Perioperative Prophylaxis Research Articles

Incidence and Risk Factors for Postoperative Venous Thromboembolism After Gender Affirming Vaginoplasty: A Retrospective Analysis of a Large Insurance Claims Database

To investigate the incidence and associated risk factors of venous thromboembolism (VTE) after gender affirming vaginoplasty. We searched International Business Machines Corporation (IBM) Marketscan, a commercial claims database, for Current Procedural Terminology and International Classification of Diseases (ICD) procedure codes to identify patients who underwent gender affirming vaginoplasty from 2011-2020. We quantified deep venous thrombosis and pulmonary embolism using ICD-9 and ICD-10 codes found within 90days after surgery. Univariate and multivariate analyses were performed to establish association between VTE events and age, residency location, and comorbidities. We identified 1588 patients who underwent gender affirming vaginoplasty. Overall, 1.1% of patients experienced a VTE within 90days following surgery. Patients who experienced postoperative VTE were older, more likely to have had a prior VTE, less likely to be from an urban area, and more likely to have a higher Charlson Comorbidity Index score. Among patients with postoperative VTE, 47.1% had previous VTE. Among patients without a postoperative VTE, 1.3% had previous VTE. In patients undergoing gender affirming vaginoplasty, the incidence of postoperative VTE was 1.1%. Older age, rurality, increased comorbidities, and prior VTE were associated with increased risk of postoperative VTE. Current guidelines do not recommend cessation of gender affirming hormone therapy (GAHT) prior to vaginoplasty. Further research is needed to evaluate if certain high-risk patients would benefit from perioperative adjustment of GAHT or perioperative VTE prophylaxis.

Association between perioperative prophylaxis with cefuroxime plus metronidazole or amoxicillin/clavulanic acid and surgical site infections in paediatric uncomplicated appendectomy: a Swiss retrospective cohort study

ObjectiveWe aimed to evaluate the association between post-appendectomy SSI rates and the two most commonly used regimens for perioperative antimicrobial prophylaxis in Swiss children.MethodsWe conducted a retrospective cohort study, analysing data from the Swiss national SSI surveillance database with a study period from 2014 to 2018. All hospitals undertaking paediatric appendectomies in Switzerland participate in the surveillance. We compared the cumulative incidence and odds of post-appendectomy SSI within 30 days of surgery in children ≤ 16 years of age undergoing appendectomy for uncomplicated appendicitis and receiving perioperative antimicrobial prophylaxis with cefuroxime plus metronidazole or with amoxicillin/clavulanic acid using multivariable adjusted logistic regression and propensity-score matching.ResultsA total of 6207 cases were recorded in the study time frame. Overall SSI cumulative incidence was 1.9% (n = 119). 4256 children (54.9% male, median (IQR) age 12 [10, 14] years) received either cefuroxime plus metronidazole (n = 2348, 53.8% male) or amoxicillin/clavulanic acid (n = 1491, 57.0% male). SSI cumulative incidence was 1.1% (25/2348) among children receiving cefuroxime plus metronidazole and 2.8% (42/1491, p < 0.001) when receiving amoxicillin/clavulanic acid. The administration of cefuroxime plus metronidazole was associated with statistically significantly lower SSI odds compared to amoxicillin/clavulanic acid (aOR 0.35, 95%CI [0.20, 0.61], p < 0.001), and this was confirmed upon propensity-score matching.ConclusionWe found lower odds of post-appendectomy SSI in children receiving cefuroxime plus metronidazole compared to amoxicillin/clavulanic acid. Treating amoxicillin/clavulanic acid as the baseline, only 55 children need to receive cefuroxime plus metronidazole perioperative prophylaxis to avert one SSI. Existing guidelines recommending amoxicillin/clavulanic acid may need to be revised.Trial registration ISRCTN47727811, registered retrospectively.

Association of antimicrobial perioperative prophylaxis with cefuroxime plus metronidazole or amoxicillin/clavulanic acid and surgical site infections in colorectal surgery

ObjectiveTo compare intravenous (IV) amoxicillin/clavulanic acid (A/CA) to IV cefuroxime plus metronidazole (C + M) for preventing surgical site infections (SSI) in colorectal surgery.BackgroundGiven their spectra that include most Enterobacterales and anaerobes, C + M is commonly recommended as prophylaxis of SSI in colorectal surgery. A/CA offers good coverage of Enterobacterales and anaerobes as well, but, in contrast to C + M, it also includes Enterococcus faecalis which is also isolated from patients with SSI and could trigger anastomotic leakage.MethodsData from a Swiss SSI surveillance program were used to compare SSI rates after class II (clean contaminated) colorectal surgery between patients who received C + M and those who received A/CA. We employed multivariable logistic regression to adjust for potential confounders, along with propensity score matching to adjust for group imbalance.ResultsFrom 2009 to 2018, 27,922 patients from 127 hospitals were included. SSI was diagnosed in 3132 (11.2%): 278/1835 (15.1%) in those who received A/CA and 2854/26,087 (10.9%) in those who received C + M (p < 0.001). The crude OR for SSI in the A/CA group as compared to C + M was 1.45 [CI 95% 1.21–1.75]. The adjusted OR was 1.49 [1.24–1.78]. This finding persisted in a 1:1 propensity score matched cohort of 1835 patients pairs with an OR of 1.60 [1.28–2.00]. Other factors independently associated with SSI were an ASA score > 2, a longer duration of operation, and a reoperation for a non-infectious complication. Protective factors were female sex, older age, antibiotic prophylaxis received 60 to 30 min before surgery, elective operation, and endoscopic approach.ConclusionsDespite its activity against enterococci, A/CA was less effective than C + M for preventing SSI, suggesting that it should not be a first choice antibiotic prophylaxis for colorectal surgery.

Optimal Perioperative Antimicrobial Management Strategies of Kidney Transplant Recipients Guided by Metagenomic Next-Generation Sequencing of Deceased Donors' Microbiology Samples.

There is no consensus on the optimal use of perioperative antibiotics prophylaxis after kidney transplantation, but there is a common trend to limit the duration of antibiotic use worldwide. Metagenomic next-generation sequencing (mNGS) has emerged as a novel technology for pathogen detection in clinical practice due to its noninvasive, rapid, precise and high susceptibility to detect infectious pathogens. However, data are lacking on whether mNGS analyses could be used to detect pathogens and guide anti-infection regimens in kidney transplant donors and recipients. We conducted a retrospective study to review all clinic data of mNGS and traditional laboratory methods (TMs) for pathogen detection in kidney transplant recipients and their corresponding deceased donors from August 1, 2021 to October 30, 2022 in our center. A total of 57 donors and 112 of their corresponding recipients were included. The antimicrobial strategy mainly depended on mNGS results combined with traditional pathogen culture and clinical conditions. The percentages of positive pathogen detected by mNGS in blood, urine, bronchoalveolar lavage fluid (BALF) and preservation fluids (PFs) were 50.9% (29/57), 35.1% (20/57), 84.2% (48/57) and 54.4% (31/57) respectively, and were 24.6% (14/57), 15.8% (9/57), 57.9% (33/57) and 14.1% (8/57) respectively when using TMs. mNGS could detected all of pathogens which were detected by TMs. However, samples with negative TMs testing can be additionally detected as positive by mNGS (15/43 in blood, 11/48 in urine, 15/24 in BALF and 23/49 in PFs). Drug resistance genes were detected in 9 donors by mNGS,which were consistent with 6 donors by TMs. There was only one case of donor-derived infection in this study. This study showed that it is effective to combine mNGS with traditional pathogen detection methods and clinical features to develop optimal perioperative antimicrobial management strategies for deceased donor kidney transplantation.

Standard-Dose Azithromycin in Class III Obese Patients Undergoing Unscheduled Cesarean Delivery.

Perioperative antibiotic prophylaxis reduces cesarean wound complications. This study investigates whether integration of standard-dose (500 mg) azithromycin prophylaxis reduced wound complications in patients with class III obesity (body mass index [BMI] ≥ 40 kg/m2) undergoing unscheduled cesarean delivery. Retrospective cohort study of patients with class III obesity undergoing unscheduled cesarean delivery in single hospital system from January 1, 2017, to January 1, 2020. A standard dose (500 mg) of azithromycin was integrated into system order sets in 2018. Medical history and postoperative wound outcomes were compared in pre- and postintegration cohorts. Wound complication was defined as composite of wound seroma, hematoma, superficial or deep infection. A total of 1,273 patients met inclusion criteria, 303 patients in the preorder set group, and 970 patients in the postorder set group. Demographics were similar between the pre- and postintegration cohorts, including BMI (median: 44.4 kg/m2, p = 0.84) and weight at delivery (mean: 121.2 ± 17.8 kg, p = 0.57). Patients in the postintegration cohort had lower rates of composite postpartum wound complication (7.9 vs. 13.9%, p = 0.002), superficial infection or deep infection/abscess (6.7 vs. 10.2%, p = 0.042), and postpartum readmission or unscheduled visits (18.7 vs. 24.4%, p < 0.029). Rates of chorioamnionitis and endometritis were similar between the pre- and postintegration groups (8.6 vs. 6.9%, p = 0.33, and 1.7 vs. 1.9%, p = 0.81, respectively). Patients in the postintegration cohort had lower risk of postoperative composite wound complication (unadjusted odds ratio [OR]: 0.54, confidence interval [CI]: 0.36-0.80, p = 0.002) and lower rates of wound infection (unadjusted OR: 0.63, 95% CI: 0.40-0.99, p = 0.044). When comparing patients who received azithromycin at delivery and patients who did not, standard-dose azithromycin reduced risk of postoperative wound complication (unadjusted OR: 0.67, 95% CI: 0.46-0.99, p = 0.043). A standard dose of azithromycin provides adequate perioperative prophylaxis in class III obese patients, decreasing rates of postcesarean wound complications and unscheduled postpartum outpatient visits. · Class III obese patients undergoing unscheduled cesarean have high rates of wound complications.. · Standard-dose azithromycin reduces risk of postcesarean wound infection in class III obese patients.. · Standard-dose azithromycin reduces readmission, unscheduled visits in class III obese patients..

Early Intra-Abdominal Bacterial Infections after Orthotopic Liver Transplantation: A Narrative Review for Clinicians.

Despite recent advances in the transplant field, infectious complications after orthotopic liver transplantation (OLT) are major causes of morbidity and mortality. Bacterial intra-abdominal infections (IAIs) are predominant during the first month post-transplantation and affect patient and graft survival. Recently, the emergence of multidrug resistant bacteria has generated great concern in OLT patients. We performed this narrative review of the literature in order to propose a "ready-to-use" flowchart for reasoned empirical antibiotic therapy in the case of suspected post-OLT IAIs. The review was ultimately organized into four sections: "Epidemiology and predisposing factors for IAI"; "Surgical-site infections and perioperative prophylaxis"; "MDRO colonization and infections"; and "Reasoned-empirical antibiotic therapy in early intra-abdominal infections post OLT and source control". Multidisciplinary teamwork is warranted to individualize strategies for the prevention and treatment of IAIs in OLT recipients, taking into account each patient's risk factors, the surgical characteristics, and the local bacterial epidemiology.

No difference in risk of revision due to infection between clindamycin and cephalosporins as antibiotic prophylaxis in cemented primary total knee replacements: a report from the Norwegian Arthroplasty Register 2005-2020.

Systemic antibiotic prophylaxis with clindamycin, which is often used in penicillin- or cephalosporin-allergic patients', has been associated with a higher risk of surgical revision for deep prosthetic joint infection (PJI) than cloxacillin in primary total knee replacement (TKR). We aimed to investigate whether clindamycin increases the risk of surgical revisions due to PJI compared with cephalosporins in primary cemented TKR. Data from 59,081 TKRs in the Norwegian Arthroplasty Register (NAR) 2005-2020 was included. 2,655 (5%) received clindamycin and 56,426 (95%) received cephalosporins. Cox regression analyses were performed with adjustment for sex, age groups, diagnosis, and ASA score. Survival times were calculated using Kaplan-Meier estimates and compared using Cox regression with revision for PJI as endpoint. The cephalosporins cefalotin and cefazolin were also compared. Of the TKRs included, 1.3% (n = 743) were revised for PJI. 96% (n = 713) had received cephalosporins and 4% (n = 30) clindamycin for perioperative prophylaxis. Comparing cephalosporins (reference) and clindamycin, at 3-month follow-up the adjusted hazard ratio rate (HRR) for PJI was 0.7 (95% confidence interval [CI] 0.4-1.4), at 1 year 0.9 (CI 0.6-1.5), and at 5 years 0.9 (CI 0.6-1.4). Analysis using propensity score matching showed similar results. Furthermore, comparing cefalotin (reference) and cefazolin, HRR was 1.0 (CI 0.8-1.4) at 3 months and 1.0 (CI 0.7-1.3) at 1-year follow-up. We found no difference in risk of revision for PJI when using clindamycin compared with cephalosporins in primary cemented TKRs. It appears safe to continue the use of clindamycin in penicillin- or cephalosporin-allergic patients.

Real-World Experience with a Human Fibrinogen Concentrate: Clinical Data from Adult and Pediatric Patients Requiring Fibrinogen for Bleeding Control and Prevention.

Human fibrinogen concentrate (Fibryga) received temporary approval for fibrinogen replacement therapy in France (2017), with subsequent full approval for congenital and acquired hypofibrinogenemia. We evaluated real-world use for on-demand treatment of bleeding and prophylaxis to enhance our knowledge on fibrinogen concentrate as an option for fibrinogen replacement. Data were retrospectively collected from adult and pediatric patients with fibrinogen deficiency. The primary end point was indication for fibrinogen concentrate use; the secondary end point was treatment success for on-demand treatment/perioperative prophylaxis. The study included 150 adult (median age, 62years; range, 18-94years) and 50 pediatric (median age, 3years; range, 0.01-17years) patients with acquired fibrinogen deficiency. Fibrinogen concentrate was administered to 47.3% for nonsurgical bleeding, 22.7% for surgical bleeding, and 30.0% for perioperative prophylaxis in adult patients, and to 4.0% for surgical bleeding and 96.0% for perioperative prophylaxis in pediatric patients. Cardiac surgeries accounted for 79.5%/75.0% perioperative prophylaxis and 82.4%/100.0% surgical bleeding cases in adult/pediatric patients, respectively. The mean±standard deviation (SD, median) total fibrinogen doses were 3.06±1.69g (32.61mg/kg), 2.09±1.36g (22.99mg/kg), and 2.36±1.25g (29.67mg/kg) for adult nonsurgical bleeding, surgical bleeding, and perioperative prophylaxis, respectively; doses of 0.75±0.35g (47.64mg/kg) and 0.83±0.62g (55.56mg/kg) were used for pediatric surgical bleeding and perioperative prophylaxis, respectively. Treatment success was 85.7%/97.1/93.3% in adults and 50.0%/87.5% in pediatrics for nonsurgical bleeding (adults only), surgical bleeding, and perioperative prophylaxis, respectively. Fibrinogen concentrate demonstrated favorable effectiveness and safety across the age groups. This study contributes to evidence supporting fibrinogen concentrate for bleeding control/prevention in real-world clinical practice, particularly for patients with acquired fibrinogen deficiency.

Hemophilia patients: are they naturally anticoagulated?

Hemophilia is an X-linked bleeding disorder, characterized by low plasma levels of coagulation factor VIII (FVIII) (hemophilia A) or FIX (hemophilia B). Because of this, hemophilia patients (HP) were considered as naturally-anticoagulated and therefore protected from thrombosis. Over the last decades hemophilia care underwent striking changes by the introduction of prophylaxis with repeated injections of standard or modified coagulation factor products that maintain steady-state trough levels of the deficient factor. Meanwhile, new medications, not based on replacement therapy, were developed (i.e., emicizumab and others). However, emicizumab (the only licensed drug) can be used only for prophylaxis; during acute bleeding or surgery, HP require additional therapies, supplementing emicizumab with FVIII/IX concentrates or with bypassing agents (e.g., recombinant activated FVII or activated prothrombin complex concentrate). Owing to the new therapeutic strategies, the hemostatic competency of HP is now much better assured than in the past and therefore their life expectancy is considerably improved. Furthermore, the combined effects of the improved life-expectancy and of the steady-state hemostatic competence achieved by prophylaxis, make HP to be near(normal). They are, therefore, liable to be affected by the circumstantial risk factors of venous thromboembolism (VTE) that are common in the general population. Furthermore, HP undergo frequent surgery/invasive procedures (especially major orthopedic surgery) when they are treated with coagulation factor concentrates or bypassing agents that may increase the risk of post-operative VTE. Therefore, one wonders if HP should be considered for perioperative antithrombotic prophylaxis to prevent postoperative VTE.Clinical data on the value of antithrombotic prophylaxis in this setting are scanty. Indeed, data from an observational multicentre prospective study of 46 HP who underwent orthopedic surgery concluded that the prevalence of postoperative symptomatic VTE was similar to that estimated in the general population. Multicenter prospective trials are warranted to address the value of antithrombotic prophylaxis to avoid post-operative VTE in HP, especially during major surgery when regular prophylaxis is supplemented with additional coagulation factor products or bypassing agents. Until this information is available, HP undergoing major surgery whilst on antihemorrhagic prophylaxis supplemented with coagulation factor concentrates or bypassing agents, should at least receive intermittent pneumatic compression.

Prolonged antibiotic prophylaxis after pancreatoduodenectomy: systematic review and meta-analysis.

Previous studies have reported conflicting results of prolonged antibiotic prophylaxis on infectious complications after pancreatoduodenectomy. This study evaluated the effect of prolonged antibiotics on surgical-site infections (SSIs) after pancreatoduodenectomy. A systematic review and meta-analysis was undertaken of SSIs in patients with perioperative (within 24 h) versus prolonged antibiotic (over 24 h) prophylaxis after pancreatoduodenectomy. SSIs were classified as organ/space infections or superficial SSI within 30 days after surgery. ORs were calculated using a Mantel-Haenszel fixed-effect model. Ten studies were included in the qualitative analysis, of which 8 reporting on 1170 patients were included in the quantitative analysis. The duration of prolonged antibiotic prophylaxis varied between 2 and 10 days after surgery. Four studies reporting on 782 patients showed comparable organ/space infection rates in patients receiving perioperative and prolonged antibiotics (OR 1.35, 95 per cent c.i. 0.94 to 1.93). However, among patients with preoperative biliary drainage (5 studies reporting on 577 patients), organ/space infection rates were lower with prolonged compared with perioperative antibiotics (OR 2.09, 1.43 to 3.07). Three studies (633 patients) demonstrated comparable superficial SSI rates between patients receiving perioperative versus prolonged prophylaxis (OR 1.54, 0.97 to 2.44), as well as in patients with preoperative biliary drainage in 4 studies reporting on 431 patients (OR 1.60, 0.89 to 2.88). Prolonged antibiotic prophylaxis is associated with fewer organ/space infection in patients who undergo preoperative biliary drainage. However, the optimal duration of antibiotic prophylaxis after pancreatoduodenectomy remains to be determined and warrants confirmation in an RCT.

Effect of an E-Prescription Intervention on the Adherence to Surgical Chemoprophylaxis Duration in Cardiac Surgery: A Single Centre Experience.

In our hospital, adherence to the guidelines for peri-operative antimicrobial prophylaxis (PAP) is suboptimal, with overly long courses being common. This practice does not offer any incremental benefit, and it only adds to the burden of antimicrobial consumption, promotes the emergence of antimicrobial resistance, and it is associated with adverse events. Our objective was to study the effect of an electronic reminder on the adherence to each element of PAP after cardiac surgery. We conducted a single center, before and after intervention, prospective cohort study from 1 June 2014 to 30 September 2017. The intervention consisted of a reminder of the hospital guidelines when ordering PAP through the hospital information system. The primary outcome was adherence to the suggested duration of PAP, while secondary outcomes included adherence to the other elements of PAP and incidence of surgical site infections (SSI). We have studied 1080 operations (400 pre-intervention and 680 post-intervention). Adherence to the appropriate duration of PAP increased significantly after the intervention [PRE 4.0% (16/399) vs. POST 15.4% (105/680), chi-square p < 0.001]; however, it remained inappropriately low. Factors associated with inappropriate duration of PAP were pre-operative hospitalization for <3 days, and duration of operation >4 h, while there were significant differences between the chief surgeons. Unexpectedly, the rate of SSIs increased significantly during the study (PRE 2.8% (11/400) vs. POST 5.9% (40/680), chi-square p < 0.019). The implemented intervention achieved a relative increase in adherence to the guideline-recommended PAP duration; however, adherence was still unacceptably low and further efforts to improve adherence are needed.

SURGICAL TREATMENT OF SEVERE HETEROTOPIC OSSIFICATION AFTER CONTEMPORARY TOTAL HIP ARTHROPLASTY: SYSTEMATIC REVIEW OF THE LITERATURE AND NEW CASE SERIES

Severe heterotopic ossification (grade III and IV) after contemporary total hip arthroplasty (THA) requiring excision is very uncommon. We performed a systematic review of the literature, and report a new case series with operative treatment after primary uncemented THA.A systematic review identified papers describing patients who had excision of heterotopic ossification (HO) after contemporary THA, defined as performed after 1988. Concepts of hip arthroplasty, heterotopic ossification, and surgical excision were searched in MEDLINE, Embase, and Scopus, from database inception to November 2022. Inclusion criteria were: articles that included specific patient data on grade of heterotopic ossification, operative procedure, and prophylaxis. Studies were screened for inclusion by two independent reviewers. Extracted data included demographic data, interval from index surgery to excision, clinical results, and complications. One surgeon performed reoperation for ankylosis of primary THA in three patients with severe pain and deformity.Seven case series or case report studies were included. There were 41 patients, with grade III or IV HO, that had excision, and in five patients, revision of a component was also performed. Perioperative prophylaxis was irradiation alone in 10 patients, irradiation and indomethacin in 10, and indomethacin alone in 21 patients. At a mean follow-up time of 14.8 months, definition of the results was not uniform, and range of motion was improved, but relief of pain was inconsistent. There was one dislocation, one gastrointestinal complication, and two recurrences. Treatment of the three patients, with wide excision of peri-articular bone, selective exchange of components, and peri-operative irradiation prophylaxis, was successful in improving motion and deformity.There is insufficient data on the treatment of severe symptomatic HO after contemporary THA. Prophylaxis with low-dose irradiation was successful to prevent recurrence. Multicenter studies will be needed to determine the optimum timing and prognosis for treatment.

The main causative agents of infectious complications during reconstructive surgery using allomaterials in patients with breast cancer

Introduction: Surgical site infections (SSI) are one of the key problems in surgical practice. Despite the achievements of modern medicine, ongoing preventive measures, the incidence of wound infection remains quite high. This is especially relevant for oncoplastic surgery, since in most cases the installation of foreign materials (expanders, implants, meshes) is required to achieve a satisfactory cosmetic result.The purpose of the study: to identify the most common cause of infectious complications after reconstructive operations on the mammary gland using endoprostheses.Materials and methods: In a retrospective review of 526 consecutive implant-based breast reconstructions at a single institution from June 2020 to June 2022 was conducted. The frequency of development of infectious complications was assessed, as well as the taxonomic structure of the main pathogens that were isolated in the department of oncomammology in 2020–2022.Results: The incidence of infectious complications that led to the loss of the endoprosthesis during reconstructive surgery on the mammary gland was 6.7 %. The main causative agents of SSI leading to the loss of implants and the need for reoperations were Corynebacterium striatum (35.2 %) and Staphylococcus aureus (27.2 %). The spectrum of the most common pathogens that led to the loss of implants corresponded to the flora most often detected during bacterial culture in the department. The probability of implant loss was higher in the group of patients who underwent chemotherapy (14 of 197, 7.1 %) or chemoradiotherapy (14 of 188, 7.4 %) compared with patients who did not receive specific anticancer treatment (7 of 141, 4.9 %). However, taking patients who did not receive drug or radiation treatment as a reference group, statistical significance could not be achieved (p = 0.56 in the chemotherapy group and p = 0.49 in the chemoradiotherapy group).Conclusions: Our own experience has shown that, despite the current preventive measures, the frequency of infectious complications remains quite high. In the etiological structure of SSI pathogens, microorganisms of the genera Staphylococcus and Corynebacterium predominate. The use of broad-spectrum antibiotics in perioperative prophylaxis did not guarantee the absence of SSI in the postoperative period. An analysis of the sensitivity of isolated pathogens to antibacterial drugs, an assessment of the effectiveness of various antibiotic regimens in the future may allow us to develop an optimal antibiotic prophylaxis scheme for infectious complications during breast reconstructive surgery, therefore, further prospective studies in this direction are needed.

Early surgical site infections in patients undergoing orthopaedic oncologic resection following change in perioperative antibiotic selection: A pre-post intervention study

BackgroundAt our institution, cefepime and vancomycin (FEP/VAN) were historically used for perioperative antimicrobial prophylaxis in malignant musculoskeletal tumor patients; however, prophylaxis was modified to cefazolin and vancomycin (CFZ/VAN) on June 6th, 2015. Due to the paucity of guidance and data, this study was conducted to optimize perioperative antimicrobial prophylaxis and compare early surgical site infection (SSI) rates within this patient population. MethodsThis was a single center, pre-post intervention, non-inferiority study. We included orthopedic surgery patients with musculoskeletal tumors who underwent resection and endoprosthetic or allograft replacement and received perioperative antibiotic prophylaxis. Perioperative antimicrobial prophylaxis included FEP/VAN or CFZ/VAN followed by oral antibiotic prophylaxis. The main outcome was the incidence of early culture-proven SSIs occurring within 90 days post-procedure. Results75 patients were included in each arm (150 total). Early SSI rates were low (FEP/VAN: 2.67% vs CFZ/VAN: 5.4%, P = 0.68) with no statistically significant differences. There was not a single independent factor associated with an increased odds of early SSI. ConclusionThis study supports CFZ/VAN as appropriate perioperative antibiotic prophylaxis in this patient population. There was no statistically significant change in SSIs with the change from FEP/VAN. Hospital length of stay differed but did not contribute to increased early SSI development odds.

Increased bleeding risk with enoxaparin venothromboembolism prophylaxis compared with heparin in patients undergoing bariatric surgery.

Perioperative venothromboembolism (VTE) chemoprophylaxis is an established tenant of bariatric surgery; however, there is little comparative data to guide medication choice. The objective of this study was to determine if a change in VTE prophylaxis from heparin to enoxaparin was associated with differing rates of postoperative bleeding and VTE occurrence after bariatric surgery. This retrospective cohort study included patients 18years or older who underwent primary bariatric surgery (sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)) at a single institution between March 2012 and December 2021. Subcutaneous unfractionated heparin was utilized for VTE prophylaxis from March 2012 through February 2018 and then enoxaparin was used from March 2018 through December 2021. Postoperative bleeding was defined as requiring a blood transfusion or reoperation for bleeding within 30days of surgery. Chi-square test was used to test for differences between groups. There were 2159 patients who underwent bariatric surgery with 1324 (61.3%) patients in the heparin group and 835 (38.7%) in the enoxaparin group. Overall, 1,503 (69.6%) patients underwent SG and 656 (30.4%) RYGB. There was no difference in the ratio of SG to RYGB between the heparin and enoxaparin groups. Most patients were female (n = 1709, 79.2%) with a median age of 43.2years (interquartile range (IQR): 35.6-52.2), and median BMI of 44.9 (IQR: 40.9-50.5). Overall postoperative bleeding occurred more frequently in the enoxaparin group (n = 26, 3.1%) compared with the heparin group (n = 12, 0.9%) (p < 0.01). Additionally, reoperation for bleeding was more frequent with enoxaparin (enoxaparin 0.8% vs. heparin 0.2%, p = 0.04). There was no difference in VTE occurrence between the two groups (heparin: n = 14, 1.1%, enoxaparin: n = 7, 0.8% (p = 0.61)). An institutional change from heparin to enoxaparin for bariatric surgery perioperative VTE prophylaxis was associated with a significant increase in postoperative bleeding, with no difference in VTE complications.

Invasive Fungal Infections: The Early Killer after Liver Transplantation

Background: Liver transplantation is a standard of care and a life-saving procedure for end-stage liver diseases and certain malignancies. The evidence on predictors and risk factors for poor outcomes is lacking. Therefore, we aimed to identify potential risk factors for mortality and to report on overall 90-day mortality after orthotopic liver transplantation (OLT), especially focusing on the role of fungal infections. Methods: We retrospectively reviewed medical charts of all patients undergoing OLT at a tertiary university center in Europe. Results: From 299 patients, 214 adult patients who received a first-time OLT were included. The OLT indication was mainly due to tumors (42%, 89/214) and cirrhosis (32%, 68/214), including acute liver failure in 4.7% (10/214) of patients. In total, 8% (17/214) of patients died within the first three months, with a median time to death of 15 (1–80) days. Despite a targeted antimycotic prophylaxis using echinocandins, invasive fungal infections occurred in 12% (26/214) of the patients. In the multivariate analysis, patients with invasive fungal infections had an almost five times higher chance of death (HR 4.6, 95% CI 1.1–18.8; p = 0.032). Conclusions: Short-term mortality after OLT is mainly determined by infectious and procedural complications. Fungal breakthrough infections are becoming a growing concern. Procedural, host, and fungal factors can contribute to a failure of prophylaxis. Finally, invasive fungal infections may be a potentially modifiable risk factor, but the ideal perioperative antimycotic prophylaxis has yet to be determined.

Impact of Perioperative Prophylaxis With Enterococcus Activity on Risk of Surgical-Site Infection After Pancreas Transplantation.

We performed a retrospective cohort study of PT recipients from 2010-2020 to examine the effect of perioperative antibiotic prophylaxis with Enterococcus coverage. Enterococcus coverage included antibiotics that would be active for penicillin-susceptible Enterococcus isolates. The primary outcome was SSI within 30 d of transplantation, and secondary outcomes were Clostridioides difficile infection (CDI) and a composite of pancreas allograft failure or death. Outcomes were analyzed by multivariable Cox regression. Of 477 PT recipients, 217 (45.5%) received perioperative prophylaxis with Enterococcus coverage. Eighty-seven recipients (18.2%) developed an SSI after a median of 15 d from transplantation. In multivariable Cox regression analysis, perioperative Enterococcus prophylaxis was associated with reduced risk of SSI (hazard ratio [HR] 0.58; 95% confidence interval [CI], 0.35-0.96; P = 0.034). Anastomotic leak was also significantly associated with elevated risk of SSI (HR 13.95; 95% CI, 8.72-22.32; P < 0.001). Overall, 90-d CDI was 7.4%, with no difference between prophylaxis groups (P = 0.680). SSI was associated with pancreas allograft failure or death, even after adjusting for clinical factors (HR 1.94; 95% CI, 1.16-3.23; P = 0.011). Perioperative prophylaxis with Enterococcus coverage was associated with reduced risk of 30-d SSI but did not seem to influence risk of 90-d CDI after PT. This difference may be because of the use of beta-lactam/beta-lactamase inhibitor combinations, which provide better activity against enteric organisms such as Enterococcus and anaerobes compared with cephalosporin. Risk of SSI was also related to anastomotic leak from surgery, and SSI itself was associated with subsequent risk of a poor outcome. Measures to mitigate or prevent early complications are warranted.

Perioperative cefazolin prescribing rates following suppression of alerts for non-IgE-mediated penicillin allergies

Background: Cefazolin is the preferred antimicrobial for prevention of surgical-site infections in most procedures at our institution. Our first alternative is vancomycin which is associated with higher adverse events and infection rates. The presence of penicillin allergies can influence prescribing of vancomycin despite a low risk of cross-reactivity between penicillin and cephalosporins. Nebraska Medicine implemented a systemwide change in April 2022 that suppressed alerts for non–IgE-mediated penicillin allergies in the electronic medical record (EMR, Epic Systems) upon cephalosporin prescribing. We evaluated changes in perioperative antimicrobial surgical infection prophylaxis after this change. Methods: We conducted a quasi-experimental study of all patients undergoing procedures for which cefazolin is considered preferred per institutional guidance. Preintervention data were from April 1, 2021, to March 31, 2022, and postintervention data included patients from April 11, 2022, to October 31, 2022, after guidance was distributed to surgeons, operating room staff, and pharmacists. Patients were excluded if they were aged &lt;19 years, had a hospital length of stay &lt;24 hours, underwent procedures after their first throughout the time frame, or received both vancomycin and cefazolin. Statistical significance was set at P &lt; .05, determined using the Fisher exact test. Results: The study included 6,676 patients: 4,147 in the preintervention group and 2,529 in the postintervention group. We identified 15 procedure categories, with no significant differences between periods (Table 1). The average age was 61 years. Penicillin allergy was reported in 508 patients (12.3%) in the preintervention group and in 319 patients (12.6%) in the postintervention group. In individuals with penicillin allergy, cefazolin prescribing increased from 49.6% to 74.3% (P &lt; .01) and vancomycin prescribing decreased from 50.4% to 25.7% (P &lt; .01). The largest changes occurred in patients undergoing cardiac, spinal, neurological, and vascular procedures. For patients without penicillin allergy, prescribing remained unchanged. Overall, cefazolin prescribing increased from 92.0% to 95.0% (P &lt; .01), and the rate of vancomycin prescribing decreased from 8.0% to 5.0% (P &lt; .01) in procedures for which cefazolin was preferred. Conclusions: Following the suppression of EMR alerts for non–IgE-mediated allergies when ordering cephalosporins, penicillin prescribing rates of cefazolin for surgical infection prophylaxis improved significantly in procedures for which it was the preferred agent. Further research on infection rates and adverse events with these and other alternative agents are needed.Disclosures: None

Optimizing Cefazolin Prophylaxis in Obstetrical Patients with Reported Beta-Lactam Allergy Undergoing Cesarean Delivery

ObjectivesEvaluate the impact of an allergy history-guided algorithm for optimizing perioperative cefazolin use in patients with reported beta-lactam allergy undergoing cesarean delivery. MethodsThe Allergy Clarification for Cefazolin Evidence-based Prescribing Tool (ACCEPT) was developed through consensus by allergists, anesthesiologists, and infectious diseases specialists, and implemented over a 2-month period (December 1, 2018, to January 31, 2019). A segmented regression on monthly cefazolin use was conducted during the baseline (January 1 to November 30, 2018) and intervention (February 1 to December 31, 2019) periods to evaluate the impact of ACCEPT on the monthly use of perioperative cefazolin in patients with reported beta-lactam allergy undergoing cesarean delivery. The frequency of perioperative allergic reactions and surgical site infections was collected during both periods. ResultsOf the 3128 eligible women who underwent a cesarean delivery, 282 (9%) reported a beta-lactam allergy. The most common beta-lactam allergens were penicillin (64.3%), amoxicillin (16.0%), and cefaclor (6.0%). The most frequently reported allergic reactions were rash (38.1%), hives (21.4%), and unknown (11.6%). Use of cefazolin increased from 52% (baseline) to 87% during the intervention period. Segmented regression analysis confirmed a statistically significant increase following implementation (incidence rate ratio 1.62, 95% CI 1.19–2.21, P = 0.002). There was 1 perioperative allergic reaction in the baseline period and 2 during the intervention period. Cefazolin use remained high (92%) 2 years after algorithm implementation. ConclusionsImplementation of a simple allergy history-guided algorithm in obstetrical patients with reported beta-lactam allergy resulted in a sustained increase in perioperative cefazolin prophylaxis.

Trends over 20 years of antimicrobial prophylaxis for artificial urinary sphincter surgery.

Perioperative antimicrobial prophylaxis is crucial for prevention of prosthesis and patient morbidity after artificial urinary sphincter (AUS) placement. While antibiotic guidelines exist for many urologic procedures, adoption patterns for AUS surgery are unclear. We aimed to assess trends in antibiotic prophylaxis for AUS and outcomes relative to American Urological Association (AUA) Best Practice guidelines. The Premier Healthcare Database was queried from 2000 to 2020. Encounters involving AUS insertion, revision/removal, and associated complications were identified via ICD and CPT codes. Premier charge codes were used to identify antibiotics used during the insertion encounter. AUS-related complication events were found using patient hospital identifiers. Univariable analysis between hospital/patient characteristics and use of guideline-adherent antibiotics was done via chi-squared and Kruskal-Wallis tests. A multivariable logistic mixed effects model was used to assess factors related to the odds of complication, specifically the use of guideline-adherent versus nonadherent regimens. Of 9775 patients with primary AUS surgery, 4310 (44.1%) received guideline-adherent antibiotics. The odds of guideline-adherent regimen use increased 7.7% per year with 53.0% (830/1565) receiving guideline-adherent antibiotics by the end of the study period. Patients with guideline-adherent regimens had a decreased risk of any complication (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.74-0.93) and surgical revision (OR: 0.85, 95% CI: 0.74-0.96) within 3 months; however, no significant difference in infection within was noted (OR: 0.89, 95% CI: 0.68-1.17) within 3 months. Adherence to AUA antimicrobial guidelines for AUS surgery appears to have increased over the last two decades. While guideline-adherent regimens were associated with decreased risk of any complication and surgical intervention, no significant association was found with risk of infection. Surgeons appear to be increasingly following AUA recommendations for antimicrobial prophylaxis for AUS surgery, however, further level 1 evidence should be obtained to demonstrate conclusive benefit of these regimens.