30-day Infection Research Articles

633. Eravacycline Use in Immunocompromised Patients: Multicenter Evaluation of Clinical and Safety Endpoints

Abstract Background Infections caused by multidrug-resistant (MDR) bacteria are an increasingly common public health threat associated with worse outcomes in immunocompromised patients. Eravacycline (ERV) has potent in-vitro activity against MDR Gram-negative and Gram-positive bacteria and has demonstrated non-inferiority to meropenem in the phase III IGNITE4 trial; however, the trial excluded immunocompromised patients. We aimed to evaluate clinical and safety endpoints of immunocompromised patients receiving ERV as definitive therapy. Methods Multicenter, retrospective, observational study conducted from October 2018 to April 2022. Adult hospitalized immunocompromised patients treated with ERV for ≥72 hours were included. Immunocompromised patients were defined as having any of the following: chemo or radiation therapy < 30 days of hospital admission, HIV/AIDS with CD4 < 200, chronic steroids ( >40 mg prednisone or equivalent. The primary outcome was 30-day survival. Secondary outcomes were lack of 30-day infection recurrence and drug-related safety events. Results Overall, 75 immunocompromised patients treated with ERV were included from 17 United States medical centers. Median (IQR) age was 62 (53-70) and 61.6% were male. Hospital length of stay was 28 (13-42) days and 67% were admitted to the intensive care unit. SOFA and APACHE II scores were 3.5 (1-7) and 16 (11-20), respectively. Common infection sources were intra-abdominal (26%) and lower respiratory tract (18%); 24% were bacteremic. Most patients had cultured Enterobacterales (58.7%) and Enterococci (37%) spp. infections. Of those, 21.3% were CRE and 19% were VRE. Infectious diseases consult was obtained in 91.8% of cases. Time elapsed from index culture collection to ERV initiation was 4 (2-8) days and duration of ERV therapy was 7 (4-12) days. In total, 81.3% of immunocompromised patients achieved 30-day survival and 90.7% did not have 30-day infection recurrence. Probable drug-related adverse events occurred in 5.3% of patients (GI 4%, rash 1%). Conclusion A majority of immunocompromised patients receiving ERV as definitive therapy achieved 30-day survival and did not experience infection recurrence. ERV use in immunocompromised subpopulations will benefit from studies tailored to their specific characteristics. Disclosures Kimberly C. Claeys, PharmD, BioFire Diagnostics: Honoraria Bruce M. Jones, Pharm.D., FIDSA, BCPS, AbbVie: Advisor/Consultant|AbbVie: Honoraria|La Jolla: Honoraria|Melinta: Advisor/Consultant|Paratek: Honoraria|Regeneron: Honoraria.

1729. Real-world Experience with Ceftazidime-avibactam Compared with Ceftolozane-tazobactam on Clinical Outcomes in Pseudomonas aeruginosa Infections

Abstract Background The 2022 IDSA Guidance on the Treatment of Antimicrobial-Resistant Gram-negative Infections recommends the use of a novel beta-lactam/beta-lactamase inhibitor, such as ceftolozane-tazobactam (C/T) or ceftazidime-avibactam (C/A), as first-line for treatment of resistant Pseudomonas aeruginosa infections. C/T is often preferred for these infections due to a narrower spectrum and lower cost. However, from December 2020 to January 2022, a global shortage of C/T resulted in widespread adoption of C/A as an alternative. While in vitro susceptibilities support the use of C/A for P. aeruginosa, real-world experience comparing clinical outcomes to C/T is limited. Methods This multicenter, retrospective analysis was conducted at an urban, academic healthcare system in the Bronx, NY. Between January 2018 and December 2020, admitted adult patients who received C/A or C/T to treat P. aeruginosa infections were included. Patients were excluded if in vitro resistance to either drug was demonstrated or if susceptibility was missing. The primary outcome was clinical success, defined as resolution of signs and symptoms of infection, by end of treatment. Secondary outcomes included 30-day mortality, resistance to study drug after therapy, modification of therapy, 14-day microbiological failure, 90-day infection recurrence, and length of stay. Results A total of 46 patients received C/A and 56 patients received C/T to treat P. aeruginosa infections. Most baseline characteristics were similar between the two arms, though more patients were critically ill in the C/A arm (Table 1). Clinical success was similar between C/A and C/T patients (72% vs. 63%, p=0.33). No significant differences between arms were identified for secondary outcomes (Table 2). Development of drug resistance within 90 days of treatment occurred more frequently in the C/A arm, approaching significance. On multivariate regression analysis, vasopressor use at the time of study drug initiation was the only variable associated with reduced clinical success. Conclusion C/A may be an effective alternative treatment for multidrug-resistant P. aeruginosa infections with close monitoring for development of resistance. Larger comparative studies are needed to confirm these findings. Disclosures Yi Guo, PharmD, BCIDP, Merck: Grant/Research Support.

Can Currently Suggested Quality Indicators Be Transferred to Meningioma Surgery?-A Single-Center Pilot Study.

Risk stratification based on standardized quality measures has become crucial in neurosurgery. Contemporary quality indicators have often been developed for a wide range of neurosurgical procedures collectively. The accuracy of tumor-inherent characteristics of patients diagnosed with meningioma remains questionable. The objective of this study was the analysis of currently applied quality indicators in meningioma surgery and the identification of potential new measures. Data of 133 patients who were operated on due to intracranial meningiomas were subjected to a retrospective analysis. The primary outcomes of interest were classical quality indicators such as the 30-day readmission, 30-day reoperation, 30-day mortality, 30-day nosocomial infection, and the 30-day surgical site infection rate. Uni- and multivariate analyses were performed. The occurrence of a new postoperative neurologic deficit was analyzed as a potential new quality indicator. The overall unplanned readmission rate was 3.8%; 13 patients were reoperated within 30 days (9.8%). The 30-day nosocomial infection and surgical site infection rates were 6.8 and 1.5%, respectively. A postoperative new neurologic deficit or neurologic deterioration as a currently assessed quality feature was observed in 12 patients (9.2%). The edema volume on preoperative scans proved to have a significant impact on the occurrence of a new postoperative neurologic deficit (p = 0.023). Classical quality indicators in neurosurgery have proved to correlate with considerable deterioration of the patient's health in meningioma surgery and thus should be taken into consideration for application in meningioma patients. The occurrence of a new postoperative neurologic deficit is common and procedure specific. Thus, this should be elucidated for application as a complementary quality indicator in meningioma surgery.

Care fragmentation predicts 90-day durable ventricular assist device outcomes.

To examine whether fragmentation of care is associated with worse in-hospital and 90-day outcomes following durable ventricular assist device (VAD) implant. Cohort study. This study was conducted using Medicare claims linked to the Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) among patients undergoing VAD implant between July 2009 and April 2017. Medicare data were used to measure fragmentation of the multidisciplinary care delivery network for the treating hospital, based on providers' history of shared patients within the previous year. STS Intermacs data were used for risk adjustment and outcomes ascertainment. Hospitals were sorted into terciles based on the degree of network fragmentation, measured as the mean number of links separating providers in the network. Multivariable regression was used to associate network fragmentation with 90-day death or infection risk. The cohort included 5159 patients who underwent VAD implant, with 11.2% dying and 27.6% experiencing an infection within 90 days after implant. After adjustment, a 1-unit increase in network fragmentation was associated with an increase of 0.179 in the probability of in-hospital infection and an increase of 0.183 in the probability of 90-day infection (both P < .05). Similar results were observed in models of the numbers of in-hospital and 90-day infections. Network fragmentation was predictive of the probability of 90-day mortality, although this relationship was not significant after adjustment. Care delivery network fragmentation is associated with higher in-hospital and 90-day infection rates following durable VAD implant. These networks may serve as novel targets for enhancing outcomes for patients undergoing VAD implant.

Impact of Fried Frailty Phenotype on Postoperative Outcomes After Durable Contemporary Mechanical Circulatory Support: A Single-Center Experience.

Frailty is prevalent in advanced heart failure patients and may help distinguish patients at risk of worse outcomes. However, the effect of frailty on postoperative clinical outcomes is still understudied. Therefore, we aim to study the relationship between frailty and postoperative clinical outcomes in patients undergoing long-term mechanical circulatory support (MCS). Forty-six patients undergoing durable MCS (left ventricular assist device and total artificial heart) placement at our medical center were assessed for frailty pre-implant. Frailty was defined as ≥ 3 physical components of the Fried frailty phenotype. Our primary endpoint is 1 year of survival post-implant. Secondary endpoints include 30-day all-cause rehospitalization, pump thrombosis, neurological event (stroke/transient ischemic attack), gastrointestinal bleeding, and driveline infection within 12 months post-MCS support. Of the 46 patients, 32 (69%) met the criteria for frailty according to Fried. The cohort's median age was 67.0 years. The frail group had statistically significant lower left ventricular ejection fraction (LVEF) (11% vs. 20%, P = 0.017) and lower albumin (3.5 vs. 4.0 g/dL, P = 0.021). The frail cohort also had significantly higher rates of comorbid chronic kidney disease (47% vs. 7%, P = 0.016). There were no differences between the frail vs. non-frail group in terms of 30-day readmission rates (40% vs. 39%, P = 0.927) and 1-year post-intervention survival (log-rank, P = 0.165). None of the other secondary endpoints reached statistical significance, although the incidence of gastrointestinal bleed (24% vs. 16%, P = 0.689) and pump thrombosis (8% vs. 0%, P = 0.538) were higher in the frail group. Preoperative Fried frailty was not associated with readmission at 30 days, mortality at 365 days, and other postoperative outcomes in long-term durable MCS patients. Findings may need further validation in larger studies.

Abstract 13175: The Effect of Impella Placement on Morbidity and Mortality in Cardiogenic Shockcomparing Outcomes of Two Percutaneous Mechanical Circulatory Support Modalities as Bridges to Advanced Heart Failure Therapy

Objectives: The use of percutaneous mechanical circulatory support (PMCS) devices offers a means to maintain hemodynamic stability in pre-transplant patients. The Impella Heart Pump and the intra-aortic balloon pump (IABP) are two devices commonly employed for this purpose. We sought to compare the relative safety and efficacy of Impella vs IABP using a retrospective cohort of patients at our institution from 2014-2021. Methods: 239 patients received Impella support, and 220 patients received IABP. Of these patients, 26 receiving Impella and 49 receiving IABP were identified as pre-transplant/VAD. The incidences of 30-day mortality, major bleeding, hemolysis, limb ischemia, stroke, repositioning, and infection were recorded. The number of patients receiving transplants, VADs, Mechanical Circulatory Support escalation, and ECMO were also recorded. The relative risks of complications were calculated, and an alpha of 0.05 was assigned to identify significance. Results: The average age of the IABP group was 54.8 +/- 12.1 years with 39 males to 10 females. The average age of the Impella group was 44.8 +/- 15 years with 15 males to 11 females. There was no significant difference in pre-placement EF between these two groups (IABP EF = 19.28+/-8.62, Impella EF = 21.15+/-9.69; p = 0.4016). A significantly higher relative risk of mortality (RR = 3.23; 95% CI = 1.45-7.20, p = 0.0041), major bleeding (RR = 8.48; 95% CI = 3.2 - 22.45, p &lt; 0.00001), and hemolysis (RR = 35.2; 95% CI = 2.12-582, p = 0.0128) was noted in patients receiving Impella support. No significant difference in the incidence of limb ischemia, stroke, repositioning, or infection was observed between these two groups. A significantly higher number of patients receiving Impella support also required ECMO (p = 0.0003) Conclusions: These data suggest that a higher risk of mortality or major complications may exist for patients receiving Impella support pre-transplant/VAD. Further analysis is needed to correct for baseline differences between these two cohorts.

Incisional Wound Vacuum-Evaluation of Wound Outcomes in Comparison With Standard Dressings for Posterior Spinal Fusions in Traumatic Patients.

Postoperative incisional negative pressure wound vacuum-assisted closure (VAC) dressings are being used as a primary dressing to optimize wound healing and help avoid complications of infection and dehiscence. Few studies have investigated whether application of VAC dressings on postoperative posterior spinal wounds can reduce the incidence of surgical site infections. To describe our single-surgeon experience of using primary VAC after posterior spinal fusion (PSF) in a large sample of trauma patients. This was an Institutional Review Board-approved retrospective comparative study and included all trauma patients presenting to our level 1 safety-net trauma center who required PSF and were operated on by the senior surgeon between 2016 and 2021. Primary outcomes were complications (surgical site infection, readmission for infection, and wound-related return to operating room [OR]) within 90 days after surgery. χ2 testing and Student t testing were used to assess differences between treatment groups while bivariate and multivariate regression was performed for outcome assessment. Two hundred sixty-four patients met criteria and were included. One hundred fifty-seven (59%) were treated with standard dressing and 107 (41%) with VAC. Patients treated with VAC were more likely to be older (P = .015), have diabetes (P = .041), have an elevated body mass index (P = .020), and had more levels of fusion (P = .002). Despite this, presence of VAC was independently associated with decreased 90-day infection (hazard ratio = 0.397, P = .023) and decreased 90-day return to OR for wound-related reasons (hazard ratio = 0.099, P = .031). Compared with the use of standard dressing, VAC was found to decrease surgical site infection and return to OR risk in trauma patients undergoing PSF.

The safety of continuous fascia iliaca block in patients with hip fracture taking pre-injury anticoagulant and/or antiplatelet medications

BackgroundFascia iliaca compartment block (FICB) is an effective method to treat pain in adult trauma patients with hip fracture. Of importance is the high prevalence of preinjury anticoagulants and antiplatelet medications in this population. To date, we have not identified any literature that has specifically evaluated the safety of FICB with continuous catheter infusion in patients on antiplatelet and/or anticoagulant therapy. The purpose of this study is to quantify the complication rate associated with FICB in patients who are actively taking prescribed anticoagulant and/or antiplatelet medications prior to injury and identify factors that may predispose patients to an adverse event. MethodsThis retrospective study included consecutive adult trauma patients (age ≥18) with hip fracture who underwent placement of FICB within 24 h of admission and had been taking anticoagulant and/or antiplatelet medications pre-injury. Patients were excluded if their catheter was placed more than 24 h post-hospital admission. Patients were evaluated for demographics, injury severity, laboratory values, medication history, receipt of coagulation-related reversal medications, and complications related to FICB placement. Complications included bleeding at the insertion site requiring catheter removal and 30-day catheter site infection. The incidence of complications was reported and risk factors for complications were identified using univariate and multivariate statistics. ResultsThere were 124 patients included. The mean age was 81 ± 10 years, and the most common mechanism was ground level fall (94%). Most patients were taking single antiplatelet therapy (65%), followed by anticoagulant alone (21%), combined antiplatelet and anticoagulant therapy (7.3%) and dual antiplatelet therapy (7.3%). The most common antiplatelet was aspirin (88%) and the most common anticoagulant was warfarin (60%). Of the patients taking warfarin, the average INR on admission was 2.3 ± 0.8. Only 1 bleeding complication (0.8%) was noted in a patient prescribed clopidogrel pre-injury which occurred 5 days post-catheter placement. This same patient was noted to have superficial surgical site bleeding most likely secondary to the use of enoxaparin for post-operative deep venous thrombosis prophylaxis. There were 4 orthopedic superficial surgical site infections (3.2%), all remote from the catheter site. The pre-injury medication prescribed in these patients was aspirin 81 mg, aspirin 325 mg, rivaroxaban and dabigatran, respectively. No factors were associated with a complication thus multivariate analysis was not performed. ConclusionThe incidence of complications associated with fascia iliaca compartment block (FICB) in adult trauma patients prescribed pre-injury anticoagulants or antiplatelet medications is low. In this retrospective review, we did not identify any complications that were directly associated with the FICB procedure. Fascia iliaca block with continuous infusion catheter placement can be safely performed on patients who are on therapeutic anticoagulant and/or antiplatelet agents.

Meta-analysis of total versus partial graft excision: Which is the better choice to manage arteriovenous dialysis graft infection?

Arteriovenous graft infection (AVGI) is a major cause of hemodialysis access failure. Delayed diagnosis and inappropriate treatment may lead to increased morbidity (3-35%) and mortality up to 12%. Compare the postoperative outcomes of total graft excision (TGE) and partial graft excision (PGE) in the treatment of AVGI. Systematic review and meta-analysis METHODS: The dataset was defined by searching PubMed, EMBASE, Google Scholar, and the Cochrane database for articles outlining the terms arteriovenous graft infection, infected dialysis graft, TGE and PGE published between 1995-2020. The data analysis evaluated the outcomes of TGE and PGE in the management of AVGI. The meta-analysis was performed using Review Manager Software version 5.4.1. 30-day mortality, recurrent infection, and reoperation rate. Eight studies, including 555 AVGI, and 528 patients. PGE showed a significant increase in recurrent graft infection rate (OR=0.23,95% CI=0.13-0.41, P<.00001) and re-operation rate for control of infection (OR=0.14,95% CI=0.03-0.58, P<.007). However, the 30-day mortality rate did not differ significantly between the groups (OR=0.92,95% CI=0.39-2.17, P=.85). TGE remains a safe and effective surgical method for the management of AVGI. PGE is associated with a higher risk of graft infection and need for re-operation. As a result, PGE should only be considered in carefully selected patients. Risk of bias due to the differences in patient characteristics. None.

Evaluation of an adaptive, multimodal intervention to reduce postoperative infections following cesarean delivery in Ethiopia: study protocol of the CLEAN-CS cluster-randomized stepped wedge interventional trial

BackgroundWe previously developed and pilot tested Clean Cut, a program to prevent postoperative infections by improving compliance with the WHO Surgical Safety Checklist (SSC) and strengthening adherence to infection control practices. This protocol describes the CheckList Expansion for Antisepsis and iNfection Control in Cesarean Section (CLEAN–CS) trial evaluating our program’s ability to reduce infections following CS and other obstetric and gynecological operations in Ethiopia.Methods/designCLEAN-CS is a cluster-randomized stepped wedge interventional trial with five clusters (two hospitals per cluster). It aims to assess the impact of Clean Cut on six critical perioperative infection prevention standards including antiseptic practices, antibiotic administration, and routine SCC use. The trial involves baseline data collection followed by Clean Cut training and implementation in each cluster in randomized order. The intervention consists of (1) modifying and implementing the SSC to fit local practices, (2) process mapping each standard, (3) coupling data and processes with site-specific action plans for improvement, and (4) targeted training focused on process gaps. The primary outcome is 30-day CS infection rates; secondary outcomes include other patient-level complications and compliance with standards. Assuming baseline SSI incidence of 12%, an effect size of 25% absolute reduction, and the ability to recruit 80–90 patients per cluster per month, we require a sample of 8100 patients for significance. We will report our study according to CONSORT.DiscussionA cluster-randomized stepped wedge design is well-suited for evaluating this type of surgical safety program. The targeted standards are not in doubt, yet compliance is frequently difficult. Solutions are available and may be recognized by individuals, but teams dedicated to improvement are often lacking. Clean Cut was successfully piloted but requires a more rigorous methodological assessment. We seek to understand the qualities, characteristics, and resources needed to implement the program, the magnitude of effect on processes and outcomes, and to what degree it can enhance compliance with care standards. Challenges include a fraught social and political environment, pandemic travel restrictions, and a limited budget.Trial registrationClinicalTrials.gov NCT04812522 (registered on March 23, 2021); Pan-African Clinical Trials Registry PACTR202108717887402 (registered on August 24, 2021).

25. Perioperative complications associated with epidural injections followed by cervical decompression and fusion

<h3>BACKGROUND CONTEXT</h3> Cervical epidural steroid injections (CESIs) are widely used to alleviate pain caused by degenerative diseases of the cervical spine. However, some data suggest a potential link between CESIs and infection rates following fusion surgeries. No prior studies have assessed the association between CESI and other postoperative outcomes such as hematomas, revision rates, or wound complications following anterior cervical discectomy and fusion (ACDF) and posterior cervical decompression and fusion (PCDF). Therefore, using a national dataset, we aimed to explore whether an association exists between preoperative CESIs and a variety of serious complications following ACDF and PCDF surgery. <h3>METHODS</h3> In this retrospective cohort study, we queried the IBM MarketScan national claims dataset (after IRB approval) and included adult patients who had undergone inpatient or outpatient ACDF or PCDF surgery due to disc herniation, stenosis, radiculopathy, spondylosis, or myelopathy from January 2014 to September 2017. Current procedural terminology codes were used to identify patients who received a CESI within one year prior to their surgery. Multivariable logistic regression measured the association between preoperative CESI and postoperative rates of 90-day infection, hematoma, wound complications, revision surgery, or combined complications (the former first three complications). We report odds ratios (OR) and 95% confidence intervals (CI). <h3>RESULTS</h3> Among 44,777 ACDF patients, 31.2% (n=13,950) received a preoperative CESI. For PCDF, 3,284 patients underwent the surgery of which 22.3% (n=734) received a preoperative CESI. The median time from most recent CESI to ACDF surgery is 76 days (interquartile range 41-144 days) and 95 days (interquartile range 49-176 days) for PCDF. Among ACDF patients, preoperative CESI was associated with lower odds of developing a hematoma following ACDF (OR 0.60; 95% CI 0.37-0.99; p=0.0453); no significant associations existed for the other outcomes including infection (OR 0.98; 95% CI 0.77-1.26; p=0.8846), revision surgery (OR 0.94; 95% CI 0.71-1.23; p=0.6300), wound complications (OR 0.92; 95% CI 0.71-1.17; p=0.4865) or combined complications (OR 0.88; 95% CI 0.73-1.07; p=0.1904). In the PCDF cohort, no significant associations existed between preoperative CESI and post-PCDF infection (OR 1.26; 95% CI 0.82-1.95; p=0.2962), revision surgery (OR 1.96; 95% CI 0.91-4.18; p=0.0842), wound complications (OR 1.11; 95% CI 0.71-1.72; p=0.6608) or combined complications (OR 1.14; 95% CI 0.78-1.68; p=0.4929). <h3>CONCLUSIONS</h3> Our study is the first to assess a broad complication profile that includes hematoma rates, infection rates, revision rates, and wound complications following ACDF and PCDF surgeries. We found no association between preoperative CESI and the aforementioned complications following ACDF and PCDF which supports first-hand clinical outcomes. Future work will aim to delineate the role of timing of CESI before ACDF and PCDF surgery, and the impact of quantity of CESIs on complication risks. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Comparison of Breast Reconstruction Outcomes Using Oxychlorosene versus Triple Antibiotic Solution for Pocket Irrigation.

Background:Breast pocket irrigation with antiseptic solutions is performed to reduce contamination with breast implants. The optimal antiseptic irrigation solution and the efficacy of individual practices are unclear. Oxychlorosene sodium is frequently used at our institution. Oxychlorosene is bactericidal with a mechanism of action of oxidation and hypochlorination. The purpose of our study was to compare the outcomes of oxychlorosene sodium irrigation with triple antibiotic solution (TAS) in implant-based breast reconstruction.Methods:All patients who underwent implant-based reconstruction after mastectomy were reviewed. The primary predictive variable was type of solution used for pocket irrigation (TAS or oxychlorosene). Outcome variables included surgical site infection, device removal, and wound complications.Results:Between 2013 and 2018, 331 implant-based breast reconstructions were performed. Of these, 62% (n = 206) received oxychlorosene for surgical pocket irrigation (group I), and 38% (n = 125) received TAS (group II). Group I had an 11.7% (n = 24) 90-day surgical site infection rate, with 4.9% (n = 10) requiring oral antibiotics, 2.4% (n = 5) requiring intravenous antibiotics without device removal, and 4.4% (n = 9) requiring prosthetic removal. Group II had an 11.2% (n = 14) 90-day infection rate, with 5.6% (n = 7) requiring oral antibiotics, 2.4% (n = 3) requiring intravenous antibiotics without device removal, and 3.2% (n = 4) requiring removal (P = 0.90). When comparing the cost of oxychlorosene irrigation with TAS irrigation, oxychlorosene was less expensive.Conclusions:Oxychlorosene and TAS have similar surgical site infection rates in prosthetic breast reconstruction. Ease of preparation and cost make oxychlorosene a more favorable option for antibiotic irrigation in reconstructive breast surgery with prosthetic devices.

Prognostic Significance of the Relative Load of KPC-Producing Klebsiella pneumoniae within the Intestinal Microbiota in a Prospective Cohort of Colonized Patients.

ABSTRACTIncreased relative bacterial load of KPC-producing Klebsiella pneumoniae (KPC-KP) within the intestinal microbiota has been associated with KPC-KP bacteremia. Prospective observational study of KPC-KP adult carriers with a hospital admission at recruitment or within the three prior months (January 2018 to February 2019). A qPCR-based assay was developed to measure the relative load of KPC-KP in rectal swabs (RLKPC, proportion of blaKPC relative to 16S rRNA gene copy number). We generated Fine-Gray competing risk and Cox regression models for survival analysis of all-site KPC-KP infection and all-cause mortality, respectively, at 90 and 30 days. The median RLKPC at baseline among 80 KPC-KP adult carriers was 0.28% (range 0.001% to 2.70%). Giannella Risk Score (GRS) was independently associated with 90-day and 30-day all-site infection (adjusted subdistribution hazard ratio [aHR] 1.23, 95% CI = 1.15 to 1.32, P < 0.001). RLKPC (adjusted hazard ratio [aHR] 1.04, 95% CI = 1.01 to 1.07, P = 0.008) and age (aHR 1.05, 95% CI = 1.01 to 1.10, P = 0.008) were independent predictors of 90-day all-cause mortality in a Cox model stratified by length of hospital stay (LOHS) ≥20 days. An adjusted Cox model for 30-day all-cause mortality, stratified by LOHS ≥14 days, included RLKPC (aHR 1.03, 95% CI = 1.00 to 1.06, P = 0.027), age (aHR 1.10, 95% CI = 1.03 to 1.18, P = 0.004), and severe KPC-KP infection (INCREMENT-CPE score >7, aHR 2.96, 95% CI = 0.97 to 9.07, P = 0.057). KPC-KP relative intestinal load was independently associated with all-cause mortality in our clinical setting, after adjusting for age and severe KPC-KP infection. Our study confirms the utility of GRS to predict infection risk in patients colonized by KPC-KP.IMPORTANCE The rapid dissemination of carbapenemase-producing Enterobacterales represents a global public health threat. Increased relative load of KPC-producing Klebsiella pneumoniae (KPC-KP) within the intestinal microbiota has been associated with an increased risk of bloodstream infection by KPC-KP. We developed a qPCR assay for quantification of the relative KPC-KP intestinal load (RLKPC) in 80 colonized patients and examined its association with subsequent all-site KPC-KP infection and all-cause mortality within 90 days. Giannella Risk Score, which predicts infection risk in colonized patients, was independently associated with the development of all-site KPC-KP infection. RLKPC was not associated with all-site KPC-KP infection, possibly reflecting the large heterogeneity in patient clinical conditions and infection types. RLKPC was an independent predictor of all-cause mortality within 90 and 30 days in our clinical setting. We hypothesize that KPC-KP load may behave as a surrogate marker for the severity of the patient’s clinical condition.

Safety of Bariatric Surgery in ≥ 65-Year-Old Patients During the COVID-19 Pandemic

BackgroundAge ≥ 65 years is regarded as a relative contraindication for bariatric surgery. Advanced age is also a recognised risk factor for adverse outcomes with Coronavirus Disease-2019 (COVID-19) which continues to wreak havoc on global populations. This study aimed to assess the safety of bariatric surgery (BS) in this particular age group during the COVID-19 pandemic in comparison with the younger cohort.MethodsWe conducted a prospective international study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into two groups — patients ≥ 65-years-old (Group I) and patients < 65-years-old (Group II). The two groups were compared for 30-day morbidity and mortality.ResultsThere were 149 patients in Group 1 and 6923 patients in Group II. The mean age, preoperative weight, and BMI were 67.6 ± 2.5 years, 119.5 ± 24.5 kg, and 43 ± 7 in Group I and 39.8 ± 11.3 years, 117.7±20.4 kg, and 43.7 ± 7 in Group II, respectively. Approximately, 95% of patients in Group 1 had at least one co-morbidity compared to 68% of patients in Group 2 (p = < 0.001).The 30-day morbidity was significantly higher in Group I (11.4%) compared to Group II (6.6%) (p = 0.022). However, the 30-day mortality and COVID-19 infection rates were not significantly different between the two groups.ConclusionsBariatric surgery during the COVID-19 pandemic is associated with a higher complication rate in those ≥ 65 years of age compared to those < 65 years old. However, the mortality and postoperative COVID-19 infection rates are not significantly different between the two groups.Graphical abstract

MP16-08 MAJOR SHIFT IN ANTIBIOTIC PROPHYLAXIS PATTERNS FOLLOWING IMPLEMENTATION OF GUIDELINES BASED CYSTOSCOPY SURVEY

You have accessJournal of UrologyCME1 May 2022MP16-08 MAJOR SHIFT IN ANTIBIOTIC PROPHYLAXIS PATTERNS FOLLOWING IMPLEMENTATION OF GUIDELINES BASED CYSTOSCOPY SURVEY Kelly R. Pekala, Danielle Sharbaugh, Jonathan G. Yabes, Adam J. Sharbaugh, Michelle Yu, Valentina Grajales, Oluwaseun Orikogbo, Hermoon Worku, Jordan M. Hay, Toby S. Zhu, Kody M. Armann, Chandler N. Hudson, Benjamin J. Davies, and Bruce L. Jacobs Kelly R. PekalaKelly R. Pekala More articles by this author , Danielle SharbaughDanielle Sharbaugh More articles by this author , Jonathan G. YabesJonathan G. Yabes More articles by this author , Adam J. SharbaughAdam J. Sharbaugh More articles by this author , Michelle YuMichelle Yu More articles by this author , Valentina GrajalesValentina Grajales More articles by this author , Oluwaseun OrikogboOluwaseun Orikogbo More articles by this author , Hermoon WorkuHermoon Worku More articles by this author , Jordan M. HayJordan M. Hay More articles by this author , Toby S. ZhuToby S. Zhu More articles by this author , Kody M. ArmannKody M. Armann More articles by this author , Chandler N. HudsonChandler N. Hudson More articles by this author , Benjamin J. DaviesBenjamin J. Davies More articles by this author , and Bruce L. JacobsBruce L. Jacobs More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002549.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inappropriate antibiotic administration has a host of well-defined deleterious downstream effects. The American UrologicalAssociation (AUA) released antibiotic guidelines for cystoscopy in June 2019 that recommended oral antibiotics only if there is a break in the mucosal barrier and fluoroquinolones were no longer the antibiotic of choice. As a result, we created a novel clinic-based rapid survey to increase AUA antibiotic guideline adherence. METHODS: To obtain baseline data, we retrospectively reviewed the urology clinic schedule for three-months and identified all patients who underwent cystoscopy. We then completed a literature review and designed a cystoscopy survey based on previous protocols and AUA guidelines to identify patients at high risk of infection. We then implemented a multi-pronged intervention for a twelve-month period where we provided a ‘formal’ grand rounds presentation, ad hoc emails with individual updates, monthly progress reports, edited the electronic health record cystoscopy order set, educated clinic staff, and started using the cystoscopy survey. We then recorded antibiotics given for prophylaxis at time of procedure, individual patient risk factors for infection, 30-day infection outcomes, and urine culture data both pre-intervention and post-intervention. RESULTS: We identified 473 cystoscopies pre-intervention, 2,137 cystoscopies in the intervention, and 417 cystoscopies post-intervention. There was a 30% decrease in the total amount of antibiotics administered and infection rates did not increase. We found that 99% of patients were administered antibiotics pre-intervention, the majority of which were fluoroquinolones. During and after the intervention phase, fluoroquinolone use decreased significantly to 15% and 6.5% respectively. (Figure 1) The utilization rates of recommended antibiotics increased to 91% and persisted post-intervention. CONCLUSIONS: We found that implementation of a cystoscopy survey enabled rapid adoption of new AUA guidelines on antibiotic prophylaxis for cystoscopy, which resulted in a drastic reduction in the amount of antibiotics administered without a spike in infection rates. The use of recommended antibiotics improved dramatically during the intervention period and persisted post-intervention. Source of Funding: Bruce L. Jacobs, MD, MPH is supported in part by the Shadyside Hospital Foundation © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e277 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kelly R. Pekala More articles by this author Danielle Sharbaugh More articles by this author Jonathan G. Yabes More articles by this author Adam J. Sharbaugh More articles by this author Michelle Yu More articles by this author Valentina Grajales More articles by this author Oluwaseun Orikogbo More articles by this author Hermoon Worku More articles by this author Jordan M. Hay More articles by this author Toby S. Zhu More articles by this author Kody M. Armann More articles by this author Chandler N. Hudson More articles by this author Benjamin J. Davies More articles by this author Bruce L. Jacobs More articles by this author Expand All Advertisement PDF DownloadLoading ...

Evaluating hip disarticulation outcomes in a 51-patient series

Hip disarticulations are proximal lower extremity amputations with high postoperative complication and mortality rates. The purpose of the study was to evaluate hip disarticulation outcomes at our institution. Targeted Muscle Reinnervation (TMR) is an effective surgical technique shown to reduce pain in amputees. A secondary goal of the study was to evaluate the impact of implementing TMR on this patient population. A retrospective review was performed for patients who underwent hip disarticulation with and without TMR between 2009 and 2020. Information on one-year mortality, thirty-day complication rates, operation times, surgical charges, and pain scores was collected. Fifty-one patients underwent hip disarticulation, eight of which had TMR performed at the time of their hip disarticulation. The one-year mortality rate was 37% with 30-day infection, readmission, reoperation, and rates of 37%, 39%, and 27% respectively. The thirty-day major complication rate was 47% overall but not statistically significantly different between groups. There were no differences between groups with regard to 30-day readmission, reoperation, and infection rates. Our results represent one of the largest series of hip disarticulation outcomes. Performing TMR at the time of hip disarticulation did not negatively affect outcomes and may be a beneficial adjunct to improve pain. Further research is warranted.

Missingness of Quality of Life Assessments Before Left Ventricular Assist Device Implant: A Novel Hospital Quality Metric

<h3>Purpose</h3> While improved health-related quality of life (HRQOL) is an important durable left ventricular assist device (LVAD) implant outcome, 50% of HRQOL data are missing in the STS-Intermacs registry. Pre-implant HRQOL missingness may reflect patient and hospital characteristics and thus serve as a novel hospital quality metric. We hypothesized that hospital pre-implant HRQOL missingness independently predicts 90-day outcomes. <h3>Methods</h3> The study cohort included 14,063 patients receiving a primary LVAD (4/2012 - 8/2017) with or without RVAD at 169 hospitals. Patient risk factors of pre-implant HRQOL (using the EQ-5D visual analog scale) missingness were examined by a stepwise logistic model. Direct standardization method was used to calculate hospital adjusted missing rates using a mixed effects logistic model. Hospitals were dichotomized as low/high based on median adjusted missing rates. Cox models, adjusting for patient risk, were used to associate a hospital's pre-implant HRQOL adjusted missing rate with 90-day infection, renal dysfunction and mortality. <h3>Results</h3> Patients with missing pre-implant EQ-5D (47.1% of patients) were younger (mean age: 56.2 vs. 57.9), more often non-White (36.3% vs. 32.0%), with an Intermacs Profile 1 (25.1% vs. 7.3%), compared to those with complete EQ-5D (all p<.0001). Probability of 90-day composite outcome differed by high and low adjusted missing rate hospitals (p<.0001, Figure). A 10% increase in hospital EQ-5D adjusted missingness was significantly associated with 90-day infection (HR: 1.05; 95%CI: 1.03-1.07), infection mortality (HR: 1.09; 95%CI, 1.01-1.18), renal dysfunction (HR: 1.03; 95%CI: 1.004-1.05) but not all-cause mortality (adjusted HR: 1.01; 95%CI, 0.98-1.04). <h3>Conclusion</h3> Higher hospital adjusted pre-implant HRQOL missingness was predictive of higher 90-day infection, infection mortality and renal dysfunction. Hospital pre-implant HRQOL missingness may serve as a novel LVAD quality metric.

VSHR: A Mathematical Model for the Prediction of Second-Wave COVID-19 Epidemics in Malaysia.

Since December 2019, a novel coronavirus (COVID-19) has spread all over the world, causing unpredictable economic losses and public fear. Although vaccines against this virus have been developed and administered for months, many countries still suffer from secondary COVID-19 infections, including the United Kingdom, France, and Malaysia. Observations of COVID-19 infections in the United Kingdom and France and their governance measures showed a certain number of similarities. A further investigation of these countries' COVID-19 transmission patterns suggested that when a turning point appeared, the values of their stringency indices per population density (PSI) were nearly proportional to their absolute infection rate (AIR). To justify our assumptions, we developed a mathematical model named VSHR to predict the COVID-19 turning point for Malaysia. VSHR was first trained on 30-day infection records prior to the United Kingdom, Germany, France, and Belgium's known turning points. It was then transferred to Malaysian COVID-19 data to predict this nation's turning point. Given the estimated AIR parameter values in 5 days, we were now able to locate the turning point's appearance on June 2nd, 2021. VSHR offered two improvements: (1) gathered countries into groups based on their SI patterns and (2) generated a model to identify the turning point for a target country within 5 days with 90% CI. Our research on COVID-19's turning point for a country is beneficial for governments and clinical systems against future COVID-19 infections.

Factors associated with early shunt revision within 30 days: analyses from the National Surgical Quality Improvement Program.

CSF shunt insertion is the most commonly performed neurosurgical procedure for pediatric patients with hydrocephalus, and complications including infections and catheter obstruction are common. The rate of readmission in the first 30 days after surgery has been used across surgical disciplines to determine healthcare quality. In the current study, the authors sought to assess factors associated with early shunt revision within 30 days using real-world data. Targeted shunt data set participant user files of the National Surgical Quality Improvement Program (NSQIP) from 2016 to 2019 were queried for patients undergoing a shunt procedure. A multivariable logistic regression model was performed to assess the impact of demographics, etiologies, comorbidities, congenital malformations, and shunt adjuncts on shunt revision within 30 days, as well as shunt revision due to infection within 30 days. A total of 3919 primary pediatric shunt insertions were identified in the NSQIP database, with a mean (± SD) patient age of 26.3 ± 51.6 months. There were a total of 285 (7.3%) unplanned shunt revisions within 30 days, with a mean duration of 14.9 ± 8.5 days to first intervention. The most common reason for intervention was mechanical shunt failure (32.6% of revision, 2.4% overall, n = 93), followed by infection (31.2% of all interventions, 2.3% overall, n = 89) and wound disruption or CSF leak (22.1% of all interventions, 1.6% overall, n = 63). Patients younger than 6 months of age had the highest overall unplanned 30-day revision rate (8.5%, 203/2402) as well as the highest 30-day shunt infection rate (3%, 72/2402). Patients who required a revision were also more likely to have a cardiac risk factor (34.7%, n = 99, vs 29.2%, n = 1061; p = 0.048). Multivariable logistic regression revealed that compared to patients 9-18 years old, those aged 2-9 years had significantly lower odds of repeat shunt intervention (p = 0.047), while certain etiologies including congenital hydrocephalus (p = 0.0127), intraventricular hemorrhage (IVH) of prematurity (p = 0.0173), neoplasm (p = 0.0005), infection (p = 0.0004), and syndromic etiology (p = 0.0136), as well as presence of ostomy (p = 0.0095), were associated with higher odds of repeat intervention. For shunt infection, IVH of prematurity was found to be associated with significantly higher odds (p = 0.0427) of shunt infection within 30 days, while use of intraventricular antibiotics was associated with significantly lower odds (p = 0.0085). In this study of outcomes after pediatric shunt placement using a nationally derived cohort, early shunt failure and infection within 30 days were found to remain as considerable risks. The analysis of this national surgical quality registry confirms that, in accordance with other multicenter studies, hydrocephalus etiology, age, and presence of ostomy are important predictors of the need for early shunt revision. IVH of prematurity is associated with early infections while intraventricular antibiotics may be protective. These findings could be used for benchmarking in hospital efforts to improve quality of care for pediatric patients with hydrocephalus.

141. Effectiveness of a Multipronged Approach to Improve Prophylactic Antibiotic Prescribing in Patients Undergoing Trans-Arterial Chemoembolization

BackgroundIn our institution, the significant use of broad-spectrum antibiotics for antibiotic prophylaxis (AP) in trans-arterial chemoembolization (TACE) was operator dependent and not evidence based. Hence, an AP guideline was developed with the Department of Vascular and Interventional Radiology and launched in May 2019, following department roadshows and creation of user-friendly electronic AP order sets. We analyzed the effectiveness and outcomes of our multipronged approach towards improving the standardization of AP prescribing.MethodsThis was a retrospective study of TACE procedures from November 2018 to March 2020, pre and post guideline implementation (Figure 1). Single IV cefazolin 2g dose (or IV clindamycin 600mg in the setting of β-lactam allergy) before TACE in patients with an uncompromised sphincter of Oddi was recommended. Patients with active infections prior to TACE were excluded. AP was deemed inappropriate if it deviated from guidelines (antibiotic choice and/or duration). Primary outcome was AP appropriateness and 30-day TACE related infections.Figure 1. Timeline of our multipronged approach ResultsSeventy patients were included. There were no differences in baseline demographics pre and post implementation (Table 1). Following guideline implementation, there was a significant improvement in AP used for TACE. AP appropriateness pre-implementation and post-implementation was 14/31 (45.2%) and 37/39 (94.9%) respectively (p< 0.001). Guideline compliant antibiotics were selected more frequently (14 [45.2%] vs 38 [97.4%], p< 0.001), and more patients received single dose AP (22 [71.0%] vs 38 [97.4%], p=0.004). Of the 18 patients who did not receive guideline recommended AP, 16 (88.9%) received IV ceftriaxone and metronidazole, 1 (5.6%) IV amoxicillin/clavulanic acid, and 1 (5.6%) IV ciprofloxacin. Ten patients received a prolonged course of AP with a median duration of 6 days (IQR 4.3, 6.5). There were no significant differences in 30-day TACE related infections (1 [3.2%] vs 2 [5.1%], p=1.000) and 30-day mortality (1 [3.2%] vs 1 [2.6%], p=1.000). No patient had surgical site skin infection. ConclusionOur multipronged approach improved AP prescribing in patients undergoing TACE. Single dose IV cefazolin prophylaxis for TACE did not compromise safety outcomes in the post implementation review.Disclosures All Authors: No reported disclosures