Deep Space Infections Research Articles

Preoperative hematocrit on early prosthetic joint infection and deep venous thrombosis rates in primary total hip arthroplasty: A database study

BackgroundTotal hip arthroplasty (THA) is a very successful surgery in restoring a patient’s quality of life. Infection is a devastating complication of THA. Many risks factors for infection in THA have been identified but little is known of the effect by preoperative hematocrit. PurposeWe aimed to evaluate the effect of preoperative hematocrit on early superficial site infections, deep infections, and deep organ space infections. MethodsOur study cohort included patients undergoing a THA in the ACS National Surgical Quality Improvement Program database from 2006 to 2015. We conducted a multivariate logistic regression analysis to evaluate an association between preoperative hematocrit and infection controlling for patients demographics and known risk factors. ResultsA total of 98,869 patients were identified in this study. Of these, 702 (0.71%) developed a superficial site infection, 314 (0.32%) a deep infection, and 226 (0.23%) an organ space infection. Our results suggested a significant increased risk of deep infection (OR=2.38, p=0.0120) and organ space infection (OR=3.05, p=0.0234) in patients with lower preoperative hematocrit (<41). In addition, patients with lower preoperative hematocrit had higher chance to receive postoperative transfusion (OR=2.93, p<0.0001). However, no significant associations between preoperative hematocrit and superficial site infections (p=0.8554), wound dehiscence (p=0.0660) and DVT (p=0.9236) were detected. ConclusionLow preoperative hematocrit is associated with increased risk of deep, organ space infections, and postoperative transfusion in THA, but not with superficial site infections, wound dehiscence and DVT.

Factors Associated with 60-Day Readmission Following Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy.

Readmission rates following surgery are subject to scrutiny in efforts to control health care costs. This study was designed to define the 60-day readmission rate following cytoreduction and HIPEC at a high-volume center and to identify factors associated with readmission. Patients who underwent complete cytoreduction and HIPEC at a single institution from August 2007 through June 2014 were identified from a prospectively maintained database. Multiple preoperative and operative factors were analyzed for their ability to predict 60-day readmission following surgery. A total of 250 patients were identified. Forty patients (17%) experienced readmission within 60days of surgery. The most common reasons for readmission were ileus/dehydration (12, 31%), deep space infection (8, 21%), and DVT/PE (6, 15%). Initial postoperative length of stay was longer for patients readmitted within 60days (median 12 vs. 9days, p=0.013). Of categorical variables analyzed, including gender, histology, HIPEC agent, intraoperative transfusion, and individual procedures performed during cytoreduction, adjuvant systemic therapy, and postoperative morbidity, only Charlson comorbidity index CCI (odds ratio (OR)=3.80 [1.68-8.60]) and stoma creation (OR=6.04 [1.56-12.14]) were associated with 60-day readmission. Few measurable variables are associated with readmission following cytoreduction and HIPEC. Patients with high CCI and those with stomas created at the time of CRS/HIPEC may be at increased risk of readmission within 60days. Earlier or more frequent follow-up for high-risk patients should be considered as a strategy to reduce readmissions.

Risky business? Investigating outcomes of patients undergoing urgent laparoscopic appendectomy on antithrombotic therapy

IntroductionThe literature regarding outcomes in patients on irreversible antithrombotic therapy (IAT) undergoing urgent laparoscopic appendectomy is limited. The aim of this multicenter retrospective study was to examine the impact of prehospital IAT on outcomes in this population. MethodsFrom 2010 to 2014, seven institutions from the Southwest Surgical Multicenter Trials (SWSC MCT) group conducted a retrospective study to evaluate the clinical course of all patients on IAT who underwent urgent/emergent laparoscopic appendectomy. The IAT+ group was subdivided into IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix). These groups were matched 1:1 to controls. The primary outcomes were estimated blood loss (EBL) and transfusion requirement. Secondary outcomes included infections (SSI – Surgical Site Infection, DSI – Deep Space Infection, and OSI – Organ Space Infection), hospital length of stay (HLOS), complications, 30-day readmissions, and mortality. ResultsOut of the 2903 patients included in the study, 287 IAT+ patients were identified and matched in a 1:1 ratio to 287 IAT-patients. In the IAT+ vs IAT-analysis, no significant differences in EBL (p = 1.0), transfusion requirement during the preoperative (p = 0.5), intraoperative (p = 0.3) or postoperative periods (p = 0.5), infectious complications (SSI; p = 1.0, DSI; p = 1.0, and OSI; p = 0.1), overall complications (p = 0.3), HLOS (p = 0.7), 30-day readmission (p = 0.3), or mortality (p = 0.1) were noted. Similarly, outcomes in the IAT+ (Aspirin only) and IAT+ (Aspirin-Plavix) subgroups failed to demonstrate any significant differences when compared to controls. ConclusionsOur analysis suggests that IAT is not associated with worse outcomes in urgent/emergent laparoscopic appendectomy. Prehospital use of IAT should not be used to delay laparoscopic appendectomy.

Comparative study of single dose preoperative antibiotics versus both preoperative and postoperative antibiotics in laparoscopic appendicectomy for nonperforated appendicitis

Background: Antibiotics are being administered both preoperatively and postoperatively even in uncomplicated nonperforated appendicitis. Studies regarding role of postoperative antibiotics in laparoscopic appendicectomy for nonperforated appendicitis are sparse. The aim of the study is therefore to study the efficacy of single dose preoperative antibiotics versus both preoperative and postoperative antibiotics in reducing surgical site infection in laparoscopic appendicectomy for uncomplicated nonperforated acute appendicitis.Methods: This is a prospective study done in general surgery department at Malla Reddy institute of medical sciences from September to April 2016.162 patients with nonperforated appendicitis were randomly allocated into two groups. 80 patients in Group A were given single dose of preoperative prophylactic antibiotics. No further antibiotics were given. 82 patients in Group B were given both preoperative and postoperative antibiotics. Postoperative surgical site infection and duration of postoperative hospital stay were compared between both groups. Statistical analysis was done using ANOVA, Fisher’s Exact test and Chi-square test wherever necessary.Results: There was no significant difference in the rate of surgical site infection in both groups. The mean duration of postoperative hospital stay was shorter in preoperative antibiotics only group (Group A). Age and gender had no significant association with surgical site infection. There was no deep incisional or organ space infection in this study.Conclusions: Single dose prophylactic antibiotics would be sufficient in cases of laparoscopic appendicectomy for simple uncomplicated nonperforated acute appendicitis. Postoperative antibiotic administration would not be necessary in these cases.

Mandibular Coronoidectomy Could Significantly Accelerate the Healing Process of Infratemporal Fossa Abscess

Management of an infratemporal fossa abscess (IFA), which is a specific form of severe and advanced deep fascial space infection (DFI), is based mainly on traditional methods. The purpose of this study was to investigate the role of mandibular coronoidectomy in accelerating IFA healing. This research is a single-center retrospective study composed of 23 patients with IFA. The predictor variables were gender, age, diabetes, severity score, and mandibular coronoidectomy. The outcome variables included hospitalization time (HT) and irrigating time (IT). A comparison of treatment outcomes between the improved and traditional surgical interventions for IFA was performed. Compared with patients who did not receive mandibular coronoidectomy (NC group; HT, 17.54±1.80days; IT, 38.54±3.73days), patients who underwent mandibular coronoidectomy (AC group) had significantly decreased HT (7.20±1.19days) and IT (15.10±1.27days; P<.01). In addition, 4 patients (31%) in the NC group received reoperation for osteomyelitis, whereas no osteomyelitis and DFI recurrence occurred in the AC group. Mandibular coronoidectomy with extra intraoral drainage could considerably accelerate the healing process of IFAs and obviously decrease the reoperation rate for osteomyelitis.

Incidence of deep fascial space infections following lower third molar removal

AbstractAimThe aim of this study is to investigate the incidence of systemic infection in the deep fascial spaces after a third molar extraction of the neck.Material and methodsThis article presents a retrospective study of 723 cases of third molar extractions under the care of Edinburgh Dental Institute over a 1 year period (July 2012 to the end of June 2013) and investigates the incidence of systemic infection in the deep fascial spaces of the neck.Results and conclusionsFour (0.5%) out of the 723 cases acquired a deep fascial space infection and required hospitalisation and further treatment. No correlation saw between the development of a deep cervical space infection and age, gender, smoking status, predisposing medical history, difficulty of extraction or experience of operator. Patients are now informed of the low risk of post‐operative deep fascial space infection following lower third molar removal. But there is a need for prospective studies, which would provide reliable and accurate information on the true incidence of this significant post‐operative complication.

Association between retained third molars and depth of impaction with prevalence of deep fascial space infections

Association between retained third molars and depth of impaction with prevalence of deep fascial space infections

Timing of Complications Occurring Within 30 Days After Adult Spinal Deformity Surgery

Study DesignCross-sectional study of a national surgical database. ObjectiveTo investigate the timing of complications after adult spinal deformity (ASD) surgery. Summary of Background DataThere is limited data on the range of days when complications after ASD surgery occur. MethodsThe American College of Surgeons National Surgical Quality Improvement database was reviewed for the years 2007–2013. Inclusion criteria were adult patients (over 21 years of age) who underwent spinal fusion for ASD. Ten unique complications occurring within 30 postoperative days were examined and the median day to diagnosis was recorded. ResultsA total of 1,250 patients met inclusion criteria with an overall complication rate of 13.5%. The median day of diagnosis (and interquartile range) for each complication was as follows: myocardial infarction (3.5, 1–5), pulmonary embolism (4, 2–16), reintubation (4.5, 1–11), pneumonia (6, 3–9), urinary tract infection (11, 5–15), sepsis (12, 6–18.5), deep vein thrombosis (12, 6–19), deep surgical site infection (SSI; 18.5, 13–23), superficial SSI (19, 13–24), and organ space SSI (21, 17–25). The three complications that were most commonly diagnosed before hospital discharge included pneumonia, reintubation, and myocardial infarction (diagnosed before discharge on more than 70% of cases). On the other hand, superficial, deep, and organ space infection were diagnosed in less than 40% of cases before patients left the hospital. On univariate analysis, predictors of complication occurrence included older age (p = .014), instrumentation of 7–12 levels (p = .034), and instrumentation of 13 or more levels (p = .035). ConclusionUnderstanding the timing of specific complications after adult spinal deformity surgery is important for both patients and clinicians. Efforts in prevention of such conditions should continue, as well as heightened awareness during the periods of highest risk.

An Unusual Masticator Space Infection Initially Presenting as Temporomandibular Joint Dislocation: A Case Report

Masticator space infection can easily be misdiagnosed as temporomandibular joint (TMJ) disorder. However, the association between masticator space infection and TMJ dislocation has not been studied. The present study describes a case of masticator space infection that initially presented as TMJ dislocation. A 63-year-old woman complained of dislocation and pain on the right TMJ for 3 weeks. Physical examination revealed right TMJ dislocation, which was confirmed by computed tomography (CT). Bimanual reduction of the dislocated TMJ was performed under general anesthesia with intermaxillary fixation. However, progressive right facial swelling was noted after the closed reduction of the right TMJ. Magnetic Resonance Imaging (MRI) revealed marked soft tissue swelling and mass forming-like change in the periarticular region of the right TMJ. Moreover, a necrotic area of the masseter and buccinators muscles was noted, which indicated dislocation-induced injury or hemorrhage. However, neoplasm arising from the joint space could not be ruled out. CT-guided biopsy was then performed, which showed chronic inflammation and necrotic tissue in the right masticator space, thus excluding the possibility of neoplasm. Extraoral Incision and Drainage (I&D) was then performed, and the final pathologic diagnosis coincident with cellulitis involved the masticator space and parotid spaces. After I&D and surgical debridement, the patient recovered satisfactorily. Although rare, we must consider the possibility of deep space infection when diagnosing patients presenting TMJ dislocation for their adequate and prompt management.

A study of deep space infections of neck

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The objective of the study was to analyse the signs and symptoms, etiology, site and outcome of deep space infections of neck.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This was retrospective study and included 50 patients admitted with deep neck space infections to Government Mc Gann teaching hospital SIMS, Shimoga, Karnataka, India between January 2009 – January 2015. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The extreme age group, high virulence of organism, underlying clinical conditions, low socioeconomic groups are vulnerable for above infections. Mortality in 3 cases was due to mediastinitis and extended space infection.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Deep neck space infection is still a challenging disease in otorhinolaryngology. Early surgical drainage remains the main method of treating deep neck abscesses and conservative medical treatment are effective in selective cases that have minimal cellulitis.&lt;/p&gt;

Laparoscopic Repair for Perforated Peptic Ulcer: A Retrospective Study.

The incidence of patients presenting with perforated peptic ulcers (PPU) has decreased during the last decades. At the same time, a laparoscopic approach to this condition has been adopted by increased number of surgeons. The aim of this study was to evaluate the early postoperative results of the laparoscopic treatment of perforated peptic ulcer performed in eight Romanian surgical centers with extensive experience in laparoscopic surgery. Between 2009 and 2013, 297 patients with perforated peptic ulcer were operated in the eight centers participating in this retrospective study. The patients' charts were reviewed for demographics, surgical procedure, complications and short-term outcomes. Boey score of 0 was found in 122 patients (41.1%), Boey 1 in 169 (56.9%), Boey 3 in 6 (2.0%). For 145 (48.8%) patients, primary suture repair was performed, in 146 (49.2%) primary suture repair with omentopexy. There were 6 (2.0%) conversions to open surgery. The operative time was between 25 and 120min, with a mean of 68min. Two (0.7%) deaths were noted. Mean hospital stay was 5.5days, ranges 3-25days. Postoperative complications included: 7 (2.4%) superficial surgical site infections, 5 (1.6%) cardiovascular, 3 (1.0%) pulmonary, 2 (0.7%) duodenal leakages, 3 (1.0%) deep space infections and 1 (0.3%) upper digestive hemorrhage. This study shows that the laparoscopic approach for PPU is feasible; the procedure is safe, with no increased risk of duodenal fistulae or residual intraperitoneal abscesses. We now consider the laparoscopic approach for PPU as the "gold standard" in patients with Boey score 0 or 1.

What Is the Real Rate of Surgical Site Infection?

Surgical site infections (SSIs) are associated with patient morbidity and increased health care costs. Although several national organizations including the University HealthSystem Consortium (UHC), the National Surgical Quality Improvement Program (NSQIP), and the National Healthcare Safety Network (NHSN) monitor SSI, there is no standard reporting methodology. We queried the UHC, NSQIP, and NHSN databases from July 2012 to June 2014 for SSI after gynecologic surgery at our institution. Each organization uses different definitions and inclusion and exclusion criteria for SSI. The rate of SSI was also obtained from chart review from April 1 to June 30, 2014. SSI was classified as superficial, deep, or organ space infection. The rates reported by the agencies were compared with the rates obtained by chart review using Fisher's exact test. Overall SSI rates for the databases were as follows: UHC, 1.5%; NSQIP, 8.8%; and NHSN, 2.8% (P < .001). The individual databases had wide variation in the rate of deep infection (UHC, 0.7%; NSQIP, 4.7%; NHSN, 1.3%; P < .001) and organ space infection (UHC, 0.4%; NSQIP, 4.4%; NHSN, 1.4%; P < .001). In agreement with the variation in reporting methodology, only 19 cases (24.4%) were included in more than one database and only one case was included in all three databases (1.3%). There is discordance among national reporting agencies tracking SSI. Adopting standardized metrics across agencies could improve consistency and accuracy in assessing SSI rates.

The DISINFECT Initiative: Decreasing the Incidence of Surgical INFECTions in Gynecologic Oncology.

Surgical site infections (SSIs) lead to increased patient morbidity and healthcare costs. Our objective was to decrease the SSI rate following gynecologic surgery. Adult patients undergoing abdominal surgery for gynecologic malignancy or benign disease received the following: patient education; preoperative antibacterial soap; appropriate antibiotic prophylaxis; change of gloves and use of clean instruments at surgical closure; surgical dressing for 48h; and a post-discharge phone call. The baseline SSI rate was determined retrospectively (1 April 2014-30 June 2014), while the post-intervention SSI rate was determined prospectively (16 February 2015-15 October 2015). The main outcome was the overall SSI rate with secondary outcomes, including the rate of superficial, deep, incisional and organ space infection, as well as the cost effectiveness of the bundle. A total of 232 baseline and 555 post-intervention patients were included in the study. No differences were observed between the baseline and post-intervention groups with regard to median body mass index (BMI), surgical approach, receipt of preoperative chemotherapy and/or radiation therapy, and cases including bowel surgery. Overall, the SSI rate decreased significantly from baseline [12.5%] to post-intervention [7.4%] (odds ratio [OR] 0.56, 90% confidence interval [CI] 0.37-0.85; p=0.01). A 40% decrease was noted in the rate of superficial and deep infections (9.5 vs. 5.9%; OR 0.60, 90% CI 0.38-0.97; p=0.04) and SSIs after open surgery (21.4 vs. 13.2%; OR 0.56, 90% CI 0.34-0.92; p=0.03). The estimated cost of the intervention was $19.26/case and the net total amount saved during the post-intervention period was $65,625month. This bundled intervention led to a significant decrease in the overall SSI rate and was cost effective. The largest decreases in SSIs were in incisional infections and following open surgery.

Risk of Surgical Site Infection Varies Based on Location of Disease and Segment of Colorectal Resection for Cancer.

Current quality-monitoring initiatives do not accurately evaluate surgical site infections based on type of surgical procedure. This study aimed to characterize the effect of the anatomical site resected (right, left, rectal) on wound complications, including superficial, deep, and organ space surgical site infections, in patients who have cancer. Data were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database. This study was designed to determine the independent risk associated with the anatomical location of cancer resection for all subtypes of surgical site infection. Statistical methods included the Fisher exact test, the χ test, and univariable and multivariable analyses for each outcome of interest. All colon and rectal resections for colorectal cancer between 2006 and 2012 were selected. Included were 45,956 patients: 17,993 (39.2%) underwent right colectomy, 11,538 (25.1%) underwent left colectomy, and 16,425 (35.7%) underwent rectal resections. The overall surgical site infection rate was 12.3%: 3.7% organ space, 1.4% deep, and 7.2% superficial. On multivariable analysis, rectal resection was associated with the greatest odds of overall surgical site infections in comparison with left- or right-sided resections (rectal OR, 1.51; 95% CI, 1.35-1.69 vs left OR, 1.09; 95% CI, 0.97-1.23 vs right OR, 1). Rectal resections were also associated with greater odds of developing a deep surgical site infection than either right (rectal OR, 1.45; 95% CI, 1.06-1.99) or left (OR, 0.89; 95% CI, 0.62-1.27). The likelihood of organ space surgical site infection followed a similar pattern (rectal OR, 1.83; 95% CI 1.49-2.25; left colon, OR, 0.95; 95% CI, 0.75-1.19). Rectal and left resections had increased odds of superficial surgical site infections compared with right resections (rectal OR, 1.31; 95% CI, 1.14-1.51; left OR, 1.19; 95% CI, 1.03-1.37). This is a retrospective observational study. Rectal resections for cancer are independently associated with an increased likelihood of superficial, deep, and organ space infections. The policy on surgical site infections as a quality measure currently in place requires modification to adjust for the location of pathology and, hence, the anatomical segment resected when assessing the risk for type of surgical site infection.

Wound Infections After Pancreaticoduodenectomy.

Fongandcolleagues reporton the“DiscordanceBetweenPerioperative Antibiotic Prophylaxis and Wound Infection Cultures inPatientsUndergoingPancreaticoduodenectomy.”1Their observational study1 is the largest, multi-institutional evaluation of perioperative antibioticuse that is correlatedwith postoperative wound infections after pancreatoduodenectomy. Interestingly, thewound infection rate is exactly the same despite different prophylactic antibiotic regimens. The authors are to be commended for their great effort in collecting and analyzing data from 1623 patients. It iswellknownthatpreoperativebiliarymanipulationleads to bactobilia, resulting in a greater risk of wound infection.2 There are several randomized trials3 that suggest that preoperativebiliarydrainage shouldbeavoided for this reason.Practically speaking, most patients undergo pancreatoduodenectomyafterhavingundergonemanipulationof thebiliary tree,4 andgiven the increased riskof infection,howshould thesepatients be managed? There is a rich body of literature suggesting that patientswhounderwent biliarymanipulationprior to pancreatoduodenectomy should receive special attention,5,6 with some centers continuing antibiotic treatment until intraoperative bile cultures are known to be negative.7 Despite the different practice patterns at the 3 institutionswhosepancreatic databaseswere queried byFong et al,1 theconsistent findingwas that intraoperativebile culturespredicted the spectrumofpostoperativewound infections. In addition, the therapeutic range of the prophylactic antibiotics used did not correspond to the spectrum of wound infection cultures found at each institution. Despite this, all 3 institutions combined had an acceptably low overall wound infection rate of 8.2%. This study1 does not demonstrate a correlation between any perioperative intervention and an actual reduction in the rate ofwound infections. Any suchproposed intervention would need to be evaluated from a cost and adverse-effectpointofviewin lightof the fact that it isnotneeded for the 91.8% of patients who do not get infections. It is not clear that obtaining intraoperative bile cultures will improve the outcomes of patients with wound infections. Unfortunately, this study1 focused only on wound infections, not deep space infections, which potentially can have much more of an impact on a patient’s clinical course. Fong et al1 advocate for routine bile cultures to direct antibiotic therapy in the event that awound infection subsequently occurs. This seems reasonable, although fewsurgeonsdo it, and local wound treatments rather than choice of systemic antibiotics likelyhas abigger impact onultimate resolution.There is an important universal message in this study1 that may apply to all fields of surgery: institution-specific internal reviews should be undertaken to ensure that the prophylactic antibiotic chosen actually covers the organisms identified in wound infections for that institution. It seems that infections, like politics, are local.

Prolonged Length of Stay after Esophageal Resection: Identifying Drivers of Increased Length of Stay Using the NSQIP Database

Although influence of technical complications in association to hospital length of stay has been studied extensively in esophageal resection, nontechnical factors responsible for prolonged length of stay have not been reported. Using the NSQIP dataset, we hypothesized that we would be able to identify factors associated with prolonged length of stay after esophagectomy. National Surgical Quality Improvement Program data from 2005 to 2012 were reviewed for CPT codes for esophagectomy. Outlier status for length of stay was defined as >75th percentile. Logistic regression was used to predict outlier status and linear regression to discern factors contributing to longer lengths of stay. A total of 3,538 cases were reviewed. The 75th percentile for length of stay was 17 days. Preoperative predictors of hospital stay outliers include emergency surgery and frailty index (odds ratios= 3.7 and 3.6; p < 0.001). Deep organ space infection and progressive renal insufficiency had the highest likelihood of prolonged length of stay (odds ratios= 5.2 and 5.1; p<0.001). Failure to wean off of ventilator in 48 hours, urinary tract infection, and pneumonia were associated with length of stay outlier (odds ratios= 3.7, 2.7, and 2.7; all p < 0.001). Urinary tract infection and pneumonia after esophagectomy are associated with longer hospital stays. Although meticulous surgical technique remains paramount, our study demonstrates that postoperative nontechnical complications factor into prolonged hospital stays. Focus on such factors can lead to reductions in hospital stays.

Drivers of readmissions in vascular surgery patients

Postoperative readmissions are frequent in vascular surgery patients, but it is not clear which factors are the main drivers of readmissions. Specifically, the relative contributions of patient comorbidities vs those of operative factors and postoperative complications are unknown. We sought to study the multiple potential drivers of readmission and to create a model for predicting the risk of readmission in vascular patients. The 2012-2013 American College of Surgeons National Surgical Quality Improvement Program data set was queried for unplanned readmissions in 86,238 vascular patients. Multivariable forward selection logistic regression analysis was used to model the relative contributions of patient comorbidities, operative factors, and postoperative complications for readmission. The unplanned readmission rate was 9.3%. The preoperative model based on patient demographics and comorbidities predicted readmission risk with a low C index of .67; the top five predictors of readmission were American Society of Anesthesiologists class, preoperative open wound, inpatient operation, dialysis dependence, and diabetes mellitus. The postoperative model using operative factors and postoperative complications predicted readmission risk better (C index, .78); postoperative complications were the most significant predictor of readmission, overpowering patient comorbidities. Importantly, postoperative complications identified before discharge from the hospital were not a strong predictor of readmission as the model using predischarge postoperative complications had a similar C index to our preoperative model (.68). However, the inclusion of complications identified after discharge from the hospital appreciably improved the predictive power of the model (C index, .78). The top five predictors of readmission in the final model based on patient comorbidities and postoperative complications were postdischarge deep space infection, superficial surgical site infection, pneumonia, myocardial infection, and sepsis. Readmissions in vascular surgery patients are mainly driven by postoperative complications identified after discharge. Thus, efforts to reduce vascular readmissions focusing on inpatient hospital data may prove ineffective. Our study suggests that interventions to reduce vascular readmissions should focus on prompt identification of modifiable postdischarge complications.

Change in Adverse Events After Enrollment in the National Surgical Quality Improvement Program: A Systematic Review and Meta-Analysis.

BackgroundThe American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) is the first nationally validated, risk-adjusted, outcomes-based program to measure and compare the quality of surgical care across North America. Participation in this program may provide an opportunity to reduce the incidence of adverse events related to surgery.Study DesignA systematic review of the literature was performed. MedLine, EMBASE and PubMed were searched for studies relevant to NSQIP. Patient characteristics, intervention, and primary outcome measures were abstracted. The intervention was participation in NSQIP and monitoring of Individual Site Summary Reports with or without implementation of a quality improvement program. The outcomes of interest were change in peri-operative adverse events and mortality represented by pooled risk ratios (pRR) and 95% confidence intervals (CI).ResultsEleven articles reporting on 35 health care institutions were included. Nine (82%) of the eleven studies implemented a quality improvement program. Minimal improvements in superficial (pRR 0.81; 95% CI 0.72–0.91), deep (pRR 0.82; 95% CI0.64–1.05) and organ space (pRR 1.15; 95% CI 0.96–1.37) infections were observed at centers that did not institute a quality improvement program. However, centers that reported formal interventions for the prevention and treatment of infections observed substantial improvements (superficial pRR 0.55, 95% CI 0.39–0.77; deep pRR 0.61, 95% CI 0.50–0.75, and organ space pRR 0.60, 95% CI 0.50–0.71). Studies evaluating other adverse events noted decreased incidence following NSQIP participation and implementation of a formal quality improvement program.ConclusionsThese data suggest that NSQIP is effective in reducing surgical morbidity. Improvement in surgical quality appears to be more marked at centers that implemented a formal quality improvement program directed at the reduction of specific morbidities.

Aerobic microbiology and culture sensitivity of head and neck space infection of odontogenic origin.

Context:Head and neck space infections source, age, gender, tooth involved, fascial spaces involved, microbiological study of aerobic flora, and antibiotic susceptibilities.Aims:The aim of the present study is to identify causative aerobic microorganisms responsible for deep fascial spaces of head and neck infections and evaluate the resistance of antibiotics used in the treatment of such.Settings and Design:Prospective study in 100 patients.Materials and Methods:This prospective study was conducted on 100 patients who reported in the outpatient department and fulfilled the inclusion criteria to study aerobic microbiology and antibiotic sensitivity in head and neck space infection of odontogenic origin. Pus sample was obtained either by aspiration or by swab stick from the involved spaces, and culture and sensitivity tests were performed.Statistical Analysis Used:Chi-square test and level of significance.Results:Result showed aerobic Gram-positive isolates were 73% and aerobic Gram-negative isolates were 18%. Nine percent cases showed no growth. Streptococcus viridans was the highest isolate in 47% cases among Gram-positive bacteria, and in Gram-negative, Klebsiella pneumoniae was the highest isolate of total cases 11%. Amoxicillin showed resistance (48.4%) as compared to other antibiotics such as ceftriaxone, carbenicillin, amikacin, and imipenem had significantly higher sensitivity.Conclusions:Amoxicillin with clavulanic acid showed (64.8%) efficacy for all organisms isolated, whereas ceftriaxone showed (82.4%) efficacy and could be used in odontogenic infections for both Gram-positive and Gram-negative microorganisms. Substitution of third generation cephalosporin for amoxicillin in the empirical management of deep fascial space infections can also be used. Carbenicillin, amikacin, and imipenem showed (93.4%) sensitivity against all microorganisms and should be reserved for more severe infection. Newer and broad-spectrum antibiotics are more effective in vitro than older narrow spectrum antibiotics.

Retropharyngeal cellulitis complicated by cervical spondylodiscitis: A case report

Secondary to pharyngeal trauma such as endotracheal intubation, endoscopy and after foreign body ingestion, or removal may develop retropharyngeal cellulitis in adults. These infections occur mainly in children between 1 to 8 years of age with 75% of cases occurring before the age of 5 years. Retropharyngeal cellulitis is a serious deep space infection which can extend from neck to the mediastinum. Herein, we represent a case of 24-year-old female patient who presented with neck pain, odynophagia, and malaise two months after accidental ingestion of a little pin. Uncomplicated removal of this pin was followed by development of retropharyngeal cellulitis and cervical spondylodiscitis. The patient was successfully treated with intravenous and oral antibiotics for 12 weeks without need to surgical intervention. We believe that early and aggressive medical treatment can eradicate nonsuppurative complicated retropharyngeal infection without the need for surgery. J Microbiol Infect Dis 2015;5(4): 180-183 Key words: Pharyngeal trauma, cervical spondylodiscitis, cellulitis