This chapter provides insight into current management strategies for the placenta accreta spectrum (PAS). PAS is one of the most morbid conditions of pregnancy, with significant maternal hemorrhage and surgical morbidity risks, and its increasing incidence. Here, we review the available data to help guide the clinical management of PAS, from time of diagnosis through delivery and postpartum care, while acknowledging the many areas of continued uncertainty. The evidence is strong for the importance of team-based, patient-centered, and multidisciplinary care for patients with PAS. However, much else remains uncertain and is predominantly guided by expert opinion. Ultimately, we aim to provide a current understanding of available literature and to emphasize that continued research is paramount to explore management and surgical approaches to move toward optimization of patient outcomes, including the patient experience.

The prevalence of obesity is rapidly increasing worldwide, however there is a notable gap in understanding how obesity affects the pharmacokinetics of drugs and how dosing should be adjusted in obese population. The goals of this work were to evaluate plasma pharmacokinetics and tissue disposition of piperacillin, cefazolin, and cefoxitin in a rat model of diet-induced obesity compared to a lean cohort. Male Long-Evans rats were fed high-fat or control diets for 23 weeks. Various measures of body size and composition were collected. The animals were administered a mixture containing 50 mg/kg cefoxitin, 50 mg/kg cefazolin, and 120 mg/kg piperacillin. Plasma and tissues were collected and analyzed using a validated LC-MS/MS method. Whole-body physiologically-based pharmacokinetic (PBPK) models were develop to capture the biodistribution of these drugs in lean and obese cohorts. Most plasma and tissue concentrations were comparable between lean and obese rats after dosing based on mg/kg of total body weight; however, in some tissues concentration was consistently higher in obese animals. PBPKs successfully captured biodistribution of three drugs and both cohorts; however, cohort-specific (lean or obese) parameters were required for liver (for cefoxitin and cefazolin) and spleen (for all three drugs) for capturing the data.The results support the necessity of using mg/kg dosing for obese rats to achieve drug exposure comparable to that of lean rats. In the future, these models could be extended to predict plasma pharmacokinetics and tissue disposition of cefoxitin, cefazolin, and piperacillin in humans by incorporating interspecies scaling approaches.

The purpose of this study was to evaluate antimicrobial prophylaxis regimens for genital gender affirmation surgery in the prevention of surgical site infections and other infectious complications and to provide a descriptive report of what was observed when using the study sites' recommended regimens.

This retrospective observational study was completed at 2 urban academic medical centers between June 1, 2020, and June 30, 2023. All data were collected through retrospective chart review. The primary outcome of this study was the prevalence of surgical site infections within 30 days following genital gender affirmation surgery completed by a single surgeon at 2 health centers. Secondary outcomes included the prevalence of surgical site infections within 6 months of surgery, potential relationships of demographic data and type of surgery with the development of postoperative infection, and relationships of antibiotics, dose, and number of subsequent doses with the development of postoperative infection.

A total of 146 surgeries (124 patients) were included in the final analysis. Surgical site infection occurred within 30 days postoperatively in 4 patients (3%), most commonly noted on the first follow-up visit within 1 month of surgery. Another 2 infections occurred within 6 months postoperatively, resulting in a total of 6 patients (4%) with surgical site infections during the study period.

This study observed an acceptable prevalence of surgical site infections within both 30 days and 6 months of genital gender affirmation surgery. This outcome supports the use of narrow gram-positive and gram-negative coverage (ie, cefazolin) for clean and clean-contaminated procedures without entry into the gastrointestinal (GI) or gastroduodenal (GU) tracts, with the addition of anaerobic coverage (ie, metronidazole) for clean-contaminated procedures with entry into the GI or GU tract, as clinically appropriate options.

This study addresses the critical need for timely and accurate diagnosis of early postoperative infection (EPI) following cardiac surgery. EPI significantly impacts patient outcomes and healthcare costs, making its early detection vital.

To develop, validate, and clinically implement a machine-learning-based model for diagnosing EPI post-cardiac surgery, enhancing postoperative care.

In this multi-center cohort study spanning 2020 to 2022, data from four medical centers involved 2001 participants. Of these, 1400 were used for trainingand 601 for validation. Several machines-learning algorithms, including XGBoost, random forest, support vector machines, least absolute shrinkage and selection operator, and single-layer neural networks, were applied to develop predictive models. These were compared against a traditional logistic regression model. The model with the highest area under the receiver operating characteristic curve (AUROC) was deemed optimal. Implemented across four centers since 1 January 2023, a retrospective real-world study assessed its clinical applicability. Among 400 patients with an estimated EPI risk above 10%, identified by the optimal model, 55 followed its antibiotic upgrade recommendations (DEICS group). The remaining 345 patients upgraded antibiotics empirically, with 55 in the control group, matched 1:1 with the DEICS group. Clinical utility was evaluated through antibiotic use density (AUD), hospital costs, and ICU stay duration.

The XGBoost model achieved the highest performance with an AUROC of 0.96 (95% CI: 0.93-0.98). The calibration curve exhibited strong agreement with Brier scores of 0.02. According to the XGBoost model, the DEICS group significantly demonstrated reduced AUD ( P < 0.01) in the matched cohort, along with decreased ICU stay time (median: 5 vs. 6 days, P = 0.01) and hospital costs (median: ¥150 000 vs. median: ¥200 000, P = 0.01) in the EPI cohort.

The successful implementation of the XGBoost model facilitates accurate EPI diagnosis, improves postoperative recovery, and lowers hospital costs.

To assess practice patterns regarding antibiotics prophylaxis in otologic surgery in the United States.

Cross-sectional study.

Tertiary care center.

Members of American Neurotology Society (ANS).

Nationwide survey.

Prevalence of antibiotic prescribing among surgeons performing the following six ear surgical procedures: cochlear implantation, tympanoplasty with a clean ear, tympanoplasty with active drainage, cholesteatoma surgery without evidence of infection, cholesteatoma surgery with evidence of infection, and stapedectomy.

Seventy-three surgeons completed the survey (15.21% response rate). Twenty-seven percent had more than 25 years in experience, and 18% had 0 to 5 years of experience. Antibiotic prescribing practices varied by procedure: cochlear implantation (64.4%, median 5 d), tympanoplasty (clean ear: 23.3%, median 5 d; active drainage: 53.4%, median 7 d), cholesteatoma surgery (no infection: 30.1%, median 7 d; with infection: 58.9%, median 7 d), and stapedectomy (34.2%, mean 5 d). Cephalosporins were preferred for noninfected procedures, whereas amoxicillin dominated for active infections.

Prophylactic oral antibiotics varies for ear surgery, with higher usage for procedures with active infection and a preference for cephalosporins in noninfected cases. These findings underscore the need for the development and dissemination of standardized, evidence-based recommendations.

Consensus guidelines from the Infectious Disease Society of America recommend against antimicrobial prophylaxis in the operative management of uncomplicated cholelithiasis; however, these guidelines were derived entirely from the adult surgical population.

To compare surgical site infection (SSI) outcomes between children undergoing cholecystectomy who received prophylaxis and those who did not.

This was a cohort study using data from 141 hospitals participating in the National Surgical Quality Improvement Program-Pediatric. Patients younger than 18 years who underwent cholecystectomy for uncomplicated cholelithiasis from January 2021 to December 2022 were identified. Exclusion criteria included diagnoses of acute cholecystitis, pancreatitis, choledocholithiasis, hematologic disorders, and emergent procedures.

Administration of prophylactic antibiotics before incision.

The main outcomes were 30-day postoperative SSI and readmission. Propensity score weighting on the likelihood of receiving prophylaxis was used to balance groups on case acuity, duration of surgery, hospital discharge diagnosis, and patient characteristics. The association between outcomes and the use of prophylaxis was estimated using logistic regression models, weighted by the inverse probability of treatment with a random effect by hospital to control for hospital-level clustering. A secondary analysis was performed exploring the association between broad-spectrum prophylaxis and outcomes.

Of 2234 children who met criteria for inclusion (median age, 15.3 years; 19.7% male [399 of 2025]), 2025 (90.6%) received prophylaxis (utilization rates ranged from 0% to 100% among hospitals). Cefazolin was the most commonly used antibiotic (69.2% [1401 of 2025]), and 559 of 2025 patients (27.6%) received extended-spectrum prophylaxis (compared with cefazolin). In the propensity-weighted cohort, SSI rates were lower for children who received prophylaxis compared with those who did not (18.0 of 2016 [0.9%] vs 7.8 of 212 [3.7%]; adjusted odds ratio [AOR], 0.28; 95% CI, 0.11-0.70), and rates were similar between children receiving cefazolin and those receiving more extended-spectrum antibiotics in a secondary propensity-weighted analysis (13.9 of 1399 [1.0%] vs 2.9 of 558 [0.5%]; AOR, 0.54; 95% CI, 0.15-1.95).

The results of this study support prophylaxis use for children undergoing nonemergent cholecystectomy; however, use of extended-spectrum antibiotics was not associated with superior outcomes compared with cefazolin alone. Opportunities to optimize infection prevention or antimicrobial stewardship were identified in more than one-third of all children undergoing cholecystectomy.

To investigate the genomic epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) endophthalmitis and correlate it with the presenting clinical features and outcomes.

Nine patients presenting with MRSA endophthalmitis from 2014 to 2022 were included. Phenotypic and genomic tests were used for strain characterization. Demographics, clinical presentation, treatment and outcomes were reviewed.

The MRSA population was dominated by multidrug-resistant (MDR) strains within the clonal complex 5 (CC5) carrying an SCCmec type II genetic element (USA100-like strains). These strains carried genes that confer resistance to five antibiotic classes, in addition to mutations in topoisomerase genes (gyrA and parC) that resulted in resistance to all fluoroquinolones tested. Patients were mostly male (56%), with a median age of 82.7 years, and most had no recent history of extensive healthcare exposure. All cases were exogenous following ocular surgery (67%) or intravitreal injection (33%). The main exam findings were visual acuity ≤ hand motion, hypopyon (89%), and vitreous opacity (89%). Five patients (56%) showed improvement in visual acuity at 1 month following presentation, three (33%) at 3 months, and two (22%) at 6 months. Complications included evisceration (n = 1) and phthisis (n = 1). Patients who had pars plana vitrectomy within 48 hours of presentation had better clinical outcomes compared to those who did not.

Exogenous MRSA endophthalmitis is caused by MDR strains that resemble the hospital-acquired lineage USA100. These strains cause severe endophthalmitis in patients with no recent hospital/healthcare exposure.

Studies have shown an association between a reported penicillin allergy and an increased risk of surgical site infection. The risk is due to avoidance of cephalosporins and to the use of alternative classes of antibiotics in surgical prophylaxis. The aim of this study was to examine the safety of using cephalosporins in patients with a penicillin allergy label.

Patients with a primary or revision hip or knee arthroplasty in a tertiary care hospital between March 2020 and February 2023 were identified (n = 14,939). Information on prophylactic antibiotics, pre-existing antibiotic allergy labels before the operation, and all recorded new antibiotic allergy labels within 2 weeks after the operation was gathered. The prophylactic antibiotic use in patients with and without a penicillin allergy label was compared. In addition, all new antibiotic allergy labels recorded after the operation were verified from the electronic health records.

A total of 1,435 (9.6%) patients had a previous penicillin allergy label. The majority of patients (14,838 of 14,939; 99.3%) received cephalosporin prophylaxis, as did most of the patients with a label of penicillin allergy (1,395 of 1,435; 97.2%). Six perioperative allergic reactions were recorded; none of these were anaphylactic reactions. In 5 cases, the allergic reaction occurred in patients receiving cefuroxime, none of whom had a previous penicillin allergy.

This study found cephalosporin antibiotic prophylaxis to be safe in patients with a pre-existing penicillin allergy label.

Cefazolin is used as a prophylactic antibiotic to reduce surgical site infections (SSIs). Obesity has been identified as a risk factor for SSIs. Cefazolin dosing recommendations and guidelines are currently inconsistent for obese patients. As plasma and target-site exposure might differ, pharmacokinetic data from the sites of SSIs are essential to evaluate treatment efficacy: these data can be obtained via tissue microdialysis. This analysis was designed to evaluate the need for dosing adaptations in obese patients for surgical prophylaxis.

Data from 15 obese (BMImedian = 52.6 kg m-2) and 15 age- and sex-matched nonobese patients (BMImedian = 26.0 kg m-2) who received 2 g cefazolin i.v. infusion for infection prophylaxis were included in the analysis. Pharmacokinetic data from plasma and interstitial space fluid (ISF) of adipose tissue were obtained and analysed simultaneously using nonlinear mixed-effects modelling. Dosing regimens were evaluated by calculating the probability of target attainment (PTA) and the cumulative fraction of response (CFR) for plasma and ISF using unbound cefazolin concentration above minimum inhibitory concentration 100% of the time as target (fT>MIC = 100%). Dosing regimens were considered adequate when PTA and CFR were ≥90%.

Evaluation of cefazolin doses of 1 and 2 g with redosing at either 3 or 4 h by PTA and CFR in plasma and ISF found 2 g cefazolin with redosing at 4 h to be the most suitable dosing regimen for both obese and nonobese patients (PTA >90% and CFR >90% for both).

This model-based analysis, using fT>MIC = 100% as a target, showed that cefazolin dosing adaptations are not required for surgical prophylaxis in obese patients.

To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management.

Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines.

After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient's unique characteristics.

The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

In terms of perioperative infections, arthroplasty for obese patients represents a high-risk procedure. Correct antibiotic prophylaxis is a central pillar of infection prophylaxis. Studies showed increased infection rates if an antibiotic other than cefazolin was administered for prophylaxis. In patients with anamnestic penicillin allergy, an existing allergy is extremely rare, and the presence of cross-allergies to cephalosporins is similarly rare. Consequently, every effort should be made to administer a first- or second generation cephalosporin such as cefazolin.

Whether the dosage of antibiotic prophylaxis should be adjusted to the body weight remains unclear due to the limited data available: case series showed increased infection rates when cefazolin was underdosed and recommended increasing the dose to 3 g if the body weight exceeds 120 kg. However, no studies with a higher level of evidence exist. Published studies on the effective antibiotic levels in the tissue remain contradictory with regard to possible weight-dependent dose adjustments. Similarly, there is insufficient data on whether local intraoperative antibiotic prophylaxis may be useful in obese patients. By contrast, there is no evidence for a positive benefit of double prophylaxis with two different antibiotics or prolonged postoperative antibiotic prophylaxis in obesity.

In summary, the data on antibiotic prophylaxis is generally insufficient, especially when focussing on possible dose adjustments in obesity. The well-timed administration of a cephalosporin such as cefazolin represents the golden standard in orthopedics and trauma surgery. A possible dose adjustment to 3 g for a body weight over 120 kg appears reasonable considering the low costs and the broad therapeutic window and is therefore recommended in the current AWMF S3 guideline.

To investigate the influence of surgical antimicrobial prophylaxis (SAP) on complication rates and surgical site infections (SSI) in horses undergoing sutured castration in a hospital setting.

Retrospective chart review of a convenience sample.

A total of 220 colts and stallions admitted for sutured castration.

Medical records of sutured castration were assessed for patient characteristics, perioperative and postoperative medications, and postoperative complications within 6 weeks after surgery. The effect of these variables on the occurrence of complications was analyzed using χ2 tests, and the association between SAP use and SSI probability was evaluated.

The median age of horses included in the study was 3 years (range 1-14 years), and the overall complication rate was 10.0% (22/220). Surgical antimicrobial prophylaxis was administered to 62% of the patients (136/220). There were no differences in the overall complication rates, with a 7.1% (6/84) complication rate among horses without SAP (SAP-) and an 11.8% (16/136) rate in those receiving SAP (SAP+) (p = .36). There was no association between the use of SAP and the probability of SSI, with an incidence of 3.6% in SAP- and 4.4% in SAP+ (3/84 and 6/136 respectively) (p = 1.0).

Administering SAP did not influence the overall complication rate or the SSI rate following sutured castrations in a hospital setting.

These findings prompt a reconsideration of the use of SAP for sutured castrations under aseptic conditions. The results may also serve as a basis for future randomized controlled trials.

Surgical site infections (SSIs) are a major yet preventable cause of poor post-operative clinical outcomes, prolonged ICU/hospital stay, increased antibiotic consumption and added cost of therapy. Low- and Middle-income Countries (LMICs) have disproportionately higher rates of SSIs as compared to high-income countries despite various national and international guidelines in place as multipronged, combined interventions are seldom used. The IMPRESS project aims to respond to this urgent need to identify and evaluate the quality improvement measures contextualized to the logistic constraints of LMIC settings such as India.

We adopt a multi-center longitudinal mixed-methods study to be conducted over a period of 2 years in various phases. Phase 1 will be formative research with the objective of identifying knowledge gaps and baseline data collection. Phase II will involve co-development of multipronged interventions addressing identified barriers. Phase III will focus on the deployment of the selected multipronged interventions. Phase IV will be the post-intervention phase to evaluate the impact of the interventions. The study has been prospectively registered with CTRI and is supported by a funding grant from the Indian Council of Medical Research, New Delhi. The Institutional Ethics Committee approval has been obtained from all the sites involved in the study.

An antimicrobial stewardship program (ASP) is crucial for reducing inappropriate antimicrobial use, improving patient outcomes, and combating increasing antimicrobial resistance. However, data on the implementation of enhanced ASP networks in Asia are limited.

This quasi-experimental study evaluated an ASP collaborative network across four hospitals in Thailand (two university hospitals, a tertiary care center, and a private hospital) during 2021 and 2022. Baseline ASP activities were assessed using gap analysis surveys. Effectiveness was measured through antibiotic consumption (daily defined dose, [DDD] per 1,000 patient-days), appropriateness of antibiotic use, and the incidence of multidrug-resistant organisms (MDROs).

The enhanced ASP network addressed key challenges, leading to significant improvements in ASP implementation. Notable achievements included an increase in the overall appropriateness of target antibiotic use (86.5% vs. 74.4 %, p < 0.05) and a reduction in target antibiotic consumptions in all hospitals. The incidence of MDROs, including carbapenem-resistant Acinetobacter baumannii (30.22 vs. 6.08 per 1,000 patient-days, p < 0.05) and methicillin-resistant Staphylococcus aureus (1.90 vs. 0.46 per 1,000 patient-days, p < 0.05), declined significantly in one hospital. The incidence of multidrug-resistant pathogens declined after the implementation of the enhanced ASP in two hospitals.

The enhanced networking program in this study significantly improved ASP implementation across diverse hospital settings in Thailand. It addressed challenges such as insufficient financial support. Notable improvements were observed in the appropriateness of antibiotic use and overall antibiotic consumption, potentially contributing to the reduction in multidrug-resistant pathogens. These findings highlight the effectiveness of a collaborative ASP network in Asia.

The Surgical Infection Society (SIS) guidelines recommend against the use of surgical antibiotic prophylaxis (SAP) for low-risk patients undergoing elective laparoscopic cholecystectomies.

Using National Surgical Quality Improvement Program (NSQIP) data, 5440 pediatric patients were identified who underwent laparoscopic cholecystectomy from 2021 to 2022. Patients who had immunodeficiency, active malignancy, American Society of Anesthesiologists (ASA) physical status classification 3-5, procedure indicated for infection, emergent procedure, received intravenous antibiotics before the prophylaxis window, or missing SAP data were excluded.

3959 patients were included in the analysis. Among these patients, 3570 (90.2 %) received SAP. Overall incidence of 30-day superficial incisional surgical site infection (SSI), deep incisional SSI, and organ space SSI were 0.9 %, 0.0 %, and 0.1 %, respectively. The incidence of superficial incisional SSI was significantly higher in the patients who did not receive SAP (SAP 0.8 %, no SAP 2.1 %; p = 0.024). The incidence of organ space SSI was also significantly higher in the patients who did not receive SAP (SAP 0.1 %, no SAP 0.8 %; p = 0.008). There was no difference in the incidence of C. diff colitis (SAP 0.1 %, no SAP 0.0 %; p = 1.000). Multivariable modeling, controlling for Hispanic ethnicity, age, and gender, demonstrated patients that received SAP were significantly less likely to have any postoperative SSI compared to patients who did not receive SAP (OR = 0.35).

Hospitals are not currently compliant with SIS guidelines regarding omission of antibiotic prophylaxis for low-risk patients undergoing elective laparoscopic cholecystectomies. The authors advocate for additional studies and reassessment of current guidelines for pediatric patients given the above findings.

Retrospective comparative study.

III.

To determine if the use of 0.05% chlorhexidine gluconate (CHG) irrigation solution during cesarean delivery (CD) can reduce the post-cesarean surgical site infection (SSI) rate when compared to standard practices without CHG irrigation.

A single-center retrospective observational study was performed at a community hospital in Toledo, Ohio. Control and treatment periods were defined, and patients in the treatment group received irrigation with CHG solution during CD, while the control group did not. An electronic medical record review was conducted to note additional perioperative procedures that affect SSI rates. Patients were evaluated for infection at standard postoperative appointments using the CDC criteria, and the hospital system's department of infection prevention provided records of all documented SSIs in both groups. Characteristics of the deliveries and SSIs of each group were compared using the chi-square or Fisher's exact two-tailed tests.

Data were available for 351 deliveries after the implementation of the CHG protocol, and 432 deliveries were used as the control group. No significant difference in rates of infection was found between the two groups (p = 0.68). There were significantly more endometritis infections diagnosed in the treatment group compared to the control group (four (1.1%) versus zero; p = 0.04). Compared to the controls, the treatment group had fewer deliveries with the use of silver dressing, more deliveries with a negative pressure dressing, and more deliveries with a diagnosis of pregestational or gestational diabetes (p < 0.05). There were no other differences between the groups, including the use of abdominal and vaginal prep, BMI > 35, and perioperative antibiotics.

This single center retrospective observational study revealed no difference in post-cesarean SSI rates when performing intra-abdominal and subcutaneous irrigation with CHG solution. A significant increase in endometritis was observed with the use of CHG irrigation; however, further studies are required to determine the benefit or harm of antimicrobial irrigation in CDs.

Beta-lactam prophylaxis is the first-line preoperative antibiotic in open abdominal wall reconstruction. However, of the 11% patients reporting a penicillin allergy (PA), most receive second-line, non-β-lactam prophylaxis. Previously, abdominal wall reconstruction research from our institution demonstrated increased wound complications, readmissions, and reoperations with non-β-lactam prophylaxis. Therefore, a collaborative quality improvement initiative was developed with the infectious disease service, and a penicillin allergy protocol was instituted that stratified patients' risk of allergic reaction with a goal to increase β-lactam prophylaxis use. The effect of the penicillin allergy protocol on open abdominal wall reconstruction outcomes was prospectively evaluated.

Patients with penicillin allergy undergoing open abdominal wall reconstruction were identified and grouped according to penicillin allergy protocol implementation. Pre-penicillin allergy protocol underwent open abdominal wall reconstruction before January 1, 2020, predominantly receiving non-β-lactam prophylaxis; post-penicillin allergy protocol underwent open abdominal wall reconstruction between January 1, 2020-November 1, 2023, predominantly receiving β-lactam prophylaxis. Incidence of surgical site infection was the primary outcome. Standard and inferential statistical analyses were performed.

Of 315 patients with penicillin allergy, 250 underwent open abdominal wall reconstruction pre-penicillin allergy protocol and 65 post-penicillin allergy protocol. Pre- and post-penicillin allergy protocol were similar in allergic reaction severity history, sex, race, age, diabetes, American Society of Anesthesiologists score, hernia defect size, and mesh type (P > .05). Post-penicillin allergy protocol had lower body mass index (33.4 ± 7.9 vs 29.8 ± 5.3 kg/m2; P = .002) and fewer active smokers (12.4% vs 1.5%; P = .019). Expectedly, post-penicillin allergy protocol received more β-lactam prophylaxis (22.8% vs 83.1%; P < .001) and no antibiotic-induced allergic reactions. Post-penicillin allergy protocol had significantly fewer surgical site infections (24.4% vs 3.1%; P < .001), wound breakdown (16.0% vs 3.1%; P = .004), reoperations (19.2% vs 0.0%; P < .001), and readmissions (25.3% vs 9.2%; P = .006) but no statistically significant reduction in recurrence (8.4% vs 1.5%; P = .057).

The penicillin allergy protocol safely increased the number of patients with penicillin allergy undergoing open abdominal wall reconstruction receiving β-lactam prophylaxis and decreased the rate of surgical site infections, wound complications, reoperations, and readmissions. These data supported the systemwide implementation of the penicillin allergy protocol for both general and orthopedic surgery, which has been incorporated into the electronic medical record of 13 hospitals within the system.

Antimicrobial resistance (AMR) is a significant global health concern, with improper antibiotic use contributing to its rise. Tanzania initiated an AMR action plan in 2017, but comprehensive surveillance and stewardship efforts remain limited. This study focused on evaluating antibiotic use, particularly surgical prophylaxis, in a rural Tanzanian hospital.

The study was conducted at Haydom Lutheran Hospital in Tanzania in May 2023, using a cross-sectional point prevalence survey. Antibiotic use in all patients admitted for >24 h and those undergoing surgery was recorded, including type, dose, indication and duration. Quality indicators for surgical prophylaxis were assessed.

Among 199 inpatients, 55% received antibiotics, with surgical prophylaxis accounting for 23% of prescriptions. Notably, none of the patients who received surgical prophylaxis received a single-dose regimen, and 67% exceeded the recommended 24-h duration. A combination of ampicillin-cloxacillin plus metronidazole was the most commonly prescribed combination for surgical prophylaxis (41% of prescriptions). Thirty-three percent of the antibiotics prescribed for surgical prophylaxis were classified as 'Not recommended' by the World Health Organization. Furthermore, 90% of surgical prophylaxis prescriptions lacked documented rationale, and 83% of prescriptions lacked stop/review dates in medical records.

This study reveals a high prevalence of prolonged antibiotic use for surgical prophylaxis, frequent use of antibiotics classified as 'Not recommended', and a lack of adequate documentation, which deviates from international standards. These practices highlight the urgent need for contextualized national guidelines, large-scale implementation projects of evidence-based interventions, and local initiatives in antibiotic stewardship, particularly in low-resource settings.

Infection is a rare complication of percutaneous renal biopsy (RB). However, the questionnaire included in the Kidney Biopsy Guidebook 2020 in Japan revealed that antibiotic prophylaxis (AP) was administered at about 60% of hospitals. The objective of this study was to evaluate whether it is possible to omit AP for RB.

Patients aged ≥ 15 years were eligible. Three hundred and sixty-four patients were recruited at 6 hospitals. The patients were randomly assigned to receive either a single dose of intravenous cefazolin or no antibiotic prophylaxis. The primary outcome was the percentage of patients that exhibited positive urine cultures 3 or 4 days after the RB. The secondary outcomes were the percentage of patients who were diagnosed with pyelonephritis, puncture site infections (PSI), or an infection other than pyelonephritis or PSI within 30 days, and cefazolin-induced side effects.

With regard to the primary outcome, there was no statistically significant difference between the cefazolin group and the no AP group (2.9% versus 5.1%, p = 0.416). With regard to the secondary outcomes, only one patient (who belonged to no AP group) developed pyelonephritis. This patient underwent urinary catheterization. No PSI occurred. There were no significant intergroup differences in any secondary outcomes.

This study revealed the incidence of post-percutaneous RB infections was minimal. Although the outcomes of this study did not lead to the conclusion that it is unnecessary to use AP for RB, the obtained data suggest that the effects of such AP may not be clinically significant.

This retrospective monocentric study aims to describe the characteristics of neurosurgical site infections (n-SSI) in neurooncological pediatric patients. The primary goal was to assess infection rates and identify common pathogens in this population.

We considered pediatric patients (0-18 years) who underwent neurosurgery for brain tumors at Meyer Children's Hospital in Florence between January 1, 2017, and December 31, 2021. Children with suspected/confirmed n-SSI were included. Data were retrospectively collected from patients' medical records, and covered tumor and surgery type, presence of foreign bodies, microbiological findings, and treatment. Infections were classified into categories according to literature. Statistical analysis was performed using GraphPad Prism. A p value of < 0.05 was considered significant.

Of 352 children undergoing neurosurgery, 43 (12.22%) had suspected/confirmed n-SSI, with a confirmed infection rate of 4%. The most frequent n-SSI was postoperative meningitis (37.2%), followed by wound infections (25.6%). A foreign body was present in 74.4% of cases. The most prevalent pathogens were Staphylococcus aureus (40%) and coagulase-negative staphylococci (33%). Lumbar puncture (LP) performed before antibiotics significantly increased pathogen isolation (p = 0.01). Most patients (95.3%) had fever, and 53.5% had CSF leakage. Antibiotic therapy was administered in all cases, and 65.1% required therapy adjustment. No significant correlation was found between foreign body and clinical symptoms or microbiological positivity.

The study reveals a high rate of n-SSI, emphasizing the importance of early diagnostic measures like LP to improve microbiological diagnosis and optimize antimicrobial treatment. The most frequent pathogen was S. aureus; however, the absence of methicillin-resistant strains is notable. These findings highlight the role of a multidisciplinary approach in managing n-SSI and the potential for n-SSI to delay adjuvant cancer treatments.

To compare the efficacy of clindamycin versus cefazolin in preventing periprosthetic joint infection (PJI) in patients undergoing hip hemiarthroplasty (HA) for femoral neck fractures.

This retrospective cohort study included 1,139 patients aged ≥ 65 years who underwent HA for femoral neck fractures between January 2017 and October 2023. Patients received either Cefazolin + Gentamicin (n = 1001) or Clindamycin + Gentamicin (n = 138). Propensity score matching was performed at a 6:1 ratio, resulting in 828 patients in the cefazolin group and 138 in the clindamycin group. PJI rates, causative organisms, and mortality were compared. Multivariate logistic regression adjusted for potential confounders.

The PJI rate was significantly higher in the clindamycin group compared to the cefazolin group (7.2% vs. 3.5%, p = 0.042). Multivariate analysis confirmed that clindamycin prophylaxis was independently associated with increased PJI risk (adjusted OR = 2.41, 95% CI: 1.16-4.99, p = 0.018). Other independent risk factors for PJI included age (adjusted OR = 1.03 per year, 95% CI: 1.01-1.05, p = 0.045), diabetes mellitus (adjusted OR = 1.76, 95% CI: 1.10-2.81, p = 0.018), and surgery duration (adjusted OR = 1.07 per minute, 95% CI: 1.01-1.16, p = 0.035). Staphylococcus aureus was the most common pathogen, with no significant differences in bacterial distribution between the groups. No significant differences were found in 30-day or 1-year mortality rates.

Clindamycin prophylaxis in hip hemiarthroplasty for femoral neck fractures is associated with a significantly higher risk of PJI compared to cefazolin. These findings support the preferential use of cefazolin in patients without contraindications and demonstrate the critical need for accurate assessment of reported beta-lactam allergies. Results suggest potential benefit from pre-operative allergy evaluation when feasible, as alternative prophylaxis choices may carry increased infection risk. Further research is needed to explore alternative prophylactic strategies for patients with beta-lactam allergies.

The role of enhanced recovery after surgery (ERAS) in cytoreductive surgery and/or Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is evolving, with promising results that improve patient outcomes. This consensus exercise was carried out to address and standardize components of the ERAS protocol pertinent to the Indian context.

The modified Delphi method was employed with two rounds of voting. All fifty invited specialists agreed to vote. There were 30 questions addressing the key elements of ERAS protocols. They were broadly distributed across four sections: Prehabilitation, Preoperative, Intraoperative, and Postoperative elements. A consensus was achieved if any one option received > 70 % votes (strong consensus > 90 %). If consensus was not achieved in round 1, the question was moved to round 2.

After rounds I and II, 48/50 (95.8%) of invited panelists voted for the questions. The highest rate of 'skipped question' was 6% in both rounds. A consensus was obtained for 28/30 (93.33%) questions, and strong consensus was obtained for 5/30 (16.6%) questions. No consensus was obtained for two questions. Some of the panelists' recommendations contradicted the standard ERAS guidelines, such as using intraperitoneal drains in all patients and mechanical bowel preparation for left-sided colonic or rectal resections.

Despite some limitations, this consensus exercise represents a significant step toward advancement and pioneering efforts to improve patient outcomes by implementing and standardizing ERAS protocols in CRS and/or HIPEC tailored for India.

There is no consensus on the perioperative use of antibiotics in pediatric solid tumor resection. This study collected data from two pediatric centers that utilize perioperative antibiotics to varying degrees in pediatric solid tumor patients to investigate the occurrence of postoperative sepsis and infectious complications.

A two-institution, retrospective cohort study was performed. Charts of children who underwent solid tumor resection between July 2018-June 2021 were reviewed. Patient characteristics, diagnosis, operative data, perioperative antibiotic use, and postoperative infection/sepsis were analyzed within 30 days of surgery. The primary outcome was surgical site infection (SSI) or systemic sepsis within 30 days of surgery. Fisher's tests were performed to evaluate differences.

250 patients underwent tumor resection between July 2018 and June 2021 at both centers. The median age was 4 years [Range: 0.02-26.1]. Seventy-five percent (N = 188) received perioperative antibiotics prophylaxis (AP), while 25 % of patients did not receive AP (N = 62). Only one patient in the AP group (0.5 %) developed postoperative sepsis, while 12 patients (19.4 %) in the non-AP group developed sepsis (p < 0.0001). There were 3 SSI in the AP group and none in the non-AP group (p = 1.0).

The administration of AP in children undergoing solid tumor resection is associated with a reduced rate of postoperative sepsis but no difference in SSI. This could possibly be related to bacterial translocation during surgery and the seeding of indwelling central venous access catheters. Our results support the standardized use of AP in this population.

Retrospective Cohort Study.

III.

Surgical site infections (SSIs) are the second leading cause of healthcare-associated infections in Europe with the highest rates being reported in colorectal surgery (ranging from 9% to 30%). Surgical antibiotic prophylaxis (SAP) is one of the most efficient measures for SSI prevention and should be started before surgical incision. Cefoxitin is an antibiotic widely used as SAP for colorectal surgery, but its continuous administration is currently the subject of debate due to its potential pharmacokinetic advantages. Therefore, the aim of the PROPHYLOXITIN study is to demonstrate that a loading dose followed by continuous infusion of cefoxitin during colorectal surgery (intervention group) decreases the rate of SSI compared to an intermittent bolus administration (control group).

The PROPHYLOXITIN study is a superiority, prospective, double-blind, randomised and multicentre study of 2000 patients undergoing colorectal surgery. The primary objective is to demonstrate the superiority of a loading dose of cefoxitin followed by continuous infusion over intermittent bolus administration in reducing the proportion of SSIs within 30 days after colorectal surgery. Subjects will be randomised 1:1 using a secure web-based random-number generator to one of two study groups. Randomised allocation of treatment will be done by minimisation and stratified according to the centre, the localisation of surgery (colon or rectum) and the type of surgical procedure (laparoscopy or laparotomy).

This research has been approved by an independent ethics committee and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.

EudraCT 2022-003262-20 and Clinical trial NCT05755789.

We aimed to determine whether benchmarking antimicrobial use (AU) to antimicrobial resistance (AR) using select AU/AR ratios is more informative than AU metrics in isolation.

We retrospectively measured AU (antimicrobial therapy days per 1,000 days present) and AU/AR ratios (specific antimicrobial therapy days per corresponding AR event) in two hospitals during 2020 through 2022. We then had antimicrobial stewardship committee members evaluate each AU and corresponding AU/AR value and indicate whether they believed it represented potential overuse, appropriate use, or potential underuse of the antimicrobials, or whether they could not provide an assessment.

Two acute-care hospitals.

Hospitalized patients.

In semi-annual facility-wide analyses, echinocandins had a median AU/AR ratio of 658.5 therapy days per fluconazole-resistant Candida event in Hospital A, IV vancomycin had a median AU/AR ratio of 114.9 and 108.2 therapy days per methicillin-resistant Staphylococcus aureus event in Hospital A and B, respectively, and linezolid had a median AU/AR ratio of 33.8 and 88.0 therapy days per vancomycin-resistant Enterococcus event in Hospital A and B, respectively. When AU and AU/AR values were evaluated by stewardship committees, more respondents were able to assess antimicrobial use based on AU/AR values compared to AU values. Based on AU/AR ratios, most respondents identified potential overuse of echinocandins and IV vancomycin in Hospital A, and potential overuse of linezolid and IV vancomycin in Hospital B.

Select AU/AR ratios provided informative metrics to antimicrobial stewardship personnel, which can be used to motivate audits of antimicrobial administration to determine appropriateness.

Introduction: Data about compliance with perioperative antimicrobial prophylaxis (PAP) guidelines in the pediatric population are limited. This study aims to evaluate PAP adherence in pediatric surgical subspecialty departments. Methods: A prospective cohort study was conducted from September 2023 to October 2024 at "Aghia Sophia" Children's Hospital, Athens, Greece. Children <16 years old undergoing surgical procedures in the neurosurgery (NS), orthopedics (OP), and otolaryngology (ORL) departments were included. Data on demographics, surgical characteristics, and PAP practices (timing, agent, duration, and redosing) were collected and compliance with the international guidelines was evaluated. Results: A total of 301 children were included, with a median age (IQR) of 7 (8) years. PAP was received by 249/301 (82.7%) children (100% in the OP and NS, and 48% in the ORL). However, indications for PAP had 50.8% of children: 102/103 (99%) in the NS, 47/98 (47.9%) in the OP, and 4/48 (8.3%) in the ORL. Most children received broad-spectrum or combination of antimicrobials and/or antibiotics for longer duration. Appropriate PAP according to the guidelines was administered in 0% children in NS, 2% in OP, and 2.1% in ORL. Multivariable analysis in the ORL regarding the use of PAP revealed that shorter procedures (≤60 min; OR: 22.9, p = 0.003) and clean wounds (OR: 33.4, p < 0.001) were significantly associated with not using PAP. Conclusions: This study highlights gaps in the PAP guideline adherence in pediatric surgical departments, and the need for educational interventions to improve compliance and reduce antimicrobial use. Based on these findings, we plan to implement an educational intervention in order to optimize PAP practices in the pediatric population.

Objective: The objective of this study was to evaluate the demographic, clinical, laboratory, and microbiological features of ventriculoperitoneal shunt (VPS) infections through a 13-year retrospective study. VPS bacterial agents and their antibiotic susceptibility were also investigated through the occurrence of single VPS (SVPS) and recurrent VPS (RVPS) infections. Methods: This study included 110 patients with SVPS infections and 55 patients with RVPS infections. Results: In patients who developed multiple infections, Gram-negative organisms were found to be the most predominant (60%, 54/90). The resistance rates were 85.2% for third-generation cephalosporins (3GCs), 83.3% for piperacillin-tazobactam, and 10.4% for carbapenem. Of the patients in the SVPS infection group, 49% were treated with combinations with carbapenem; of the patients in the RVPS infection group, 84.4% were treated in the same way. Central nervous system (CNS) tuberculosis as the etiology of hydrocephalus; short duration of antibiotics used for treatment; high cerebrospinal fluid (CSF) protein and blood C-reactive protein (CRP) levels; and prolonged use of prophylactic antibiotics were found to be related to an increased rate of recurrent infection occurrence. A two-stage shunt change approach decreased the risk of recurrent infections. Conclusions: Based on the findings of our study, it is essential to closely monitor patients with independent risk factors for RVPS infection development, due to the high rates of resistant Gram-negative bacterial growth and the initiation of empirical antimicrobial treatment with glycopeptide plus carbapenem. Certain treatment options, such as 3GCs plus glycopeptide, should be revised based on clinical progress and microbiological culture results.

Prophylactic parenteral administration of antibiotics is strongly recommended to prevent surgical site infection (SSI). Cefoxitin is mainly administered intravenously in colorectal surgery. The current standard method for administering prophylactic antibiotics in adults is to administer a fixed dose quickly before skin incision. The percentage of time that the unbound concentration is maintained above the minimum inhibitory concentration (fT > MIC) during surgery is used as a surrogate measure for the effectiveness of prophylactic antibiotics. Target-controlled infusion (TCI) is a method of administration that changes the infusion rate to maintain a constant target concentration set by the user in consideration of the patient's physical characteristics. When cefoxitin is administered using the TCI method, it is possible that fT > MIC can be well maintained while reflecting the patient's physical characteristics compared to the standard method.

This prospective, single-centre, parallel-arm, single-blinded, randomised controlled trial with a 1:1 allocation was designed to compare the effectiveness of the TCI method with that of the standard cefoxitin administration method. We shall enrol 2494 patients scheduled to undergo colon or rectal surgery. Prior to the procedure, we shall randomise each patient to the control group (standard administration method) or study group (TCI method). In the control group, 2 g of cefoxitin was dissolved in 100 ml of normal saline and administered for approximately 10 min. Redosing was performed every 2 h from the start of the first dose of cefoxitin. In the study group, 2 g of cefoxitin was dissolved in 50 ml of normal saline and administered using a commercialised TCI syringe pump until the end of surgery. It was administered at a target concentration of 80 μg/ml using the total concentration pharmacokinetic model of cefoxitin. In all groups, 2 g of cefoxitin was administered using the standard administration method 12 h after the end of surgery. The primary outcome will be the incidence of SSI. The secondary outcome will be the administered dose of cefoxitin. Preoperative, intraoperative, and postoperative data were collected.

This study will provide evidence for the effectiveness of administering cefoxitin using the TCI method compared to the standard method.

ClinicalTrials.gov, NCT05253339 , Registered on February 23, 2022 {2a, 2b}.

The following review focuses on routine postoperative care after cesarean delivery (CD), including specific Enhanced Recovery After Cesarean recommendations as well as important postpartum counseling points. Following CD, there is insufficient evidence to support administration of prophylactic multi-dose antibiotics to all patients. Additional antibiotic doses are indicated for the following scenarios: patients with obesity who did not receive preoperative azithromycin, CD lasting ≥4 hours since prophylactic dose, blood loss >1500 mL, or those with an intra-amniotic infection. An oxytocin infusion for prevention of postpartum hemorrhage should be continued post-CD. While initial measures to prevent postoperative pain occur in the intraoperative period, with the consideration of 1 g intravenous (IV) acetaminophen and IV or intramuscular nonsteroidal anti-inflammatory medications (eg, 30 mg IV ketorolac), the focus postoperatively continues with this multimodal approach with scheduled acetaminophen per os (PO, 650 mg every 6 hours) and nonsteroidal agents (ketorolac 30 mg IV every 6 hours for 4 doses followed by ibuprofen 600 mg PO every 6 hours) being recommended. Short-acting opioids should be reserved for breakthrough pain. Low-risk patients should receive mechanical thromboprophylaxis until ambulation with chemoprophylaxis being reserved for patients with additional risk factors. When an indwelling bladder catheter was placed intraoperatively for scheduled CD, it should be removed immediately postoperatively. Chewing gum to aid in return of bowel function and early oral intake of solid food can occur immediately after CD and within 2 hours, respectively. For prevention of postoperative nausea and vomiting, administration of 5HT3 antagonists with the addition of either a dopamine antagonist or a corticosteroid is recommended based on noncesarean data. Early ambulation after CD starting 4 hours postoperatively is encouraged and should be incentivized by pedometer. For patients that receive a dressing over the CD skin incision, limited evidence supports leaving it in place for 48 hours. Adjunct nonpharmacologic interventions for postoperative recovery discussed in this review are acupressure, acupuncture, aromatherapy, coffee, ginger, massage, reiki, and transcutaneous electrical nerve stimulation. In the low-risk patient, hospital discharge may occur as early as 24 to 28 hours if close (ie, 1-2 days) outpatient neonatal follow-up is available due to the potential for neonatal jaundice; otherwise, patients should be discharged at 48 to 72 hours postoperatively. Upon discharge, the multimodal pain control recommendations of acetaminophen and ibuprofen should be continued. If short-acting opioids are necessary, the prescribing practices should be individualized based upon the inpatient opioid requirements. Other portions of postoperative/postpartum counseling during the inpatient stay include the optimal interpregnancy interval of 18 to 23 months, encouraging exclusive breastfeeding for at least 6 months, quick resumption of physical activity, and vaginal intercourse guidance as tolerated. Patients should also be counseled pre-CD on the option of immediate postpartum intrauterine devices insertion, intraoperative salpingectomy, or placement of long-acting reversible contraception in the postpartum period. Implementation of such evidence-based postoperative care protocols decrease length of stay, surgical site infection rates, and improve patient satisfaction and breastfeeding rates. El resumen está disponible en Español al final del artículo.

A reported penicillin allergy reduces the likelihood that the patient will receive first-line surgical antibiotic prophylaxis (SAP), which can increase the risk of developing a surgical site infection (SSI). This project aimed to increase the use of first-line SAP agents in orthopedic and pediatric surgery patients with a reported penicillin allergy.

The Institute for Healthcare Improvement quality improvement methodology was followed. Key drivers included patient and family awareness of true penicillin allergies, standardization for ordering antibiotics, staff buy-in, electronic medical record utilization, and staff comfort with ordering first-line SAP. Initial plan-do-study-act cycles focused on provider education. Subsequent plan-do-study-act cycles focused on the antibiotic delivery process, antibiotic selection, screening tool development for severe delayed hypersensitivity reactions, education, and data transparency. The outcome measure was the percentage of orthopedic and pediatric surgery patients with a reported penicillin allergy that received first-line SAP per month.

Since the start of the project in December 2022, there were 2 statistically significant changes in the outcome measure's mean, shifting the mean from 25% to 84% in orthopedic and pediatric surgery patients with a reported penicillin allergy who received first-line SAP. There were no adverse medication reactions and no statistically significant change in SSIs.

The mean has been at 84% for 9 months showing a sustainable process and culture change regarding first-line SAP usage for orthopedic and pediatric surgery patients. This was achieved through targeting the antibiotic delivery processes without relying on hard stops within the medical record.

The optimal duration for surgical antibiotic prophylaxis (SAP) for preventing surgical site infection (SSI) in orthopaedic surgeries remains poorly supported by high-level evidence. This study aimed to assess the association between SAP duration and the occurrence of SSI within one year postoperatively.

This prospective cohort study was based on the database from Surgical Site Infection Surveillance and Improvement Project (SISIP) of a tertiary orthopaedic university hospital from October 2014 to December 2020. The main outcome was SSI, defined according to the CDC/NHSN criteria, determined by a review of index hospitalization medical records, microbiology laboratory reports, and readmission records for SSI treatment within one year after discharge. Adjusted generalized additive models (GAMs) were performed to assess the relationships between SAP duration and SSI, determine the cut-off point of SAP duration, and estimate the relative contribution of each included variable across the overall cohort and the three subgroups (open fracture, closed fracture, and non-traumatic group). Multivariable logistic regression models were used to estimate the association between prolonging SAP duration based on the cut-off point and SSI.

There were 37 046 patients (55.1% male) included, with an overall SSI incidence of 2.35% (871/37 046). In adjusted GAMs, no statistically significant relationships were observed in the overall cohort and open or closed group ( P >0.05), but a non-linear relationship was exhibited in the non-traumatic group ( P =0.03); the cut-off point was 2.4 days for the overall cohort and 3.6 days (open), 2.6 days (closed), 1.1 days (non-trauma) for three subgroups. In adjusted logistic regression, prolonging SAP duration did not demonstrate a statistically significant protective effect in overall cohort (aOR=0.868; 95% CI, 0.746-1.011) and three groups (open: aOR=0.867; 95% CI, 0.668-1.124; closed: aOR=0.925; 95% CI, 0.754-1.135; non-trauma: aOR=1.184; 95% CI, 0.832-1.683). The relative contribution ranks of SAP duration were 21st overall among 34 factors, 14th for open fractures, 28th for closed fractures, and 3rd for the non-traumatic group among 33 factors.

Prolonged postoperative SAP duration has no protective effect against SSI in orthopaedic surgery. Our findings support current guidelines against the practice of continuing SAP postoperatively.

Postoperative patients undergoing gastrointestinal surgery often encounter challenges such as low immune function, delayed wound healing owing to surgical trauma, and increased nutritional demands during recovery.

To assess the effect of comprehensive nutritional support program on immune function and wound healing in patients undergoing gastrointestinal surgery.

This retrospective comparative study included 60 patients who underwent gastrointestinal surgery, randomly assigned to either the experimental group (n = 30) or the control group (n = 30). The experimental group received comprehensive nutritional support, including a combination of enteral and parenteral nutrition, whereas the control group received only conventional comprehensive nutritional support. Evaluation indicators included immune function markers (e.g., white blood cell count, lymphocyte subsets), wound healing (wound infection rate, healing time), pain score [visual analog scale (VAS) score], and psychological status (anxiety score, depression score) 7 days post-surgery) and duration of stay.

The immune function of patients in the experimental group was significantly better than that in the control group. The white blood cell count was 8.52 ± 1.19 × 109/L in the experimental group vs 6.74 ± 1.31 × 109/L (P < 0.05). The proportion of CD4+ T cells was higher in the experimental group (40.09% ± 4.91%) than that in the control group (33.01% ± 5.08%) (P < 0.05); the proportion of CD8+ T cells was lower (21.79% ± 3.38% vs 26.29% ± 3.09%; P < 0.05). The CD4+/CD8+ ratio was 1.91 ± 0.32 in the experimental group whereas 1.13 ± 0.23 in the control group (P < 0.05). The wound infection rate of the experimental group was significantly lower than that of the control group (10% vs 30%, P < 0.05), and the wound healing time was shorter (10.35 ± 2.42 days vs 14.42 ± 3.15 days, P < 0.05). The VAS score of the experimental group was 3.05 ± 1.04, and that of the control group was 5.11 ± 1.09 (P < 0.05); the anxiety score (Hamilton Anxiety Rating Scale) was 8.88 ± 1.87, and that of the control group was 12.1 ± 3.27 (P < 0.05); the depression score (Hamilton Depression Rating Scale) was 7.37 ± 1.41, and that of the control group was 11.79 ± 2.77 (P < 0.05). In addition, the hospitalization time of the experimental group was significantly shorter than that of the control group (16.16 ± 3.12 days vs 20.93 ± 4.84 days, P < 0.05).

A comprehensive nutritional support program significantly enhances immune function, promote wound healing, reduces pain, improves psychological status, and shortens hospitalization stays in patients recovering from gastrointestinal surgery.

Due to the specific anatomical features of the tibia (limited soft tissue coverage), more than a quarter of its fractures are classified as open, representing the most common open long-bone injuries. Open tibial fractures frequently cause significant bone comminution, periosteal stripping, soft tissue loss, contamination and are prone to bacterial entry with biofilm formation, which increases the risk of deep bone infection. The main objective of this study was to determine prevalence of infection and its associated factors in surgically treated open tibial fracture, at Addis Ababa Burn Emergency and Trauma (AaBET) hospital.

A facility-based retrospective cross-sectional study was conducted among patient treated for open tibial fracture at AaBET hospital from September 2018 to September 2021. The data were collected from patient's chart using a structured data collection form and entered and analyzed using SPSS version 26. Binary logistic regression was fitted to determine risk factors associated with surgically treated open tibial fracture. Multicollinearity was checked using variance inflation factor and tolerance. Model adequacy was tested using the Hosmer-Lemeshow goodness-of-fitness test, and adjusted odds ratio (AOR) with a 95% CI at p value < 0.05 was reported statistically significant.

From a total of 235 patients enrolled in the study, 33.9% of the patients developed infection. Initial IV antibiotic time (AOR = 2.924, 95% CI 1.160-7.370) and time of wound closure from injury (AOR = 3.524, 95% CI 1.798-6.908), injury to admission time (AOR = 2.895, 95% CI 1.402-5.977) and definitive fixation method (AOR = 0.244, 95% CI 0.113-0.4508) were the factors found to had significantly increased the risk of the occurrence of infection.

The high rate of infection in open tibial fractures indicates that there is a need to improve the management of open tibial fractures treated at AaBET hospital. Significant delay of patient with open tibial fracture was found from in injury time to presentation to trauma center since majority of the cases were from peripheral health facility without getting prophylactic antibiotics.

Although it is well established that antibiotic prophylaxis is not needed in soft tissue upper extremity cases, there is still no definitive consensus when hardware implantation is involved. We hypothesize that antibiotic prophylaxis is not necessary and there is no difference in postoperative surgical site infection rates regardless of preoperative antibiotic administration.

A retrospective cohort analysis was performed on upper extremity surgical cases with hardware implantation performed at a single institution amongst 5 hand surgeons between November 2021 and November 2023. Implants included plates, screws, Kirschner wires, and suture anchors. Primary outcome measures were diagnosis of surgical site infection by 14 and 30 days postoperatively. Secondary outcomes included the type of management used to treat infection. Categorical variables were compared using Fisher exact test, and continuous variables were compared using Wilcoxon rank-sum test.

A total of 232 patients were included for analysis-152 received antibiotic prophylaxis and 80 did not. There were no differences between the 2 groups in terms of demographic factors, comorbidities, or smoking status. There was no difference in infection rates between the group who received antibiotic prophylaxis and the group who did not. Infection rate in the antibiotic prophylaxis group was 4.6% and in the sans antibiotics group was 2.5%. All infections were treated with antibiotics, and there were no differences in the rates of operative washout and hardware removal between the 2 groups.

Antibiotic prophylaxis is not necessary in upper extremity surgical cases even when implantation of hardware is involved.

SUMMARYInfective endocarditis (IE) is a life-threatening infection that has nearly doubled in prevalence over the last two decades due to the increase in implantable cardiac devices. Transcatheter aortic valve implantation (TAVI) is currently one of the most common cardiac procedures. TAVI usage continues to exponentially rise, inevitability increasing TAVI-IE. Patients with TAVI are frequently nonsurgical candidates, and TAVI-IE 1-year mortality rates can be as high as 74% without valve or bacterial biofilm removal. Enterococcus faecalis, a historically less common IE pathogen, is the primary cause of TAVI-IE. Treatment options are limited due to enterococcal intrinsic resistance and biofilm formation. Novel approaches are warranted to tackle current therapeutic gaps. We describe the existing challenges in treating TAVI-IE and how available treatment discovery approaches can be combined with an in silico "Living Heart" model to create solutions for the future.

Current guidelines support routine perioperative antibiotic prophylaxis (PAP) to minimize surgical site infection in kidney transplantation (KT), though data regarding the current practices of PAP is lacking in China.

To survey the routine PAP strategies in KT, and analyze main clinical considerations associated with adjusted antibiotic dosing regimens in different Chinese hospitals.

A nationwide survey was conducted on behalf of the National Alliance of Transplant Pharmacists. An online questionnaire was created via Wen Juan Xing (http://www.wjx.cn) and sent to all pharmacists in the Alliance.

Twenty-three pharmacists from different teaching hospitals with Grade IIIA participated in the survey, with a response rate of 46.0%. There were wide differences in routine dosing regimens and clinical considerations. Six strategies were involved in living-donor KT and monotherapy was most often used (80.9%), while combination therapy was most common (69.6%) among the ten strategies in deceased-donor KT. Of fifteen antibiotics submitted in the survey, eight agents were prescribed with different doses and/or frequencies among different hospitals. Only 37.5% and 23.1% of the hospitals would stop PAP within 72 hours in living-donor KT and deceased-donor KT, respectively. Among 28 preset factors, four factors were considered significantly important to decide PAP regimens, and eight factors were considered significantly unimportant (P<0.05).

There was wide variability in routine dosing regimens and clinical considerations in PAP decisions in KT. Further investigations are warranted to obtain high-quality evidence and to make PAP in KT more rational.