Duration Of Prophylaxis Research Articles

Evaluation of the frequency of hepatitis b virus reactivation and the importance of hepatitis b prophylaxis in hematology patients receiving immunosuppressive therapy: a single-center study

Aims: The aim of this study was to evaluate the rate of hepatitis B virus reactivation (HBVr) in hematology patients receiving immunosuppressive therapy in our center and the clinical characteristics of patients with HBVr. We will also investigate the importance of effective prevention of this potentially life-threatening event and management of hepatitis B virus (HBV) prophylaxis. Methods: In this study, hepatitis B prophylaxis and its effects on patients over 18 years of age receiving immunosuppressive therapy in the hematology clinic were analyzed. 122 patients were included in the study. The HBV markers of the patients were determined by the chemiluminescence method. In the study, HbsAg(+) and isolated antiHbc IgG-positive patients received prophylactic antiviral treatment. The differential diagnosis of HBV reactivation and the criteria determined to define HBV reactivation were performed. Clinical characteristics and descriptive information of patients receiving HBV prophylaxis were analyzed using SPSS 25.0. Results: The median age of 122 patients (59.8% male) was 58 years. It was determined that five HbsAg-positive patients had no prior follow-up and did not receive antiviral treatment. 117 patients had isolated anti-HBc IgG positivity. The median duration of prophylaxis was 15 (9- 21.25) months, and the total follow-up period was 19.5 (11.75- 30.25) months. 81.1% of the patients received regular HBV prophylaxis treatment; 59% of them received entecavir, and the rest received tenofovir disoproxil. Bone marrow transplantation was performed in 25 patients. HBV reactivation was detected in only 4 patients (3.3%); one of these patients had received allogeneic and one autologous bone marrow transplantation; and three patients had received chemoimmunotherapy including Rituximab. The diagnoses of the patients with HBVr were acute myeloid leukemia, lymphoma, and chronic lymphocytic leukemia. During the follow-up period, 29 patients (23.8%) died due to their primary disease, but there were no deaths due to HBV reactivation. Conclusion: The data obtained in this study show that effective hepatitis B prophylaxis treatment is successful in preventing HBV reactivation in hematology patients. HBVr was observed in four patients who did not take HBV prophylaxis medication regularly.

Impact of Letermovir Prophylaxis for Cytomegalovirus Reactivation on Post-Transplant Outcomes 100 Days before and after Allogeneic Hematopoietic Cell Transplantation

Background: Cytomegalovirus (CMV) infection is a major infectious complication following allogeneic hematopoietic cell transplantation (allo-HCT). Although letermovir (LMV) prophylaxis dramatically reduces the incidence of early clinically significant CMV (csCMV) infection, it remains unclear whether it has a beneficial effect on nonrelapse mortality (NRM) and overall survival (OS). Additionally, because the incidence of csCMV infection increases after completing LMV prophylaxis, the impact of late csCMV infection beyond 100 days after transplantation on posttransplant outcomes should also be verified. Study Design: We included adult patients with acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), chronic myeloid leukemia (CML), or myelodysplastic syndrome (MDS) aged ≥16 years who underwent allo-HCT between 2017 and 2019. These patients' data were obtained from the registry database of the Japanese Society for Transplantation and Cellular Therapy (JSTCT). Results: Donor CMV seronegativity (D-CMV −)/recipient CMV seronegativity (R-CMV −) was recorded in 558 cases (9.3%), and R-CMV +/D-CMV + or - was recorded in 4,562 cases (78.0%). The median age was 51 (range, 16-80) years. The median follow-up length was 389 (range, 0-1,334) days. LMV prophylaxis was administered to 1,640 patients (LMV group), and the median duration of LMV prophylaxis was 85 (range, 2-152) days. LMV prophylaxis significantly reduced the incidence of early csCMV infection compared with those not administered LMV prophylaxis (15.4% vs. 54.1%; p<0.01, hazard ratio [HR], 0.30; p<0.01)). However, LMV prophylaxis did not have any beneficial effect on the 1-year NRM (HR, 0.93; p=0.40) and OS (HR, 0.96; p=0.49) in multivariate analysis. The possible causes were breakthrough csCMV infection within 100 days after transplantation during LMV prophylaxis and late csCMV infection after 100 days after transplantation after completion of LMV prophylaxis. Breakthrough csCMV infection during LMV prophylaxis developed in 74 (4.5%) of the 1,640 patients who had received LMV prophylaxis. Breakthrough csCMV infection occurred at a median of 33 (range, 6-139) days after transplantation. R-CMV +, prior transplantation, cord blood (CB) transplants, anti-thymocyte globulin (ATG) or posttransplant cyclophosphamide (PTCY) use for GVHD prophylaxis, and grade II-IV acute GVHD were associated with an increased risk of breakthrough csCMV infection. The breakthrough csCMV infection group showed inferior NRM (HR, 3.44; p<0.01) and OS (HR, 1.93; p=0.02) compared with those without infection among LMV prophylaxis group. After completing LMV prophylaxis, 252 patients had late csCMV infection at a median of 134 (range, 101-405) days after transplantation. In multivariate analysis, R-CMV +, older age, CB transplantation, ATG and/or PTCY use for GVHD prophylaxis, grade II-IV acute GVHD, and LMV prophylaxis before day 100 after transplantation were associated with an increased risk of late csCMV infection. Late csCMV infection showed inferior NRM (HR, 1.83; p<0.01) and OS (HR, 1.58; p<0.01) in multivariate analysis. Conclusion: LMV prophylaxis efficiently suppressed the development of early csCMV infection; however, this effect did not translate into improved posttransplant outcomes. Breakthrough csCMV infection during LMV prophylaxis and the development of late csCMV infection after completing LMV prophylaxis worsened transplant outcomes in the LMV prophylaxis group. Further improvements in posttransplant CMV management will be required to address these issues.

From Widespread to Tailored Antifungal Prophylaxis in Lymphoma Patients Treated with CD19 CAR T- Cell Therapy: Less Is Better

Introduction: Invasive fungal infections (IFI) are a major threat in patients with hematological malignancies with substantial associated morbidity. Patients who receive CD19 CAR T-cell therapy have multiple immune defects that may predispose them to IFI. However, the role and duration of antifungal prophylaxis in this population is debated. Methods: This retrospective study at Memorial Sloan Kettering Cancer Center (MSK) describes the characteristics of antifungal prophylaxis and the frequency of IFI after CD19 CAR T-cell therapy in patients with R/R B-cell lymphoma. Two groups of patients were analyzed. Group A (2016-2020): patients primarily received fluconazole, as clinically indicated, regardless of clinical risk profile; Group B (2020-2023) standard guidelines were established in 2020 with antifungal prophylaxis recommended only in high-risk patients with prolonged neutropenia (≥ 3 weeks), those on systemic steroids (≥0.5 mg/kg/day of prednisone equivalent) for ≥ 3 days, or in patients with previous IFI; patients were treated based on a more restrictive mold-active and patient-tailored prophylactic strategy. Results: Three hundred thirty-two patients treated with CAR T-cell therapy for R/R lymphoma between 2016 and 2023 were analyzed. Group A was comprised of 144 patients, whereas group B had 188 patients. Patients' characteristics are described in Table 1. Overall antifungal prophylaxis was prescribed in 95 (66.4%) and 58 (30.9%) patients in group A and B, respectively. While fluconazole was most frequently given in both groups, there was 50% less use in group B (Figure 1). Anti-mold azoles were prescribed in 8.4% of group A patients, whereas for group B, it increased to 34.5%. In group A, a switch to another antifungal was observed in 42 (29%) patients, mainly to micafungin because of transaminitis with azoles. In group B, 21 (11.2%) patients switched their first antifungal drug, mainly from fluconazole or micafungin to a mold-active agent following updated guidelines. Median duration of grade IV neutropenia was 9 days (range 1-93) for group A and 12 days (range 1-90) for group B. Grade IV neutropenia was present at the start of prophylaxis in 30 (31.5%) patients in group A and 30 (51.7%) patients in group B. In the subgroup of patients without prophylaxis, only 13% in group A and 4% in group B were neutropenic. Bridging therapy was administered in 70% of patients in group A and 80% in group B. IFI infections after CAR T-cell therapy were rare: one patient had cryptococcal meningoencephalitis in group A (0.7%) and one had invasive aspergillosis in group B (0.5%), both on micafungin prophylaxis, not effective on molds and cryptococcus. These results show better rates for IFI compared to the FDA adverse events reporting system (FAERS) database: which is 3.1% considering the same CAR-T products. All-cause mortality was similar between both groups (A: 29.8% vs B: 35.7%). Conclusion: This large single-center cohort of R/R lymphoma patients after CAR T-cell therapy offers a valuable snapshot of two different antifungal prophylactic approaches with remarkably low rates of IFI in both strategies, even after the 2020 guideline update with more restrictive antifungal use. Given the risk of toxicity, drug-drug interactions, and concerns for emerging antifungal resistance with azoles, a restrictive prophylactic strategy seems the best choice in this setting.

Appropriateness of Surgical Antimicrobial Prophylaxis in a tertiary care hospital: A prospective observational study

Surgical site infections (SSIs) are a significant concern in global healthcare, particularly in middle and low-income countries, leading to increased hospitalizations, morbidity, mortality, and financial strain. Ranked third in the CDC's National Nosocomial Infections Surveillance System, SSIs have prompted a focus on preventive measures, notably surgical antimicrobial prophylaxis (SAP). However, SAP is often used inappropriately, contributing to the rise of Antimicrobial Resistance (AMR). Addressing this, a six-month prospective observational study was conducted in a tertiary care hospital to assess the adherence to SAP guidelines among 386 patients undergoing surgeries in various specialties. The study aimed to evaluate the appropriateness of SAP practices and identify factors leading to non-compliance. Results showed that only 58.3% of patients fully adhered to the guidelines. While 100% compliance was observed in SAP indication, lower adherence was noted in the timing of administration (97.7%), choice of SAP (85%), and duration of prophylaxis (70.2%). These findings underscore a significant gap between recommended SAP practices and actual implementation. This gap highlights the need for stronger Institutional Antimicrobial Stewardship (AMS) programs and the critical role of clinical pharmacists in regularly evaluating SAP and prescribing practices. To combat the rise of antibiotic resistance while ensuring patient safety, enhancing SAP practices in line with national and international recommendations is essential. The study advocates for more active interventions at the time of order to optimize antibiotic use, thereby addressing the challenge of compliance in SAP guidelines.

2739. Evaluation of a Perioperative Fungal Prophylaxis Protocol Change in Orthotopic Liver Transplant

Abstract Background Orthotopic liver transplant (OLT) carries a high rate of fungal infections, including invasive fungal infections (IFI). A targeted antifungal prophylaxis protocol can identify OLT patients who warrant antifungal prophylaxis and optimize agent selection. In January 2021, a targeted antifungal prophylaxis post-liver transplant protocol was implemented at Cleveland Clinic. Since its introduction, rates of fungal infections and adherence to the protocol have not been assessed. The goal of this project is to describe the impact of a protocol change in OLT recipients. Methods This was a retrospective observational cohort study of patients ≥ 18 years old with an OLT +/- sequential kidney transplant at Cleveland Clinic. Review of perioperative fungal prophylaxis from June 1, 2019 – May 31, 2020 was performed and used as the baseline. The post-intervention period was June 1, 2021 – May 31, 2022. The primary objective was to determine adherence to the new OLT fungal prophylaxis protocol on post-operative day (POD) 0. Secondary objectives included the 90-day incidence of proven or probable IFI post-OLT before and after implementation. Study Population Results A total of 134 patients pre-protocol and 166 patients post-protocol were included. Prior to protocol implementation, 73% patients were prescribed clotrimazole, 13% fluconazole, 13% micafungin, and 1% nystatin. After protocol implementation, 63% were prescribed clotrimazole, 16% fluconazole, and 21% micafungin. In the post-protocol group, there was an adherence rate of 66% on POD0 which increased to 84% over the duration of prophylaxis. Prior to initiation of the antifungal protocol, 6.7% of patients developed an IFI while 3.6% of patients developed an IFI post-protocol (p=0.22). Median time to IFI was 8 days (IQR 2-19) pre-protocol and 15 days (IQR 6-17) post-protocol. Mortality and ICU length of stay were comparable between groups. Primary and Secondary Results OLT: orthotopic liver transplant; POD: post-operative day; ICU: intensive care unit; IFI: invasive fungal infection Characteristics of Patients with Invasive Fungal Infections IFI: invasive fungal infection; TPN: total parenteral nutrition; IAI: intra-abdominal infection; n/a: not applicable; pRBC: packed red blood cells; OR: operating room; RRT: renal replacement therapy; ICU: intensive care unit; Dose dep.: dose dependent; GI: gastrointestinal Conclusion The implementation of a targeted antifungal prophylaxis post-liver transplant protocol can be a powerful strategy for promoting consistency in antifungal prophylaxis within a population at high risk for IFIs. Our study showed an 84% adherence rate to the implemented protocol, with numerically lower rates of IFIs post-protocol compared to pre-protocol. Disclosures All Authors: No reported disclosures

1995. Duration of letermovir primary prophylaxis in hematopoietic cell transplant recipients at high risk for cytomegalovirus infections and impact on outcomes

Abstract Background The incidence of clinically significant cytomegalovirus infection (CS-CMVi) in high risk allo-HCT recipients who are CMV seropositive (R+) has decreased in the era of letermovir (LTV) primary prophylaxis (PP) which is also associated with a reduction in all-cause mortality (ACM) and non-relapse mortality (NRM). Most reduction of CS-CMVi occur within the first 100 days when CMV PP is employed but it is unclear if PP beyond 100 days further impacts CMV outcomes and mortality. Methods In a single-center study of CMV R+ recipients of allo-HCT between March 2016 and December 2019, we compared the outcomes for those who were not on LTV PP to those on LTV PP for < 100 days, 100 – 200 days, and > 200 days. Data on baseline and transplant characteristics was collected in addition to the outcomes that included the incidence of CS-CMVi before and after day 100, CMV end-organ disease, and ACM and NRM at day 100 and week 48. Univariate analysis was done with Fisher’s exact test or Wilcoxon rank sum test. Survival curves were constructed using landmark times of day 100 and 200. Patients who relapsed after transplant were excluded from NRM analyses. Results 940 R+ patients underwent allo-HCT; 533 were not on LTV, 144 received LTV for < 100 days, 146 for 100-200 days, and 117 for > 200 days. The source of the HCT, the rates of ATG and post-Cy, and the choice of GVHD prophylaxis diferred among groups (Table 1). The rate of CS-CMVi was 44.5% in patients not on LTV, which decreased with LTV PP at all time points. Most cases of CS-CMVi occurred within 100 days after HCT (Table 2), with 0.84% of the cases in R+ not on LTV occurring after day 100 compared to 7.5% with LTV PP, most occurring after discontinuation of LTV. When LTV was used >200 days, 66.6% of these patients had CS-CMVi occurring as breakthrough infections. The ACM was similar among the patients, except for lower ACM at week 48 for patients on LTV > 200 days. NRM at week 48 was lower in the patients on LTV for 100-200 days. Survival curves demonstrated a higher survival of R+ recipients on LTV PP for 100 – 200 days.Table 1.Univariate analysis of the baseline characteristics of the 940 patients of the cohort of allogenic hematopoietic cell transplant recipients.Table 2.CMV related outcomes on univariate analysisFigure 1.Kaplan-Meier curves depicting the patients not on LTV primary prophylaxis compared with those on LTV, establishing landmark times at days 100 and 200 after the transplant. Conclusion Our study shows a consistent reduction in CS-CMVi and CMV end-organ disease for allo-HCT recipients while on LTV PP beyond 100 days. ACM and NRM decreased with LTV PP, with higher benefit for allo-HCT recipients on LTV PP beyond 200 days. Disclosures Fareed Khawaja, MBBS, MEDSCAPE: Honoraria|Viracor: Grant/Research Support Terri Lynn Shigle, PharmD, BCOP, Takeda: Advisor/Consultant Gabriella Rondon, MD, Omeros: Advisor/Consultant Elizabeth Shpall, MD, Adaptimmune: Advisor/Consultant|Axio: Advisor/Consultant|Bayer Healthcare Pharmaceuticals: Honoraria|Fibroblast and FibrioBiologics: Advisor/Consultant|Navan: Advisor/Consultant Ella Ariza Heredia, MD, Merck: Grant/Research Support Roy F. Chemaly, MD/MPH, Eurofins-VViracor: Grant/Research Support|Karius: Advisor/Consultant

1459. Association of Antibiotic Prophylaxis Duration and Length of Stay in Patients Undergoing Coronary Artery Bypass Graft Procedure

Abstract Background Antibiotic prophylaxis in surgery is a standard measure to reduce the risk of microbial contamination following an incision. For most surgeries, a single dose of antibiotics is generally required. However, in patients undergoing coronary artery bypass graft (CABG) procedure, antibiotics have been administered for ≥ 24 hours as data on the optimal duration is not sufficient. We aimed to correlate the duration of antibiotic prophylaxis in patients undergoing CABG with length of hospital stay (LOS). Methods We conducted a retrospective cohort study comparing LOS of patients undergoing CABG who received antibiotic prophylaxis for ≥ 24 hours (extended course group) and those who received it for < 24 hours (short course group). Inclusion criteria were adults who had undergone CABG between 01/09/2015 –01/03/2019 in a cardiology and cardiothoracic surgery hospital. Exclusion criteria were immunocompromised patients, in-hospital mortality and patients with a pre-existing infection. The primary outcome was LOS and we also explored other variables that may predict LOS. Effects were adjusted for confounders using a multivariate linear regression model. Results A total of 855 patients were identified. After exclusion, 840 were included in the analysis of which 425 (50.6%) received antibiotics for ≥ 24 hours and 415 (49.4%) received them for < 24 hours. The median LOS was 12.2 [IQR 11.0] days in the extended course group and 8.4 [IQR 8.8] days in the short course group, with a difference of 3.8 days (95% CI: 1.8-5.7), p-value < 0.001. However, after adjusting for potential confounders the difference was no longer significant, 1.7 days (95% CI: -0.23-3.7), p-value 0.083. Independent predictors of length of stay were, male gender, presence of chronic kidney disease, American Society of Anesthesiologists class, priority of the surgery and history of infection in the last 90 days. Conclusion There is no statistically significant difference in LOS between short and extended antibiotic prophylaxis course in patients undergoing CABG procedure. Future work should explore the cost-effectiveness of short versus extended course antibiotic prophylaxis. Disclosures All Authors: No reported disclosures

Cytomegalovirus Cell-Mediated Immunity: Ready for Routine Use?

Utilizing assays that assess specific T-cell-mediated immunity against cytomegalovirus (CMV) holds the potential to enhance personalized strategies aimed at preventing and treating CMV in organ transplantation. This includes improved risk stratification during transplantation compared to relying solely on CMV serostatus, as well as determining the optimal duration of antiviral prophylaxis, deciding on antiviral therapy when asymptomatic replication occurs, and estimating the risk of recurrence. In this review, we initially provide an overlook of the current concepts into the immune control of CMV after transplantation. We then summarize the existent literature on the clinical experience of the use of immune monitoring in organ transplantation, with a particular interest on the outcomes of interventional trials. Current evidence indicates that cell-mediated immune assays are helpful in identifying patients at low risk for replication for whom preventive measures against CMV can be safely withheld. As more data accumulates from these and other clinical scenarios, it is foreseeable that these assays will likely become part of the routine clinical practice in organ transplantation.

The Impacts of Antiretroviral and Antifungal Treatments, and Tuberculosis Co-infection on Mortality and Relapse in Patients with Talaromyces Marneffei Infection

To date, clinical data on long-term clinical outcomes, including 6-month mortality and relapse in talaromycosis (Tm) patients and impacts of ART and secondary antifungal prophylaxis are still lacking. We conducted a secondary data analysis from 6-month prospective observation of patients with culture-confirmed talaromycosis who participated in the Itraconazole versus Amphotericin B for HIV-associated Talaromycosis (IVAP) trial. The primary outcome was 6-month Tm mortality, while the secondary outcome was relapse. Multivariable Cox proportional hazard models were used to identify predictors of outcomes of interest. The median patient age was 34 years (IQR:30 – 38). The median pre-ART CD4 counts at baseline were 10 (IQR: 5-21) cells/µL. The cumulative 76/435 (17.4%) patients died, and Tm relapse was observed in 18/435 (4.1%) patients. The multivariable analyses showed that strong independent predictors of 6-month Tm mortality included ineffective ART (either absence of ART or ART failure) (HR = 6.26, 95% CI: 3.95 – 9.92, P < 0.001), and TB co-infection (HR =1.98, 95% CI: 1.23 – 3.17; P < 0.01). Induction antifungal treatment with itraconazole versus amphotericin B deoxycholate was significantly associated with Tm death in the univariable model, however, it became insignificant in the multivariable model. In addition, the significant risk factors for Tm relapse were ineffective ART, induction antifungal treatment with itraconazole than intravenous amphotericin B, and shorter duration of itraconazole secondary prophylaxis after completing induction therapy in-hospital (all with significant P-values). Antiretroviral therapy, antifungal treatment and tuberculosis co-infection were main predictors for 6-month Tm fatality as well as relapse. Keywords: Invasive fungal infections, Mortality, Relapse, Talaromyces marneffei, Vietnam.

Appropriateness of acute-care antibiotic prescriptions for community-acquired infections and surgical antibiotic prophylaxis in England: analysis of 2016 national point prevalence survey data

Estimates of inappropriate prescribing can highlight key target areas for antimicrobial stewardship (AMS) and inform national targets. To (1) define and (2) produce estimates of inappropriate antibiotic prescribing levels within acute hospital trusts in England. The 2016 national Healthcare-Associated Infections (HAI), Antimicrobial Use (AMU) and AMS point prevalence survey (PPS) was used to derive estimates of inappropriate prescribing, focusing on the four most reported community-acquired antibiotic indications (CAIs) in the PPS and surgical prophylaxis. Definitions of appropriate antibiotic therapy for each indication were developed through the compilation of national treatment guidelines. A Likert-scale system of appropriateness coding was validated and refined through a two-stage expert review process. Antimicrobial usage prevalence data were collected for 25,741 individual antibiotic prescriptions, representing 17,884 patients and 213 hospitals in England. 30.4% of prescriptions for the four CAIs of interest were estimated to be inappropriate (2054 prescriptions). The highest percentage of inappropriate prescribing occurred in uncomplicated cystitis prescriptions (62.5%), followed by bronchitis (48%). For surgical prophylaxis, 30.8% of prescriptions were inappropriate in terms of dose number, and 21.3% in terms of excess prophylaxis duration. The 2016 prevalence of inappropriate antibiotic prescribing in hospitals in England was approximated to be 30.4%; this establishes a baseline prevalence and provided indication of where AMS interventions should be prioritized. Our definitions appraised antibiotic choice, treatment duration and dose number (surgical prophylaxis only); however, they did not consider other aspects of appropriateness, such as combination therapy - this is an important area for future work.

Letermovir prophylaxis for cytomegalovirus reactivation in allogeneic hematopoietic cell transplant recipients: Single center Canadian data.

Cytomegalovirus (CMV) is associated with morbidity and mortality following allogeneic hematopoietic cell transplantation (alloHCT). Letermovir is a novel antiviral agent that prevents CMV reactivation in alloHCT patients, with limited data regarding influence on post-alloHCT outcomes. We retrospectively examined 273 alloHCT recipients, 158 in the non-letermovir cohort (NLC), and 115 in the cohort using letermovir prophylaxis (LC). Patients that received letermovir were CMV-seropositive and met criteria for high risk of CMV reactivation. Median start of letermovir was 21 days post-alloHCT, median duration of prophylaxis was 86 days. Letermovir prophylaxis demonstrated a statistically significant reduction in first CMV reactivation (at 200 days post 63.9% in the NLC vs. 35.7% in the LC; p < .001). On univariate analysis at 1 year, overall survival (OS) for NLC was 79.6% and 79.5% for LC (p = .54). Non relapse mortality (NRM) at 1 year for NLC was 12% and 12.3% for LC (p = .69). Cumulative incidence of relapse (CIR) at 1 year was 13.9% for NLC versus 17.1 for the LC (p = .27). On multivariable analysis, there was no significant difference between the two cohorts for OS, NRM, and CIR. Letermovir prophylaxis started at day +21 post-alloHCT reduced CMV reactivation, with no impact on posttransplant outcomes.

Lumbar fusion through the anterolateral mini-approach: comparison of anterior interbody (OLIF-AF) and percutaneous pedicle (OLIF-PF) fixations in the surgical treatment of single-level stenosis

Objective. To perform comparative analysis of the clinical efficacy and safety of indirect decompression of the spinal roots and interbody fusion through the lateral pre-psoas approach (OLIF) with anterolateral (OLIF-AF) and posterior percutaneous (OLIF-PF) screw fixations in the surgical treatment of single-segment lumbar stenosis.Material and Methods. A retrospective comparative analysis of treatment of 88 patients aged 29 to 72 years with single-level lumbar stenosis was carried out. Posterior instrumental fixation (OLIF-PF) was performed in 60 cases, and anterolateral (OLIF-AF) – in 28.Results. The compared groups did not statistically significantly differ from each other in terms of age, gender, body mass index, clinical picture and duration of symptoms before surgery, assessment of neurological status according to the Zurich Claudication Questionnaire (ZCQ), preoperative diagnosis, localization of stenosis, pain assessment in the back and leg before surgery according to a digital rating scale, physical status (ASA), health assessment (SF-12, ODI), follow-up period, as well as smoking and the presence of comorbidities (p &gt; 0.05). In the OLIF-AF group, compared to the OLIF-PF group, a statistically significant advantage was found in terms of blood loss, duration of surgery and anesthesia, the level of radiological exposure, duration of patient’s hospitalization and hospital stay in the postoperative period, as well as the duration of antibiotic prophylaxis and intraoperative volume of infusions (p &lt; 0.05). Despite earlier discharge and less use of local anesthesia (35.7 % vs 73.3 %; p = 0.001), patients in the OLIF-AF group had statistically significantly lower level of back pain on the day of discharge (3.0 vs 3.5; p = 0.034) and were less likely to need opioids (3.6 % vs 31.7 %; p = 0.003). With regard to complications and adverse events, there were no statistically significant differences during dynamic follow-up period from 3 to 50 months in both groups (17.9 % vs 28.3 %; p = 0.290), including depending on the timing of complications (early or late). In addition, no statistically significant differences were found for neurological, infectious, gastrointestinal, urological, or implant-related complications (p &gt; 0.05).Conclusions. Indirect decompression of the spinal roots and interbody fusion through the lateral pre-psoas approach in combination with OLIF-AF is an effective and safe technique for the surgical treatment of single-segment lumbar stenosis. This method allows to reduce the invasiveness of surgery and severity of the pain syndrome and to create conditions for enhanced recovery after surgery. Further multicenter randomized trials are needed to comprehensively evaluate long-term outcomes.

Efficacy of different durations of antifungal prophylaxis with nebulized amphotericin B after lung transplantation: a retrospective cohort study.

Nebulized amphotericin B (NAB) is recommended for preventing invasive fungal diseases (IFDs) after lung transplantation. However, the optimal duration of NAB treatment is still unknown. This study aimed to compare the effectiveness of three different durations of antifungal prophylaxis with NAB after lung transplantation: a prolonged course beyond post-transplant 3 months, a medium course of 2 weeks to 3 months, and a short course of less than 2 weeks. This a single-center retrospective cohort study analyzed 333 patients who underwent lung or heart-lung transplantation between January 2015 and November 2021. A prolonged course of NAB treatment was associated with a significantly lower incidence of IFDs (12.6%) at 1 year post-transplant compared with a short (50.9%) or a medium course (28.0%) (P<0.001). There was no significant difference in the rates of adverse effects among the three durations of NAB treatment (P>0.05). A prolonged course of NAB treatment was associated with a significantly higher 1-year survival rate (94.7%) compared with a short (36.8%) or a medium course (72.0%) (P<0.001). A prolonged course of NAB treatment provided better protection against IFDs than a short or medium course after lung transplantation. Prolonged use of NAB did not significantly increase the incidence of adverse effects.

Benefits and harms of perioperative high fraction inspired oxygen for surgical site infection prevention: a protocol for a systematic review and meta-analysis of individual patient data of randomised controlled trials

IntroductionThe use of high fraction of inspired oxygen (FiO2) intraoperatively for the prevention of surgical site infection (SSI) remains controversial. Promising results of early randomised controlled trials (RCT) have been...

İmmunsupresif Tedavi Alan Hastalarda HBV Reaktivasyonu ve Antiviral Profilaksinin Değerlendirilmesi

Aim: Patients with chronic hepatitis B and people with a history of hepatitis B (HBV) infection are at risk of HBV reactivation (HBVr) when they receive immunosuppressive therapy. In this study, we aimed to evaluate the hepatitis B serology, risk groups and antiviral prophylaxis of patients receiving various immunosuppressive therapies due to rheumatological diseases.&#x0D; Material and Method: The study included 375 patients over 18 years of age who received tumor necrosis factor-α (TNF-α) inhibitor, tyrosine kinase inhibitor, steroids, methotrexate or anti-CD20 antibodies due to rheumatic diseases in a training and research hospital between May 2022 and May 2023. Hepatitis B surface antigen (HbsAg), hepatitis B surface antibody (anti-Hbs), hepatitis B core protein antibody (anti-Hbc IgG) serologies, immunosuppressive therapies and oral antivirals were retrospectively analyzed.&#x0D; Results: The average age of the 375 patients included in the study was 43.77±13.07 years. 193 (51.5%) of the patients were male. 11 patients were HbsAg positive, 150 patients were anti-Hbs positive, 19 patients were isolated anti-Hbc IgG positive, and 79 patients were both anti-Hbs and anti-Hbc IgG positive. According to serological findings, 109 (29%) patients had HBV exposure. All three test results of 194 (51.7%) patients were negative. A total of 85 (22.7%) patients received oral antiviral prophylaxis due to the use of immunosuppressive agents. In terms of HBVr, 16.5% were evaluated as high risk, 75.3% as moderate risk, and 8.2% as low risk. Out of 85 patients 79 received entecavir, 5 reveived tenofovir disoproxil fumarate (TDF) and 1 received tenofovir alafenamide fumarate (TAF). The mean duration for the immunosuppressive therapy was 6.41±4.20 years. The mean duration of oral antiviral prophylaxis among patients was 1.02±1.72 years. HBVr was not observed in any of our patients.&#x0D; Conclusion: Before patients receive immunosuppressive therapy, hepatitis B serologies and prophylaxis indication should be evaluated firstly. In addition, as a preventive medicine activity, hepatitis B vaccinations of unvaccinated patients should be completed as quickly as possible.

A new direction for cytomegalovirus prophylaxis among transplant recipients: Benefits and nonviral outcomes of letermovir use as primary CMV prophylaxis.

Letermovir has changed the game of primary prophylaxis against cytomegalovirus (CMV) for hematopoietic stem cell transplant (HSCT) and more recently, solid organ transplant recipients. This is largely due to letermovir's similar efficacy in protecting against CMV reactivation and disease, along with its superior safety profile, notably reduced myelotoxicity, and lack of renal dose adjustment compared to standard agents like valganciclovir. This review will describe the potential benefits and clinical considerations of letermovir as prophylaxis among transplant recipients, with a focus on recent evidence describing nonviral outcomes of CMV. Recent evidence has demonstrated improved safety (e.g., less myelosuppression) and tolerability with no difference in rates of CMV infection or disease in kidney transplant recipients given letermovir compared to valganciclovir. Real-world studies and meta-analyses in HSCT populations have explored various nonviral outcomes with letermovir use. Letermovir prophylaxis was associated with reduced mortality, lower rates of graft versus host disease, delayed CMV immune reconstitution, improved tolerability with extended durations, and decreased healthcare utilization. Letermovir is an effective antiviral agent for CMV prevention and has demonstrated enhanced safety, which may allow for extended durations of primary prophylaxis among transplant recipients along with other improved clinical outcomes by mitigating the indirect effects of CMV.

Extended duration letermovir in allogeneic hematopoietic stem cell transplant

ObjectivesDespite the use of antiviral prophylaxis in recipients of allogeneic hematopoietic cell transplants (HCT), cytomegalovirus (CMV) is a common clinically significant infection and is associated with significant morbidity and mortality in this patient population. Based on current approval, letermovir is initiated within 28 days following allogeneic HCT for CMV seropositive recipients and continued through 100 days post-transplant. However, it is unknown whether patients who receive extended duration CMV prophylaxis with letermovir would result in less CMV reactivation and reactivation compared to those who do not. This study aimed to evaluate the efficacy of letermovir prophylaxis in CMV seropositive patients when continued for greater than 100 days post-allogeneic stem cell transplant. MethodsA single-center retrospective chart review was conducted on recipients of allogeneic HCT from November 2017 to July 2021. Patients were eligible for inclusion if they were at least 18 years of age, received an allogeneic HCT, CMV seropositive, and initiated letermovir between days 0–28 post-transplant. The primary endpoint of this study is to compare rates of CMV reactivation in patients who stopped letermovir prophylaxis at 100 days post-transplant (standard duration group) versus those who continued letermovir prophylaxis past day 100 (extended duration group). ResultsA total of 87 patients met the eligibility criteria for inclusion. The median duration of letermovir prophylaxis was 78 days in the standard duration group versus and 132 days in the extended duration group. There were more CMV reactivations in the standard duration group versus the extended duration group, 28% versus 19% respectively. CMV pneumonitis was observed in one of the patients in the standard duration group. All-cause mortality at day 200 post-transplant was similar between the two groups. ConclusionThe results of this study suggest that extended duration letermovir prophylaxis may be associated with less CMV reactivation compared to the standard duration of prophylaxis.

Antibiotic Utilization and Prophylaxis in Paediatric Cardiac Surgery: A Retrospective Observational Study at a Rural Tertiary Care Hospital in India.

Introduction Antimicrobial prophylaxis, involving short antibiotic courses preceding surgical procedures, is recommended to minimize postoperative infections. Paediatric cardiac surgeries are classified as clean procedures, though infection challenges persist due to illness severity and extended ICU stays. Antimicrobial prophylaxis varies, ranging from single doses to extended administration until catheters are removed. Typically lasting 24 to 48 hours, it has proven infection-reduction benefits. Despite these practices, uncertainties surround the optimal nature, timing, and duration of administration. This concern is amplified by escalating antimicrobial resistance driven by antibiotic overuse. Vulnerable paediatric populations bear heightened consequences of irrational antimicrobial use, contributing to global resistance trends. Yet, a defined optimal prophylaxis schedule for paediatric cardiac surgery is lacking. Importing adult guidelines may be inadequate due to paediatric research complexities and population diversity. Developing effective prophylaxis protocols is crucial for children undergoing cardiac surgery, given global antibiotic overuse and evolving drug resistance. Establishing an optimal prophylactic strategy remains a challenge, necessitating further research for evidence-based protocols to mitigate infections in this vulnerable patient cohort. Methods This study investigates antibiotic use in paediatric cardiac surgery. A retrospective analysis of 100 patients from a rural Indian hospital (2017-2018) assesses antibiotic patterns, including type, dose, duration, and adherence to prophylaxis protocols. Results In the studied cohort of paediatric cardiac surgery patients, complete compliance (100%) with antibiotic prophylaxis was observed. However, deviations were identified: 30% received antibiotics prematurely, and 30% did not align with institutional protocol criteria. Concerning antibiotic selection, 87% followed hospital policy with the recommended cefoperazone and sulbactam combination plus amikacin, while 9% received piperacillin/tazobactam + amikacin due to sepsis. Irregular use (22%) based on clinical records occurred. Furthermore, 4% received piperacillin/tazobactam + teicoplanin, with one instance of inappropriate higher antibiotic use. Regarding prophylaxis duration, only 27% adhered to the appropriate timeline, with 40% exceeding 48 hours, indicating extended use. Upon discharge, a notable proportion (45 patients) received antibiotic prescriptions. Among them, 73% were prescribed rationally, while 27% exhibited irrational antibiotic use. Conclusion The findings of this study shed a significant light on the issue of antibiotic misuse within the context of paediatric cardiac surgery. It underscores the pressing need for more stringent measures to regulate and address this concerning trend. The study underscores the pivotal importance of adhering rigorously to established protocols and guidelines for antibiotic prophylaxis. This adherence not only holds the potential to elevate the overall quality of patient care but also plays a critical role in combating the escalating challenge of antibiotic resistance. Through a concerted effort to optimize antibiotic usage, we can simultaneously enhance patient outcomes and contribute to the ongoing fight against the emergence of antibiotic-resistant strains, thus preserving the efficacy of these vital medications for future generations.

Venous Thromboembolism Prophylaxis in Foot and Ankle Surgery: A Worldwide Survey

Current recommendations on thromboprophylaxis for foot and ankle (FA) surgery are often inconsistent and generally based on weak evidence. The aim of this survey study was to evaluate the current practice among orthopedic surgeons regarding venous thromboembolism (VTE) prophylaxis following FA surgery. From February 2019 to March 2020, an online questionnaire was sent by e-mail to orthopedic societies across the world. The questionnaire was hosted by the International Society of Thrombosis and Haemostais RedCAP platform. Topics of interest were VTE rates following FA surgery, duration and type of thromboprophylaxis, bleeding complications, VTE risk factors for prophylaxis and use of risk assessment. A total of 693 FA orthopedic surgeons from all continents completed the survey of whom 392 (57%) performed more than 200 FA procedures per year. A total of 669/693 (97%) respondents stated that thromboprophylaxis is necessary in FA surgeries. When thromboprophylaxis was prescribed, half of surgeons prescribed it for the duration of immobilization. Acetylsalicylic acid, low molecular weight heparin and direct-oral anticoagulants were, in this order, the preferred choice. Acetylsalicylic acid and low molecular weight heparin were predominantly prescribed in North America and Europe, respectively. Previous deep vein thrombosis, immobility, obesity and inherited thrombophilia were considered the main risk factors indicative of thromboprophylaxis use. In this survey, most surgeons agree that thromboprophylaxis is indicated for FA surgery, but the prescription, type and duration of prophylaxis differs greatly with a large intercontinental discrepancy. These survey results could be a foundation for developing uniform guidelines to optimize thromboprophylactic strategies in FA procedures around the world.

Overview of Antibiotic Prophylaxis in Orthopaedic and Cardiac Procedures.

Antibiotic prophylaxis (AP) in surgical procedures is commonly used to prevent infections that may occur after operations. There are multiple factors that can contribute to increased risk of postsurgical complications that include prolonged hospitalization, reoperation, and readmissions. One of the strategies of decreasing the risk of bacterial contamination and developing infections is preprocedural antibiotic administration. When selecting an appropriate antibiotic, it is important to take into account surgery type and patient's characteristics which would also impact timing of administration and prophylaxis duration. Although surgical AP is significant for avoiding bacterial complications, it is also associated with some drawbacks such as increased antibiotic resistance and development of adverse reactions. Therefore, it is important to assess risks and benefits and select the most appropriate antibiotic regimen before initiating AP.