Severe Postoperative Infections Research Articles

Non-antigen-specific Immunoadsorption Is a Risk Factor for Severe Postoperative Infections in ABO-Incompatible Kidney Transplant Recipients.

ABO-incompatible (ABOi) living kidney transplantation (KTx) is an established procedure to address the demand for kidney transplants with outcomes comparable to ABO-compatible KTx. Desensitization involves the use of immunoadsorption (IA) to eliminate preformed antibodies against the allograft. This monocentric retrospective study compares single-use antigen-selective Glycosorb® ABO columns to reusable non-antigen-specific Immunosorba® immunoglobulin adsorption columns regarding postoperative infectious complications and outcome. It includes all 138 ABOi KTx performed at Freiburg Transplant Center from 2004-2020. We compare 81 patients desensitized using antigen-specific columns (sIA) to 57 patients who received IA using non-antigen-specific columns (nsIA). We describe distribution of infections, mortality and allograft survival in both groups and use Cox proportional hazards regression to test for the association of IA type with severe infections. Desensitization with nsIA tripled the risk of severe postoperative infections (adjusted HR 3.08, 95% CI: 1.3-8.1) compared to sIA. nsIA was associated with significantly more recurring (21.4% vs. 6.2%) and severe infections (28.6% vs. 8.6%), mostly in the form of urosepsis. A significantly higher proportion of patients with sIA suffered from allograft rejection (29.6% vs. 14.0%). However, allograft survival was comparable. nsIA is associated with a two-fold risk of developing a severe postoperative infection after ABOi KTx.

Hazardous alcohol consumption and perioperative complications in a cardiac surgery patient. A retrospective study.

We investigated the prevalence and effects of hazardous alcohol consumption on perioperative complications in cardiac surgery patients. Preoperative hazardous alcohol consumption has been associated with an increased risk of postoperative complications in noncardiac patient populations. We retrospectively collected data from the Finnish Intensive Care Consortium database and electronic patient records on all cardiac surgery patients treated in the intensive care units (ICUs) of Helsinki University Hospital (n = 919) during 2017. Data on preoperative alcohol consumption were routinely collected using the alcohol use disorder identification test consumption (AUDIT-C) questionnaire. We analyzed perioperative data and outcomes for any associations with hazardous alcohol consumption. Outcome measures were length of stay in the ICU, re-admissions to ICU, bleeding and infectious complications, and incidence of postoperative arrhythmias. AUDIT-C scores were available for 758 (82.5%) patients, of whom 107 (14.1%) fulfilled the criteria for hazardous alcohol consumption (AUDIT-C score of 5/12 or higher for women and 6/12 or higher for men). Patients with hazardous alcohol consumption were younger, median age 59 (IQR 52.0-67.0) vs. 69.0 (IQR 63.0-74.0), p < .001, and more often men 93.5% vs. 71.9%, p < .001 than other patients and had an increased risk for ICU re-admissions [adjusted OR (aOR) 4.37 (95% CI, 1.60-11.95)] and severe postoperative infections aOR 3.26 (95% CI, 1.42-7.54). Cardiac surgery patients with a history of hazardous alcohol consumption are younger than other patients and are predominantly men. Hazardous alcohol consumption is associated with an increased risk of severe postoperative infections and ICU re-admissions.

The value of point-of-care tests for the detection of SARS-CoV-2 RNA or antigen in bronchoalveolar lavage fluid

BackgroundTransmission of SARS-CoV-2 from donor to recipient is a clinically relevant risk for developing severe COVID-19 after lung transplantation (LTx). This risk of iatrogenic transmission can be reduced by timely detection of viral RNA or antigen in samples of bronchoalveolar lavage (BAL) fluid obtained at the time of lung procurement. We aimed to retrospectively evaluate the detection of SARS-CoV-2 RNA or antigen in BAL fluid samples using three point-of-care tests (POCTs). MethodsBAL fluid samples came from patients hospitalized in an intensive care unit during the COVID-19 pandemic. These pandemic samples were scored as positive or negative for SARS-CoV-2 by a RT-qPCR comparator assay for orf1ab. Three commercially available POCTs were then evaluated: cobas SARS-CoV-2 & Influenza A/B assay with the cobas Liat RT-qPCR system (Roche Diagnostics), ID NOW COVID-19 and COVID-19 2.0 (Abbott), and SARS-CoV-2 Rapid Antigen Test (RAT) (Roche Diagnostics). Samples from the pre-pandemic era served as negative controls. ResultsWe analyzed a total of 98 BAL fluid samples, each from a different patient: 58 positive pandemic samples (orf1ab Ct<38), 20 putatively negative pandemic samples (orf1ab Ct≥38), and 20 pre-pandemic samples. Univariate logistic regression shows that the probability of detection was highest for cobas Liat, followed by ID NOW, and then RAT. Of clinical relevance, cobas Liat detected SARS-CoV-2 RNA in 30 of the 31 positive pandemic samples that were collected within 10 days after RT-qPCR diagnosis of SARS-CoV-2 infection. None of the 20 pre-pandemic samples had a false-positive result for any POCT. ConclusionsPOCTs enable the detection of SARS-CoV-2 RNA or antigen in BAL fluid samples and may provide additional information to decide if donor lungs are suitable for transplantation. Detection of respiratory pathogens with POCTs at the time of donor lung procurement is a potential strategy to increase safety in LTx by preventing iatrogenic transmission and severe postoperative infections.

Clinical, Microbiological and Treatment Characteristics of Severe Postoperative Respiratory Infections: An Observational Cohort Study.

Respiratory infections are frequent and life-threatening complications of surgery. This study aimed to evaluate the clinical, microbiological and treatment characteristics of severe postoperative pneumonia (POP) and tracheobronchitis (POT) in a large series of patients. This single-center, prospective observational cohort study included patients with POP or POT requiring intensive care unit admission in the past 10 years. We recorded demographic, clinical, microbiological and therapeutic data. A total of 207 patients were included, and 152 (73%) were men. The mean (SD) age was 70 (13) years and the mean (SD) ARISCAT score was 46 (19). Ventilator-associated pneumonia was reported in 21 patients (10%), hospital-acquired pneumonia was reported in 132 (64%) and tracheobronchitis was reported in 54 (26%). The mean (SD) number of days from surgery to POP/POT diagnosis was 6 (4). The mean (SD) SOFA score was 5 (3). Respiratory microbiological sampling was performed in 201 patients (97%). A total of 177 organisms were cultured in 130 (63%) patients, with a high proportion of Gram-negative and multi-drug resistant (MDR) bacteria (20%). The most common empirical antibiotic therapy was a triple-drug regimen covering MDR Gram-negative bacteria and MRSA. In conclusion, surgical patients are a high-risk population with a high proportion of early onset severe POP/POT and nosocomial bacteria isolation.

Therapeutic Drug Monitoring of Antimicrobials in Critically Ill Obese Patients.

Obesity is a significant global public health concern that is associated with an elevated risk of comorbidities as well as severe postoperative and nosocomial infections. The treatment of infections in critically ill obese patients can be challenging because obesity affects the pharmacokinetics and pharmacodynamics of antibiotics, leading to an increased risk of antibiotic therapy failure and toxicity due to inappropriate dosages. Precision dosing of antibiotics using therapeutic drug monitoring may help to improve the management of this patient population. This narrative review outlines the pharmacokinetic and pharmacodynamic changes that result from obesity and provides a comprehensive critical review of the current available data on dosage adjustment of antibiotics in critically ill obese patients.

Minimally invasive lateral single-position surgery for multilevel degenerative lumbar spine disease: feasibility and perioperative results in a single Latin-American spine center.

Within advances in minimally invasive spine surgery, the implementation of lateral single position (LSP) increases efficiency while limiting complications, avoiding intraoperative repositioning and diminishing surgical time. Most literature describes one-level instrumentation of the lumbar spine; this study includes the use of LSP for multilevel degenerative disease. The objective of the article is to analyze initial clinical results and complications in the use of LSP for multiple level instrumentation in adults with lumbar degenerative disease. A retrospective early clinical series was performed for patients who had multiple level instrumentation in LSP between August 2019 and September 2022 at the Hospital Universitario San Ignacio in Bogota, Colombia. Inclusion criteria were patients older than 18years with symptomatic lumbar degenerative disease, undergoing any combination of multilevel anterior lumbar interbody fusion, lateral lumbar interbody fusion (LLIF) and pedicle screw fixation. Forty patients with an average age of 61.3years were included, with diagnosis of multilevel degenerative spondylotic changes. Four-, three- and two-level interventions were performed in 52.5, 35 and 12.5%, respectively. Average time per level was 68.9min, and length of hospital stay had an average of 2.4days, with all patients starting ambulation within the first postoperative day. Procedural time and blood loss were similar to those reported in literature. No severe lesions, postoperative infections or reinterventions took place. Although it was a small number of patients and further clinical trials are needed, LSP for multiple levels is apparently safe with adequate outcomes which may improve efficiency in the operating room.

The impact of pre-existing hematologic disorders on morbidity and mortality following heart transplantation: Focus on early graft dysfunction.

Heart transplantation (HT) is the gold standard therapy for advanced heart failure, providing excellent long-term outcomes. However, postoperative outcomes are limited by bleeding, infections, and primary graft dysfunction (PGD) that contribute to early mortality after HT. HT candidates with pre-existing hematologic disorders, bleeding, and clotting, may represent a higher risk population. We assessed the short- and long-term outcomes of patients with pre-existing hematologic disorders undergoing HT. Medical records of all adult patients who received HT from January 2010 to December 2019 at our institution were retrospectively reviewed. Hematologic disorders were identified via chart review and adjudicated by a board-certified hematologist. Inverse probability weighting and multivariable models were used to adjust for potential pretransplant confounders. Four hundred and ninety HT recipients were included, of whom 29 (5.9%) had a hematologic disorder. Hematologic disorders were associated with severe PGD requiring mechanical circulatory support (aOR 3.15 [1.01-9.86]; p=.049), postoperative infections (aOR 2.93 [1.38-6.23]; p=.01), and 3-year acute cellular rejection (ACR) (≥1R/1B) (aSHR 2.06 [1.09-3.87]; p=.03). There was no difference in in-hospital mortality (aOR 1.23 [.20-7.58], p=.82) or 3-year mortality (aHR 1.58 [.49-5.12], p=.44). Patients with hematologic disorders undergoing HT are at increased risk of severe PGD, postoperative infections, and ACR, while in-hospital and 3-year mortality remain unaffected.

Transmission and microevolution of methicillin-resistant Staphylococcus aureus ST88 strain among patients, healthcare workers, and household contacts at a trauma and orthopedic ward.

Surgical sites infections (SSIs) caused by Methicillin-resistant Staphylococcus aureus (MRSA) constitute a major clinical problem. Understanding the transmission mode of MRSA is important for its prevention and control. We investigated the transmission mode of a MRSA outbreak in a trauma and orthopedic hospital ward. Clinical data were collected from patients (n = 9) with MRSA infection in a trauma and orthopedic ward from January 1, 2015 to December 31, 2019. The wards (n = 18), patients (n = 48), medical staff (n = 23), and their households (n = 5) were screened for MRSA. The transmission mode of MRSA isolates was investigated using next-generation sequencing and phylogenetic analyses. The resistance genes, plasmids, and single-nucleotide variants of the isolates were analyzed to evaluate microevolution of MRSA isolates causing SSIs. The MRSA colonization-positive doctor was asked to suspend his medical activities to stop MRSA spread. Nine MRSA infected patients were investigated, of which three patients were diagnosed with SSI and had prolonged hospitalization due to the persistent MRSA infection. After screening, MRSA isolates were not detected in environmental samples. The surgeon in charge of the patients with SSI caused by MRSA and his son were positive for MRSA colonization. The MRSA from the son was closely related to the isolates detected in MRSA-induced SSIs patients with 8-9 single-nucleotide variants, while ST88-MRSA isolates with three different spa types were detected in the surgeon's nasal cavity. Comparative genomic analysis showed that ST88-MRSA isolates acquired mutations in genes related to cell wall synthesis, colonization, metabolism, and virulence during their transmission. Suspending the medical activity of this surgeon interrupted the spread of MRSA infection in this ward. Community-associated MRSA clones can invade hospitals and cause severe postoperative nosocomial infections. Further MRSA surveillance in the households of health workers may prevent the transition of MRSA from colonization to infection.

Severe infections after teeth removal – are we doing enough in preventing them?

BackgroundThe present study clarified features and prehospital care in patients with severe infection after teeth removal. Material and MethodsPatients who were hospitalized for infection following teeth removal were included in this study. Background variables and infection severity parameters were compared between patients who underwent elective and acute teeth removal prior to hospitalization. Additionally, associations of these variables with antibiotic use were evaluated. ResultsOf the 118 patients included in the study, teeth removal was due to acute infection in 64% and removal was elective in 36%. The time span from teeth removal to hospitalization varied considerably (from <1 day to 205 days). The variation was significantly greater in patients with preceding acute removal than those with elective removal (P=0.030). Smoking was significantly associated with acute teeth removal (P<0.001). Length of hospital stay (LOHS) was a day longer in the elective group (P=0.017). Overall, 70% of patients received antibiotics prior to hospitalization. There was a significant association between removal type and antibiotic use (P=0.005); antibiotic use was less common in elective teeth removal patients. Immunocompromised patients received antibiotic prophylaxis significantly more often than non-immunocompromised patients (P=0.003). LOHS was significantly associated with prehospital antibiotic use (P=0.035). LOHS was a day longer in patients who had not received antibiotics than in other patients. ConclusionsSevere infection can develop with a long delay after acute teeth removal. More attention should be paid to preceding symptoms and early effective treatment of these infections. A more precise timing of antibiotic use could reduce severe postoperative infections in elective teeth removal. Key words:Odontogenic infection, teeth removal, antibiotic use, prophylaxis, postoperative infection.

Surgical Site Infections in Gynaecological Surgeries

Surgical contaminations are one of the utmost familiar medical management related contamination within the economically developing nations. Gynecologic tactics constitute a completely distinctive venture within which the infectious pathogen arising out of pores and the underlying skin or the vagina and endo-cervix can also relocate up to the area of surgery and may bring about vaginal cuff cellulitis, cellulitis of the pelvis, and abscesses of the pelvis. Numerous organisms along with operation threat elements were recognized as dangers that grow infectious sequelae after pelvic surgical treatment. The full-size use of antibiotic prophylaxis has decreased however now no longer removed severe postoperative infections; the common anticipated SSIs price being three–15% after c-section. Those costs are multiplied by the existence of various threat elements like surgical infection, which is compounded by untimely rupture of membranes, obstructed labour, chorioamnionitis, large obesity, extended duration of surgery, emergency surgeries, and immunodeficiency, all of that are not uncommon within aid-deficient nations. Other factors linked to physician ability, such as poor operation skills, insufficient hemostasis, and the presence of a useless region, lead to increased injury contamination. Working at the pinnacle, such as those medical conditions that occur during pregnancy and malnutrition, also contribute significantly to the problem.&#x0D; SSIs as the most common motive concerning hospital-acquired contamination in obstetrics, although the present contemporary era, remains as chief residence fitness hassle within growing nations. We may even evaluate the definitions, microbiology, pathogenesis, diagnosis, and control of pelvic SSIs after gynecologic surgical procedures.

Utility of Preoperative Computed Tomography-Based Body Metrics in Relation to Postoperative Complications in Pediatric Liver Transplantation Recipients.

Computed tomography (CT)‐derived body metrics such as skeletal muscle index (SMI), psoas muscle index (PMI), and subcutaneous fat area index (ScFI) are measurable components of sarcopenia, frailty, and nutrition. While these body metrics are advocated in adults for predicting postoperative outcomes after liver transplantation (LT), little is known about their value in pediatric populations. This study assessed the relation between preoperative CT‐based body metrics and postoperative short‐term outcomes in pediatric LT recipients. Patients aged 0‐18 years who underwent a primary LT were retrospectively included (n = 101; median age 0.5 years; range 0.2‐17.1). SMI, PMI, and ScFI were derived from preoperative axial CT slices. Postoperative outcomes and complications within 90 days were correlated with the CT‐based body metrics. To classify postoperative infections, the Clavien‐Dindo (CD) classification was used. Subgroup analyses were performed for age groups (<1, 1‐10, and >10 years old). An optimal threshold for test performance was defined using Youden’s J‐statistic and receiver operating characteristic curve as appropriate. ScFI was significantly (P = 0.001) correlated with moderate to severe postoperative infections (CD grade 3‐5) in children aged <1 year, with the optimal ScFI threshold being ≤27.1 cm2/m2 (sensitivity 80.4% and specificity 77.8%). A weak negative correlation between SMI and the total duration of hospital stay (R = −0.3; P = 0.01) and intensive care unit (ICU) stay (R = −0.3; P = 0.01) was observed in children aged <1 year. No other associations between CT‐based body metrics and postoperative outcomes were shown. In children aged <1 year with cirrhotic liver disease undergoing LT, preoperative CT‐based body metrics were correlated with moderate to severe postoperative infections (ScFI) and with longer duration of hospital and ICU stay (SMI), and thus can be considered important tools for pre‐LT risk assessment.

Hyperbaric oxygen treatment: Results in seven patients with severe bacterial postoperative central nervous system infections and refractory mucormycosis

Resistant bacterial infections following brain and spine surgery and spontaneous mucormycosis with central nervous system (CNS) involvement represent a serious treatment challenge and more efficient therapeutic approaches ought to be considered. Hyperbaric oxygen treatment (HBOT) has shown promise as a complementary therapy. This case series evaluated whether HBOT contributed to infection resolution in seven patients with refractory CNS infectious conditions. Clinical results for seven patients referred for HBOT between 2010 to 2018 to treat refractory postoperative brain and spine infections or spontaneously developing mucormycosis were retrospectively analysed. The patients' clinical files and follow-up consultations were reviewed to assess evolution and outcome. Seven patients were referred with a median age of 56 years. The median follow-up was 20 months. Four patients had postoperative infections and three had rhino-orbital-cerebral mucormycosis (ROCM). HBOT was used as an adjunctive treatment to antimicrobial therapy in all patients. Prior to HBOT, all patients had undergone an average of four operations due to infection refractoriness and had completed an average of five months of antimicrobial therapy. After HBOT, infection resolution was obtained in six patients without additional operations, while one patient with ROCM stopped HBOT after the third session due to intolerance. Three patients stopped antimicrobial therapy while four were maintained on prophylactic treatment. Infection resolution was reached in the six patients that completed HBOT as prescribed. HBOT may serve as an effective complementary treatment in CNS refractory postoperative and spontaneous infections.

Outcome after Heart Transplantation in High-Urgent Listed Patients on LVAD: Impact of Type of Complication

Purpose For heart transplantation (htx) a new scoring system which considers a potential postoperative benefit is scheduled for the near future. In our patients we aimed to analyze HU-LVAD-patients after cardiac transplant, particularly with regard to the clinical conditions causing HU-status. Methods Between 2010 and 09/2018, 115 patients underwent htx in our department. 74 of these patients were supported by an LVAD before transplant and 39 of those were transplanted with HU-status, 35 with elective status “T”. With regard to the HU-causing complications the LVAD-HU-group could be divided into 6 groups: Group HU1 suffered from severe LVAD-infections, group HU2 from thromboembolic events and group-HU3 from neurological complications. Right heart failure, severe cardiac arrhythmias and intractable gastrointestinal bleeding were the reasons for HU-listing in groups HU4, HU5 and HU6, respectively. LVAD-patients which were transplanted electively (group T) served as controls. Results The subgroups HU1 to HU6 consisted of 14, 7, 6, 7, 3 and 2 patients, respectively. Thirty-day mortality was 14.3% in group T and 15.4% in group-HU, with 33.3% and 28.6% in groups HU5 and HU2. Extracorporeal life support (ECLS) was applied in 25.7% in group T, whereas 43.6 % of HU-patients needed perioperative ECLS, p=0.065, with the highest incidence in HU5 and HU1 with 66.7% and 50%. Duration of intubation, postoperative stay on ICU and in hospital was significantly prolonged in group-HU1 compared to all other HU-patients and by trend to group T. Severe postoperative infections occurred in 14.3% of group T, compared to 20.5% in all HU-patients (p>0.05), as expected most frequent in group HU1 with 57.1% (p Conclusion With our single-center experience we could show that the outcome of HU-listed LVAD-patients after htx is significantly different with regard to the underlying complication while on LVAD. Patients with severe LVAD-infections displayed the worst short- and midterm outcome after htx. This fact should be considered in preparation of the new “benefit”-allocation score.

Factors influencing the outcome of surgery for pelvic organ prolapse

Introduction and hypothesisPelvic organ prolapse (POP) surgery is a common gynecological procedure. Our aim was to assess the influence of obesity and other risk factors on the outcome of anterior and posterior colporrhaphy with and without mesh.MethodsData were retrieved from the Swedish National Register for Gynecological Surgery on 18,554 women undergoing primary and repeat POP surgery without concomitant urinary incontinence (UI) surgery between 2006 and 2015. Multivariate logistic regression analyses were used to identify independent risk factors for a sensation of a vaginal bulge, de novo UI, and residual UI 1 year after surgery.ResultsThe overall subjective cure rate 1 year after surgery was 80% (with mesh 86.4% vs 77.3% without mesh, p < 0.001). The complication rate was low, but was more frequent in repeat surgery that were mainly mesh related. The use of mesh was also associated with more frequent de novo UI, but patient satisfaction and cure rates were higher compared with surgery without mesh. Preoperative sensation of a vaginal bulge, severe postoperative complications, anterior colporrhaphy, prior hysterectomy, postoperative infections, local anesthesia, and body mass index (BMI) ≥30 were risk factors for sensation of a vaginal bulge 1 year postsurgery. Obesity had no effect on complication rates but was associated increased urinary incontinence (UI) after primary surgery. Obesity had no influence on cure or voiding status in women undergoing repeat surgery.ConclusionsObesity had an impact on the sensation of a vaginal bulge and the presence of UI after primary surgery but not on complications.

Targeting cefuroxime plasma concentrations during coronary artery bypass graft surgery with cardiopulmonary bypass.

Patients are at risk for severe postoperative infections after coronary artery bypass graft (CABG) surgery. Clinical laboratory data showed that unbound plasma concentrations of cefuroxime were not always adequate, therefore we developed a new dosing regimen. The aim of this prospective study is to evaluate the new dosing strategy by monitoring patients for unbound cefuroxime plasma concentrations during CABG surgery with cardiopulmonary bypass (CPB). A Dutch teaching hospital. In this prospective trial, patients scheduled for CABG surgery with CPB were included. A starting dose of 1500 mg cefuroxime was given with anesthesia induction, followed by 750 mg cefuroxime every hour until wound closure. In case of renal failure the dosing regimen was adapted. Serial blood samples were collected before, during and after the CPB process. Pharmacokinetic modelling was performed by using an 'iterative two-stage Bayesian population procedure'. Unbound plasma concentrations of cefuroxime. 22 patients were included, data could be evaluated of 21 patients. In 24 % of the patients the unbound cefuroxime plasma concentration was below the target range during surgery before CPB started. Patients with a bodyweight above 100 kg or age <60 years were more likely to have unbound plasma concentrations below the target range (P = 0.030 and P = 0.008). During CPB, the half-life of unbound cefuroxime increased by 17 % and the clearance decreased by 11 % compared to before CPB (P = 0.033 and P = 0.014). The mean pharmacokinetic parameters before, during and after CPB were as follows: elimination half-life 72, 84 and 76 min; clearance of unbound cefuroxime (Clu) 14.2, 12.7, 13.8 l/h and volume of distribution (Vu) 0.280, 0.284 and 0.290 l/kg respectively. Variations in unbound fractions before, during and after CPB were below 2 %, implicating the unbound fraction of cefuroxime is not influenced by CPB. Our results show that CPB during CABG surgery does not lead to inadequate unbound cefuroxime concentrations. Age, renal function and possibly also weight are more important factors that can result in unbound plasma cefuroxime concentrations below the target value.

Infectious postoperative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer: a study of 12,075 patients.

We sought to characterize the effect of postoperative complications on long-term survival after colorectal cancer (CRC) resection. The impact of early morbidity on long-term survival after curative-intent CRC surgery remains controversial. The Veterans Affairs Surgical Quality Improvement Program and Central Cancer Registry databases were linked to acquire perioperative and cancer-specific data for 12,075 patients undergoing resection for nonmetastatic CRC (1999-2009). Patients were categorized by presence of any complication within 30 days and by type of complication (noninfectious vs infectious). Univariate and multivariate survival analyses adjusted for patient, disease, and treatment factors were performed, excluding early deaths (<90 days). Subset analysis was performed to determine the specific impact of severe postoperative infections. The overall morbidity and infectious complication rates were 27.8% and 22.5%, respectively. Patients with noninfectious postoperative complications were older, had lower preoperative serum albumin, had worse functional status, and had higher American Society of Anesthesiologists scores than patients with infectious complications and without complications (all P < 0.001). The presence of any complication was independently associated with decreased long-term survival [hazard ratio, 1.24; 95% confidence interval (1.15-1.34)]. Multivariate analysis by complication type demonstrated increased risk only with infectious complications [hazard ratio, 1.31; 95% confidence interval (1.21-1.42)]. Subset analysis demonstrated this effect predominantly in patients with severe infections [hazard ratio, 1.41; 95% confidence interval (1.15-1.73)]. The presence of postoperative complications after CRC resection is associated with decreased long-term survival, independent of patient, disease, and treatment factors. The impact on long-term outcome is primarily driven by infectious complications, particularly severe postoperative infections.

Abstract 1963: Toll-like receptor activation in bacterial pneumonia increases lung cancer cell adhesion and metastasis formation

Abstract Lung cancer is the leading cause of cancer death. Surgery remains essential for cure. However, postoperative infections particularly pneumonia remain high and confer an increased risk for metastasis. Emerging evidence implicates Toll-like receptor (TLR) signalling in tumor progression after systemic infection. We hypothesize bacterial pneumonia increases lung cancer cell adhesion and metastasis and that these effects are mediated in part by TLR signalling. C57BL6 mice were intranasally inoculated with 10^5 CFU/mL of S. pneumonia and intrasplenically injected with H59 murine lung carcinoma 3 days later. Gross liver metastases were quantified at 2 weeks. Similarly, H59 cell adhesion to liver sinusoids was assessed by intravital microscopy (IVM) in wild type (WT) and TLR2 KO and TLR4 KO mice. WT, TLR2 KO, TLR4 KO, and MyD88 KO mice were intratracheally injected with lipoteichoic acid (LTA), lipopolysaccharide (LPS), or control (PBS). H59 cell adhesion was assessed 4 hours later with liver IVM. Using an in vitro pneumonia model, bronchoepithelial BEAS2B cells were stimulated with LPS, LTA, heat-inactivated E. coli or heat-inactivated S. pneumonia and supernatants collected. H59 cells were exposed to various supernatants and adhesion to extracellular matrix components was assessed. BEAS2B cells were also stimulated in the presence of anti-TLR2 antibodies or eritoran tetrasodium to inhibit TLR2 and TLR4 signalling respectively. Adhesion of supernatant treated cells to liver sinusoids was also assessed with IVM. Mice inoculated with S. pneumonia demonstrated a 2-3 fold increase in gross liver metastases compared to non-infected controls. Similarly WT and TLR4 KO mice infected with S. pneumonia demonstrated a 4-5 fold increase in H59 adhesion to liver sinusoids versus control. TLR2 KO mice infected with S. pneumonia demonstrated no significant increase in H59 cell adhesion to liver. WT mice intratracheally injected with LTA or LPS demonstrated a 3-4 fold increase in cancer cell adhesion to liver compared to control. The increased adhesion for LTA was negated in TLR2 KO and MyD88 KO mice. For LPS conditions this increase was absent in TLR4 KO and MyD88 KO mice. Incubation with TLR-activated BEAS2B supernatants increased H59 cell adhesion to collagen 1, 4 and fibronectin 2-3 , 3-6 and 4-6 fold respectively versus media control and adhesion to liver sinusoids in vivo increased 3-4 fold. These effects were abrogated by blocking TLR2 for LTA or S. pneumonia conditions and by blocking TLR4 for LPS or E. coli conditions. Bacterial pneumonia increases the metastatic potential of circulating lung cancer cells. These effects are facilitated in part by TLR2 or TLR4 activation and are mediated via interactions of the respiratory epithelium with the host systemically and lung cancer cells directly. TLR2 and TLR4 are potential therapeutic targets to decrease cancer recurrence in patients who suffer severe post-operative infections. Citation Format: Stephen D. Gowing, Simon C. Chow, Jonathan J. Cools-Lartigue, Crystal B. Chen, Betty Giannias, France Bourdeau, Simon Rousseau, Salman T. Qureshi, Lorenzo E. Ferri. Toll-like receptor activation in bacterial pneumonia increases lung cancer cell adhesion and metastasis formation. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1963. doi:10.1158/1538-7445.AM2014-1963

Osteomyelitis following Palatoplasty: A Rare Complication

Objectives: Raise awareness of potential serious complications of oropharyngeal surgery such as osteomyelitis and discuss the role of perioperative antibiotics in such operations. Explore the events leading up to the development of osteomyelitis in a 13-month-old boy following palatoplasty. Discuss the role of perioperative antibiotics in oropharyngeal surgery. Study Design: Single case report with chart and literature review. Methods: We present the case of a 13-month-old boy who underwent palatoplasty, received perioperative antibiotics, and subsequently developed group A streptococcal bacteremia along with osteomyelitis of the right calcaneus. A literature review was done to explore the role of antibiotics in oropharyngeal surgery. Results: The patient underwent treatment with antibiotics, and the osteomyelitis resolved. Conclusions: Surgeons and clinicians should maintain a high level of suspicion for bone and joint infections in any child presenting postoperatively with fevers, bacteremia, and musculoskeletal symptoms. The role of perioperative antibiotics in the prevention of severe postoperative infections such as osteomyelitis is unclear. In the era of evidence-based medicine there is a movement to temper, if not eliminate, the once standard practice of discharging children on a short course of prophylactic antibiotics following palate repair. It should therefore be noted that even when these antibiotics are given, rare infectious complications may still occur.

Surgical site infections in skin surgery: A single center experience

The main interests covered in this article are the determination of risk factors and incidence of surgical site infections in dermatosurgery and suggestions for rational use of antibiotic prophylaxis. A total of 3284 consecutive dermatosurgical interventions in 1088 patients were performed in our dermatosurgery department. Data regarding patient characteristics and perioperative course were prospectively collected and retrospective analysis of this data was performed. Association of perioperative parameters and postoperative surgical site infections was assessed by χ(2) -test. Rate of postoperative infections in our study was low (1.9%). Purulent surgical sites showed the highest incidence of severe postoperative infections (4.7%; P < 0.001). The lowest incidence of mild infections was seen in preoperatively clean surgical sites (0.8%; P < 0.001). All patients with severe infections and 68% patients with mild infections were older than 70 years. The head and neck and acral regions were the groups mostly affected by mild postoperative conditions (2.4% and 1.7%, respectively; P = 0.006). The frequency of mild and severe infections in procedures performed by experienced surgeons was lower than in procedures performed by less experienced surgeons (0.6% vs 3.1% in mild infections, 0.1 vs 0.8 in severe infections; P < 0.001). The main risk factors for postoperative infections were wounds in the head and neck region, lips and oral mucosa or acral regions, older age of patients, worse preoperative state of surgical sites and less experienced surgeons. In the majority of cases where risk factors were missing there was no need of antibiotic prophylaxis.

Blood concentrations of cefuroxime in cardiopulmonary bypass surgery

Patients with coronary artery bypass graft (CABG) surgery are at risk for severe postoperative infections. Prophylactic cefuroxime may help to reduce this risk, however sufficient concentrations, i.e. above the breakpoint (32 mg/L), are mandatory. The aim of this study is to evaluate the blood concentrations of cefuroxime during and after CABG surgery with cardiopulmonary bypass (CPB) and hypothermia, to determine the concentration of cefuroxime in sternum fluid and to evaluate possible factors of influence. Seventeen patients were enrolled in this study, given 1.5 g cefuroxime at anaesthesia induction and an additional 1.5 g at start CPB. Blood samples were collected at skin incision, start CPB, every 30 min on CPB, end CPB, at wound closure and 1 h after surgery. Cefuroxime concentrations were determined by high performance liquid chromatography. In 47 % of the patients the cefuroxime concentration was below the breakpoint at some point during the operation and in 59 % of the patients 1 h after surgery. A statistically significant inverse correlation between estimated glomerular filtration rate and plasma cefuroxime concentrations was found (P = 0.034). Cefuroxime levels in the sternum are not significantly different from blood levels from the radial artery catheter, taken at approximately the same time (P = 0.30). The current antibiotic regimen used did not maintain cefuroxime concentrations above the breakpoint throughout the operation, suggesting insufficient antibiotic prophylaxis. Further research to other antibiotic regimes is therefore necessary.