Antibiotic Guidance for OMFS inpatients

Introduction/Aims: Implementation of local antimicrobial guidelines is essential for optimal use of antibiotics and reduction of antibiotic resistance. The aims are: * To assess current antibiotic use for inpatients. * To assess which antibiotics are commonly prescribed in OMFS. * To assess dose/duration of antibiotics. * To assess second line antibiotic options for allergies. Material(s) and Method(s): Retrospective data was collected for elective and emergency admissions from October 2018 - October 2019. Data collection included: Antibiotic prescribed, clinical reason for antibiotics, dose, duration, administration method, discharge antibiotics, alternatives for penicillin allergic patients and microbiology swab results if applicable. Results/Statistics: Elective procedures included osteotomies, salivary gland surgery, TMJ surgery, cysts and major resections. 92% of osteotomies received prophylactic IV co-amoxiclav. 26% of salivary gland patients received antibiotics, majority co-amoxiclav. 58% of cyst patients received IV co-amoxiclav (43%), amoxicillin (43%) or amoxicillin and metronidazole (14%) and all major resection patients received IV antibiotics, majority amoxicillin and metronidazole (45%) 70 dental abscesses received IV antibiotics. 30% received amoxicillin and meronidazole, 22% received benzylpenicillin and metronidazole and the remaining 48% were prescribed a variety of combinations. 65% of abscesses had a microbiology pus swab taken. 48% were sensitive to penicillin, metronidazole or both. 33% had no growth. 91% of fractured mandibles received IV antibiotics, with co-amoxiclav and metronidazole the most common (30%). Conclusions/Clinical Relevance: Current practice was extremely varied. A guidance document was created for the department by a multidisciplinary team. A further round of data collection will be completed in due course following lifting covid restrictions to assess compliance. Copyright © 2022

Immunomodulators in patients receiving extracorporeal membrane oxygenation for COVID-19: a propensity-score weighted analysis of the ELSO registry

Background: Mortality for patients receiving extracorporeal membrane oxygenation (ECMO) for COVID-19 has increased over time. We investigated the association between immunomodulators and mortality for patients receiving ECMO for COVID-19. Method(s): We analysed the Extracorporeal Life Support Organisation Registry from Jan 1, 2020 through Dec 31, 2021, comparing in-hospital mortality and the overall survival since ECMO initiation of patients who did and did not receive immunomodulators (selective interleukin blockers, corticosteroids, janus-kinase inhibitors, convalescent plasma, and intravenous immunoglobulins) before or during ECMO, by using logistic regression and Cox regression. We calculated the propensity scores, and applied the overlap-weightage method to account for confounding factors. We conducted sensitivity analyses including regression models using inverse propensity score weightage method, models adjusted by propensity score, and unadjusted models to ensure robustness of results. A subgroup analysis on patients receiving corticosteroids was conducted. Result(s): 7180 patients were included in the final analysis. Immunomodulators were associated with increased mortality (OR: 1.168, 95%CI: 1.059-1.289, p=0.0020) and shorter survival since ECMO (HR: 1.05, 95%- CI: 1.078, 95%CI: 1.007-1.154, p=0.031). Similarly, corticosteroids were associated with a significant increase in mortality (OR: 1.302, 95%-CI: 1.180-1.437, p<0.0001) and shorter survival (HR: 1.221, 95%-CI: 1.139- 1.308, p<0.0001). Sensitivity analyses did not significantly change the overall results. Conclusion(s): Immunomodulators and corticosteroids, in particular, were associated with a significant increase in mortality amongst patients receiving ECMO for COVID-19, even after adjusting for potential confounding variables. Further studies are required to evaluate the timing of immunomodulators and understand the possible mechanisms behind this association.

Invasive mechanical ventilation in patients with acute respiratory distress syndrome receiving extracorporeal support: a narrative review of strategies to mitigate lung injury.

Veno-venous extracorporeal membrane oxygenation is indicated in patients with acute respiratory distress syndrome and severely impaired gas exchange despite evidence-based lung protective ventilation, prone positioning and other parts of the standard algorithm for treating such patients. Extracorporeal support can facilitate ultra-lung-protective ventilation, meaning even lower volumes and pressures than standard lung-protective ventilation, by directly removing carbon dioxide in patients needing injurious ventilator settings to maintain sufficient gas exchange. Injurious ventilation results in ventilator-induced lung injury, which is one of the main determinants of mortality in acute respiratory distress syndrome. Marked reductions in the intensity of ventilation to the lowest tolerable levels under extracorporeal support may be achieved and could thereby potentially mitigate ventilator-induced lung injury and theoretically patient self-inflicted lung injury in spontaneously breathing patients with high respiratory drive. However, the benefits of this strategy may be counterbalanced by the use of continuous deep sedation and even neuromuscular blocking drugs, which may impair physical rehabilitation and impact long-term outcomes. There are currently a lack of large-scale prospective data to inform optimal invasive ventilation practices and how to best apply a holistic approach to patients receiving veno-venous extracorporeal membrane oxygenation, while minimising ventilator-induced and patient self-inflicted lung injury. We aimed to review the literature relating to invasive ventilation strategies in patients with acute respiratory distress syndrome receiving extracorporeal support and discuss personalised ventilation approaches and the potential role of adjunctive therapies in facilitating lung protection.

Need for tracheostomy in major head and neck ablative surgery: a paradigm shift during the COVID-19 pandemic.

INTRODUCTION: Management of the airway in the perioperative period for patients requiring major head and neck ablative surgery has commonly included the performance of elective surgical tracheostomy. This has been standard practice in most maxillofacial units across the UK, including ours. However, the COVID-19 pandemic and emerging guidelines on aerosol-generating procedures required us to revisit the need for a perioperative tracheostomy. METHODS: We present our series of 29 consecutive cases, cared for during the first wave of the COVID-19 pandemic, that were managed either using surgical tracheostomy or overnight tracheal intubation. RESULTS: Out of 29 patients 3 received a surgical tracheostomy. The average duration of tracheostomy use was 8 days. Twenty patients were managed using a period of overnight tracheal intubation. Average duration of tracheal intubation was 1.2 days, with an average intensive care unit stay of 1.7 days. The average duration of hospital stay was 15.8 days for patients managed with overnight tracheal intubation and 30.1 days for patients who received a surgical tracheostomy. The return to theatre rate was 13.8% for reasons including flap failure and neck space infection. There were no airway issues reported in this series of patients. CONCLUSIONS: Our findings suggest that overnight tracheal intubation can be a safe alternative to surgical tracheostomy in the majority of cases.

A systematic review and meta-analysis of respiratory system mechanics and outcomes in mechanically ventilated patients with COVID-19 related acute respiratory distress syndrome

Introduction: The respiratory mechanics, particularly static compliance of the respiratory system ( CRS) in COVID-19 acute respiratory distress syndrome (CARDS) is poorly understood. Whether or not distinct ARDS phenotypes based on CRS exist is still widely debated. Methods: We conducted a systematic review and meta-analysis, searching three international databases from 1st December 2019 to 15th July 2021 for studies reporting on the respiratory mechanics of patients with CARDS. The primary outcome was the CRS of both COVID-19 ARDS. Secondary outcomes included the mortality rates, lengths of stay, and ventilator free days. Random-effects (DerSimonian and Laird) meta-analyses were conducted. Results: 45 studies (13,334 patients) were included for analysis. The pooled CRS in patients mechanically ventilated for COVID-19 was 34.6 (95%-CI: 33.4-35.8), and displayed a normal distribution (Shapiro- Wilk test: p = 0.35). CRS was significantly associated with an PaO2/FiO2 ratio, positive end-expiratory pressure, and tidal volume;driving pressure was negatively associated with CRS. The pooled mortality rate was 36.2% (95%-CI: 30.3-42.4%, ICU) and 38.9% (95%- CI: 32.3-45.7%, 28-day). Conclusions: The respiratory mechanics of CARDS at the time closest to the initiation of invasive mechanical ventilation was normally distributed and did not reveal any distinct CRS- based phenotypes. However, to what extent the proposed unique pathophysiology of CARDS affects the current definition of ARDS and “exposes” its potential limitations remains a question for a high-quality, large prospective dataset to answer. Nonetheless, from our study-level analysis, CRS appears to be a heterogenous metric affected by both disease and intervention factors (Fig. 1) and physicians should treat patients with personalised and precise interventions in this context. (Table Presented).

Clinical and whole genome characterization of SARS-CoV-2 in India

We report clinical profile of hundred and nine patients with SARS CoV-2 infection, and whole genome sequences (WGS) of seven virus isolates from the first reported cases in India, with various international travel histories. Comorbidities such as diabetes, hypertension, and cardiovascular disease were frequently associated with severity of the disease. WBC and neutrophil counts showed an increase, while lymphocyte counts decreased in patients with severe infection suggesting a possible neutrophil mediated organ damage, while immune activity may be diminished with decrease in lymphocytes leading to disease severity. Increase in SGOT, SGPT and blood urea suggests the functional deficiencies of liver, heart, and kidney in patients who succumbed to the disease when compared to the group of recovered patients. The WGS analysis showed that these isolates were classified into two clades: I/A3i, and A2a (four according to GISAID: O, L, GR, and GH). Further, WGS phylogeny and travel history together indicate possible transmission from Middle East and Europe. Three S protein variants: Wuhan reference, D614G, and Y28H were identified predicted to possess different binding affinities to host ACE2.