodesis for scoliosis or kyphosis correction were included. The outcome of interest was 30-day postoperative infection. Fisher's exact test and multivariable regression analysis were used to analyze the impact of intravenous antibiotic prophylaxis, intraoperative intravenous antibiotic redosing after 4h, postoperative antibiotic prophylaxis, intraoperative topical antibiotics on 30-day postoperative infection, and various antibiotic prophylaxis regimens. A total of 6974 patients were included in this study. The 30-day infection rate was 2.9%. Presurgical intravenous antibiotic (11.5% vs. 2.7%, p = 0.005), postoperative antibiotic (5.7% vs. 2.4%, p < 0.01), and intraoperative topical antibiotic (4.0% vs. 2.7%, p = 0.019) were associated with significantly reduced infection rates. There was no significant difference in infection rates between patients that received cefazolin versus vancomycin versus clindamycin. The addition of Gram-negative coverage did not result in significant differences in infection rates. Multivariable regression analysis found postoperative intravenous antibiotics and intraoperative topical antibiotics to reduce infection rates. We found the use of presurgical intravenous antibiotics, postoperative intravenous antibiotics, and intraoperative topical antibiotics to significantly reduce infection rates. Results from this study can be applied to future research on implementation of standardized infection prevention protocols. Level II.

The Clinical Efficacy of Adding Ceftazidime/Avibactam to Standard Therapy in Treating Infections Caused by Carbapenem-Resistant Klebsiella pneumonia with blaOXA-48-like Genes.

Ceftazidime/avibactam (CAZ-AVI) is FDA-approved for managing infections caused by resistant gram-negative bacilli, particularly infections via carbapenem-resistant Enterobacterales pathogens. The clinical data are still limited, particularly those in Saudi Arabia. The present study is a retrospective cohort study that was carried out at the Armed Forces Hospital in the southern region of Saudi Arabia to compare the clinical and microbiological outcomes for CAZ-AVI-treated patients as monotherapy and as an add-on to standard therapy for carbapenem-resistant Klebsiella pneumonia (CRKP) OXA-48 infections to those treated with standard drugs. The study included CRKP OXA-48-like infected patients who were administered antibiotics for more than seven days from 1 August 2018 to May 2023. Patients' baseline characteristics and demography were extracted from the clinical records, and their clinical/microbiology efficiencies were assessed as per the corresponding definitions. Univariate and multivariate logistic regressions were conducted to identify the potential independent variable for CAZ-AVI efficiency. A total of 114 patient files were included for the evaluation. Among these patients, 64 used CAZ-AVI combined with standard therapy and were included in the intervention group, and 50 of them used standard therapy and were included in the comparative group. Following analysis, CAZ-AVI's clinical success was 42.2% (p = 0.028), while the intervention versus comparative groups showed decreased 30-day all-cause mortality (50.0% versus 70.0%; p = 0.036) and infection recurrence (7.8% versus 24.0%; p = 0.019), as well as substantially increased rates of microbial eradication (68.8% versus 42.0%; p = 0.007). CAZ-AVI add-on therapy rather than monotherapy showed statistically significant favored clinical and microbial outcomes over the standard therapy. Furthermore, sex (female %), ICU admission, and fever were negatively associated with patients' 30-day all-cause mortality, serving as independent negative factors. Only fever, CRP bio levels, inotropes, and ICU admissions were significant predictors influencing the CAZ-AVI's clinical efficiency. The duration of CAZ-AVI therapy positively influenced CAZ-AVI's microbial eradication, while both WBC counts and fever experiences were negative predictors. This study shows the effective usage of CAZ-AVI against CRKP OXA-48-like infections. The influencing independent variables depicted here should recommend that clinicians individualize the CAZ-AVI dose based on co-existing risk factors to achieve optimal survival and efficacy. Prospective multicenter and randomized control studies are recommended, with individualized CAZ-AVI precision administration implemented based on patients' characteristics.

An evaluation of the management of severe open tibial fractures in the United Kingdom's major trauma centres

AimTo evaluate the management of patients with severe open tibial fractures at major trauma centres (MTCs) in the UK with respect to BOAST 4 guidelines. MethodsData collected by the Trauma and Audit Research Network (TARN) for all severe open tibial fractures treated at the 23 adult MTCs were evaluated. Key performance indicators (KPIs) included MTC admission under orthoplastics, administration of antibiotics within three hours of injury, initial debridement within 24 h and definitive fixation and soft tissue coverage within 72 h. Outcomes included 30-day infection rate, amputation rate and mortality rate.A score was calculated according to overall attainment of KPIs, and correlated to outcomes. ResultsFrom 2014 to 2020, 3359 adults with Gustilo-Anderson (GA) IIIB and/or IIIC fractures were admitted to MTCs. Male to female ratio was 2:1 with a mean age of 43 and 65 years respectively.There was a negative correlation between KPI score and mortality rate (r=-0.4929, p = 0.0169). Direct admission to an MTC was positively correlated with receipt of antibiotics within three hours (r = 0.5452, p = 0.0070). Joint orthoplastic plans were documented in 89 % of patients (MTC range 30–95 %). Soft tissue cover was achieved within 72 h for 48 % (MTC range 5.23–89.39 %).Patients over 65 were significantly more likely to have a delay to MTC admission and prophylactic antibiotic administration. Mortality rate in this group was 6% vs 2 % in those under 65. The older cohort were twice as likely to require an amputation. ConclusionThis is the largest cohort of open tibial injuries managed in the UK with wide variation in practice between centres demonstrated and better adherence to BOAST guidelines linked to reduced mortality in those aged 65 and over. The older cohort of patients also had higher rates of infection and amputation.It is unclear whether these poor outcomes are due to the pre-morbid physiological status of the patient or non-compliance to Standards. We present these data to highlight the need for improved adherence to Standards – the adoption of a scoring system provides a simple way to evidence this.

Optimizing antibiotic management for patients with acute appendicitis: A quality improvement study

BackgroundTo decrease surgical site infections after appendectomy for acute appendicitis, preoperative broad-spectrum antibiotics are often used in clinical practice. However, this treatment strategy has come under scrutiny because of increasing rates of antibiotic-resistant infections. MethodsThe aim of this multisite quality improvement project was to decrease the treatment of uncomplicated acute appendicitis with piperacillin-tazobactam without increasing the rate of surgical site infections. Our quality improvement intervention had 2 distinct components: (1) updating electronic health record orders to encourage preoperative administration of narrow-spectrum antibiotics and (2) educating surgeons and emergency department clinicians about selecting appropriate antibiotic therapy for acute appendicitis. Patient demographics, clinical characteristics, and outcomes were compared 6 months before and after implementation of the quality improvement intervention. ResultsA total of 352 laparoscopic appendectomies were performed during the 6-month preintervention period, and 369 were performed during the 6-month postintervention period. The preintervention period and postintervention period groups had similar baseline demographics, vital signs, and laboratory test values. The rate of preoperative piperacillin-tazobactam administration significantly decreased after the intervention (51.4% preintervention period vs 20.1% postintervention period, P < .001). The rate of surgical site infections was similar in both groups (superficial surgical site infections = 1.4% preintervention period vs 0.8% postintervention period, P = .50; deep surgical site infections = 1.1% preintervention period vs 0.0% postintervention period, P = .06; and organ space surgical site infections = 3.1% preintervention period vs 3.0% postintervention period, P > .99). Rates of 30-day readmission, reoperation, and Clostridioides difficile infection also did not differ between groups. ConclusionOur quality improvement intervention successfully decreased piperacillin-tazobactam administration without increasing the rate of surgical site infections in patients with acute appendicitis.

Preoperative hypocoagulative state is an independent risk factor for wound complications and infection in gender-affirming bottom surgeries

BackgroundBottom gender affirmation surgery (GAS) involves the risks of bleeding and associated complications. Effective preoperative blood management is paramount across surgical disciplines with international normalized ratio (INR)≤1.5 advised prior to certain surgeries. This study aimed to examine the proportion of patients who were hypocoagulative before they underwent bottom GAS and assess the influence of hypocoagulability on their 30-day post-operative outcomes. MethodA retrospective study on female-to-male (FtM) and male-to-female (MtF) bottom GAS was performed based on American college of surgeons national surgical quality improvement program (ACS-NSQIP) database from 2005 to 2021. Patients with hypocoagulation were identified when PTT> 60 s, PT > 30 s, and/or INR> 2. Multivariable logistic regression was used to compare the 30-day perioperative outcomes between patients with hypocoagulation and controls. ResultsIn this study, 380 patients (182 FtM, 198 MtF) with hypocoagulation and 1176 controls (886 FtM, 310 MtF) were included. Mortality and organ system complications were infrequent in both groups. Patients with hypocoagulation had higher wound complication rates (13.68% vs. 2.64%, aOR 2.858, p < 0.01), especially wound dehiscence (10.00% vs. 0.60%, aOR 4.424, p < 0.01) and organ space infection rates (2.11% vs. 0.26%, aOR 12.77, p < 0.01). Additionally, patients with hypocoagulation had higher sepsis (0.79% vs. 0.09%, aOR 15.508, p = 0.04) and readmission rates (4.74% vs. 2.47%, aOR 1.919, p = 0.03), but lower rates of discharge not to home (7.92% vs. 25.38%, aOR 0.324, p < 0.01). ConclusionPreoperative hypocoagulative state is observed in approximately a quarter of the patients undergoing bottom GAS and is an independent risk factor for increased risks of 30-day wound complications and infections. Therefore, meticulous monitoring of preoperative hemostasis and implementing hemostasis control before surgery may be necessary. Thus, it may be advisable to discontinue oral anticoagulants before the surgery.

Dalbavancin as an alternative to traditional outpatient parenteral antimicrobial therapy for deep gram-positive infections - an observational, retrospective review.

Treatment of invasive gram-positive infections in complex patient populations is challenging. Dalbavancin, approved for skin and soft tissue infections, offers advantages in this setting due to its long half-life and infrequent dosing. However, less is known about the outcomes of off-label dalbavancin for deeper infections. The objective of this study is to examine the feasibility and outcomes of patients with complex gram-positive infections treated with dalbavancin as an alternative to standard outpatient parenteral antimicrobial therapy (OPAT). We conducted a multicenter, retrospective review of adult patients managed within an OPAT program with intravenous dalbavancin for off-label indications. Adult patients were included if they had treatment details and follow-up documented between January 2020 and June 2023. Details of dalbavancin use including indications for prescription were captured. Outcomes of interest included 90-day infection recurrence, prosthesis retention rates, 90-day mortality, and adverse medication events. In all, 61 patients received dalbavancin, mostly as sequential therapy. Twenty-three percent received dalbavancin strictly in the outpatient setting. Dalbavancin was used primarily for hardware (fracture, spine, or joint), native bone or joint, and complicated soft tissue infections. The predominant pathogen was Staphylococcus aureus (61%). Dalbavancin was frequently prescribed as a two-dose 1500 mg regimen (49%) due to persistent infection (23%), difficult line access (30%), difficulty achieving therapeutic vancomycin levels (18%), or substance abuse history (18%). Overall, six patients (10%) had infection recurrence and no patients died during the follow-up period. Three of eight patients with hardware retention had infection recurrence. Adverse effects were minimal and mostly self-limiting. Dalbavancin is an efficacious and safe alternative to standard OPAT, especially in those with barriers to traditional long-term intravenous antibiotics. Improved outcomes may be achieved with hardware removal. Dalbavancin may facilitate early discharge or prevent hospitalizations. Comparative studies of standard OPAT regimens versus dalbavancin are needed.

Outcomes of an expedited same-day discharge protocol following cardiac implantable electronic device (CIED) implantation.

With increasing constraints on healthcare resources, greater attention is being focused on improved resource utilization. Prior studies have demonstrated safety of same-day discharge following CIED implantation but arelimited by vague protocols with long observation periods. In this study, we evaluate the safety of an expedited 2hour same-day discharge protocol following CIED implantation. Patients undergoing CIED implantation at three centers between 2015 and 2021 were included. Procedural, demographic, and adverse event data were abstracted from the electronic health record. Patients were divided into same-day discharge (SDD) and delayed discharge (DD) cohorts. The primary outcome was complications including lead malfunction requiring revision, pneumothorax, hemothorax, lead dislodgement, lead perforation with tamponade, and mortality within 30days of procedure. Outcomes were compared between the two cohorts using the χ2 test. A total of 4543 CIED implantation procedures were included with 1557 patients (34%) in the SDD cohort. SDD patients were comparatively younger, were more likely to be male, and had fewer comorbidities than DD patients. Among SDD patients, the mean time to post-operative chest X-ray was 2.6h. SDD had lower rates of complications (1.3% vs 2.1%, p = 0.0487) and acute care utilization post-discharge (9.6% vs 14.0%, p < 0.0001). There was no difference in the 90-day infection rate between the cohorts. An expedited 2hour same-day discharge protocol is safe and effective with low rates of complications, infection, and post-operative acute care utilization.

Impact of Aortic Root Abscess on Surgical Outcomes of Infective Endocarditis.

Locally destructive infective endocarditis (IE) of the aortic valve complicated by abscess formation in the aortic root may seriously affect patients' outcomes. Surgical repair of such conditions is often challenging. This is a single-center observational analysis of consecutive patients treated surgically for IE between 2009 and 2019. We divided the cohort into two groups considering the presence of an aortic root abscess and compared the characteristics and postoperative outcomes of patients accordingly. Moreover, we examined three different procedures performed in abscess patients regarding operative data and postoperative results: an isolated surgical aortic valve replacement (AVR), AVR with patch reconstruction of the aortic root (AVR + RR) or the Bentall procedure. The whole cohort comprised 665 patients, including 140 (21.0%) patients with an aortic root abscess and 525 (78.9%) as the control group. The abscess group of patients received either AVR (66.4%), AVR + RR (17.8%), or the Bentall procedure (15.7%). The mean age in the whole cohort was 62.1 ± 14.8. The mean EuroSCORE II was 8.0 ± 3.5 in the abscess group and 8.4 ± 3.7 in the control group (p = 0.259). The 30-day and 1-year mortality rates were 19.6% vs. 11.3% (p = 0.009) and 40.1% vs. 29.6% (p = 0.016) in the abscess compared to the control group. The multivariable regression analysis did not reveal aortic root abscess as an independent predictor of mortality. Rather, age > 60 correlated with 30-day mortality and infection with Streptococcus spp. correlated with 1-year mortality. In the analysis according to the performed procedures, KM estimates exhibited comparable long-term survival (log-rank p = 0.325). IE recurrence was noticed in 12.3% of patients after AVR, 26.7% after AVR + RR and none after Bentall (p = 0.069). We concluded that patients with an aortic root abscess suffer worse short and long-term outcomes compared to other IE patients. The post-procedural survival among ARA patients did not significantly vary based on the procedures performed.

2118. Comparative Analysis of Cefiderocol Mono- and Combination Therapy for Multi-Drug Resistant Gram-negative Infections

Abstract Background Multi-drug resistant gram-negative infections are a growing concern, necessitating the development of novel treatments. Cefiderocol (CFDC) is a new siderophore cephalosporin that targets the iron transport mechanism used by many gram-negative pathogens. We aimed to compare the clinical outcomes of CFDC monotherapy and combination therapy in various infection types. Methods We performed a retrospective cohort analysis at 5 academic medical centers from May 2022 to April 2023. Patients were included if they were ≥18 years old and received CFDC for ≥48 hours, excluding subsequent courses not separated by ≥90 days. The primary objective was composite clinical success (30-day survival, absence of 30-day infection recurrence and resolution of signs and symptoms), with secondary objectives including individual components of clinical success, on-treatment resistance, 30-day readmission, and adverse reactions. Descriptive statistics and logistic regression were used. Results We analyzed 70 patients, with 35 in each treatment group. The cohort was predominantly male (64.3%), had a mean age of 55.5 years (17.6), and 67% were admitted to the Intensive Care Unit. The mean (SD) APACHE II scores were 12.8 (7.5) for monotherapy and 14.9 (6.7) for combination therapy (p=0.22), while the mean (SD) Charlson comorbidity scores were 5.0 (3.6) and 4.5 (3.5) for the respective groups (p=0.61). The most common infection source was respiratory tract (54.3%), with Pseudomonas aeruginosa (55.7%) and Acinetobacter baumannii (25.7%) as the most frequently isolated pathogens. The median (IQR) CFDC mean inhibitory concentration (MIC) was 0.5 µg/mL (0.25-1.0). The 30-day mortality rates for the monotherapy and combination groups were 20% and 28.6%, respectively. There was no significant difference in composite clinical success between the groups (p=0.59). Conclusion Our preliminary data suggest that there is no difference in clinical success between CFDC monotherapy and combination therapy with another antibiotic. Further studies are needed to confirm these findings and evaluate the optimal use of CFDC in a variety of clinical settings. Disclosures Michael J. Rybak, PharmD, PhD, MPH, Abbvie, Merck, Paratek, Shionogi, Entasis, La Jolla, T2 Biosystems: Advisor/Consultant

Is Carbapenem Therapy Necessary for the Treatment of Non-CTX-M Extended-Spectrum β-Lactamase-Producing Enterobacterales Bloodstream Infections?

Investigations into antibiotics for extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) bloodstream infections (BSIs) have focused on blaCTX-M genes. Patient outcomes from non-CTX-M-producing ESBL-E BSIs and optimal treatment are unknown. A multicenter observational study investigating 500 consecutive patients with ceftriaxone-resistant Enterobacterales BSIs during 2018-2022 was conducted. Broth microdilution and whole-genome sequencing confirmed antibiotic susceptibilities and ESBL gene presence, respectively. Inverse probability weighting (IPW) using propensity scores ensured patients with non-CTX-M and CTX-M ESBL-E BSIs were similar before outcome evaluation. 396 patients (79.2%) were confirmed to have an ESBL-E BSI. ESBL gene family prevalence was as follows: blaCTX-M (n = 370), blaSHV (n = 16), blaOXY (n = 12), and blaVEB (n = 5). ESBL gene identification was not limited to Escherichia coli and Klebsiella species. In the IPW cohort, there was no difference in 30-day mortality or ESBL-E infection recurrence between the non-CTX-M and CTX-M groups (odds ratio [OR], 0.99; 95% confidence interval [CI], .87-1.11; P = .83 and OR, 1.10; 95% CI, .85-1.42; P = .47, respectively). In an exploratory analysis limited to the non-CTX-M group, 86% of the 21 patients who received meropenem were alive on day 30; none of the 5 patients who received piperacillin-tazobactam were alive on day 30. Our findings suggest that non-CTX-M and CTX-M ESBL-E BSIs are equally concerning and associated with similar clinical outcomes. Meropenem may be associated with improved survival in patients with non-CTX-M ESBL-E BSIs, underscoring the potential benefit of comprehensive molecular diagnostics to enable early antibiotic optimization for ESBL-E BSIs beyond just blaCTX-M genes.