An Evaluation of the Impact of 0.05% Chlorhexidine on the Prevalence of Surgical Site Infections in Aesthetic Breast Surgery

Purpose of Study Surgical site infections (SSI) burden U.S. hospitals with around $1.5 billion annually. To reduce SSI, irrigating the incision with an antimicrobial solution before closure is recommended. Hence, we evaluate the impact of Irrisept, a form of diluted chlorohexidine 0.05%, on reducing the prevalence of SSI in a high-risk breast cosmetic surgery population. Methods Used We conducted a retrospective cohort study using data in the electronic medical record for breast implant exchange patients in one practice and analyzed infection rates between 42 patients from July 2018-June 2019 that did not receive Irrisept irrigation (control group) with 16 patients from July 2019-July2020 that received Irrisept irrigation (experimental group;significantly less due to Covid-19). We executed descriptive analyses, independent T test, ANOVA (for 3 types of incision location), and Chi-squared to assess comorbidities and intraoperative factors. Summary of Results Among the control group (n=42), 4 patients had a postoperative infection;in the experimental group (n=16), 0 had an infection (9.52% vs. 0%;p=0.04) suggesting the use of Irrisept significantly decreases SSI. The p values from the T test and ANOVA (p<0.05=significant) showed no significant differences in breast cancer (0.84), previous radiation (0.32), history of chemotherapy (0.57), obesity (0.40), renal failure (0.32), smoker/previous smoker (0.41), type of implant (0.32), incision location (0.68), acellular dermal matrix use (0.32), or drain use (0.58) between two groups. The only significant comorbidity was diabetes (p=0.04) with 9.52% (control) vs. 0% (experimental). However, greater percentage of experimental group were obese (25% vs.14.29%) and had a history of smoking (25% vs. 9.52%). Conclusions A concern regarding the implementation of Irrisept irrigation is associated costs. However, the results show the use of Irrisept decreases the infection rates, ultimately relieving the financial burden of postoperative infections. Therefore, we recommend irrigating the incisions of breast surgery patients with Irrisept as both a preventative and economic measure.

Silver nitrate-induced skin inflammation mimicking surgical infection

Silver has been in medicine for hundreds of years and has proven antimicrobial properties. It was widely used until the Second World War, when antibiotics emerged. Silver nitrate (SN) sticks (75% silver nitrate and 25% potassium nitrate) are currently employed as a topical haemostatic agent for various cutaneous surgical procedures. In the initial phase of the COVID-19 pandemic, faced with a limited supply of personal protective equipment, we used SN stick haemostasis for several skin surgical procedures (including excisions). COVID-19-related guidance from the Trust recommended the avoidance of electrocautery owing to the generation of surgical plume;hence, SN stick haemostasis seemed a pragmatic option. Four female patients with a mean age of 67 years (range 48-75) presented with swelling, erythema and pain at the surgical site within a week of the procedure. Three had ellipse excisions for suspected melanoma and squamous cell carcinomas, and one had a shave excision for possible seborrhoeic keratosis. Postsurgical wound infection was suspected, but repeated microbiological swabs did not grow any pathogens. All patients failed to respond to broad-spectrum oral antibiotics, even after two courses. The inflammatory changes took up to 4 weeks to settle, with topical corticosteroids used for wound healing. On contact with moisture, SN sticks deliver free silver ions that form an eschar as they bind to the tissue and occlude vessels. The longer the tip contacts the tissue, the greater the degree of the resultant caustic action. It is widely used in clinical practice, especially wound care (overgranulation, epibole and delayed healing). A 2020 review found an increased incidence of postoperative pain along with pigmentary changes in surgical wounds treated with SN sticks vs. aluminium chloride hexahydrate and ferric subsulfate. In skin surgery, SN is used to cauterize superficial wounds after curettage and shave excision. It does not generate aerosol and, in a pandemic setting, this particular feature can be valuable. However, the potential to cause aseptic skin inflammation that mimics postoperative infection is noteworthy. There are no evidence-based guidelines for its use in dermatology. We believe that the SN is an effective haemostatic agent but can induce significant tissue inflammation in some patients, particularly if it is used in excisions when the cauterized tissue is closed. If SN-induced haemostasis for excision was to be adopted in clinical practice, our experience suggests that larger studies and guidelines are recommended.

Renal transplantation

Individuals with kidney failure face a future requiring long-term treatment with either dialysis or renal transplantation. Renal transplantation is the preferred form of renal replacement therapy, and is associated with a better quality of life, and usually increased longevity. Unfortunately, owing to excessive co-morbidities, only 30% of patients who develop end-stage renal failure are fit enough for transplantation. Over 90% of kidney transplants still function after 1 year, and most function for >15 years. Improvements in transplant outcomes are attributable to advances in histocompatibility testing, organ procurement, organ preservation, surgical techniques and perioperative care. Long-term outcomes have shown only minor improvements over the last two decades, although this should be considered in the context of deteriorating organ quality as older deceased donors with increasing co-morbidity are used more often to satisfy the need for donor organs. An overall increase in deceased donor numbers has boosted transplant activity in the UK, and it is hoped this will continue with the adoption of the 'opt-out' consent system. Living donor activity remains stable, but the use of non-directed altruistic donation and the living donor exchange scheme have reduced the need for higher immunological risk incompatible transplantation. The COVID-19 pandemic has reduced transplant rates globally, although national transplant systems are now recovering.Copyright © 2022

Skin cancer surgery at the time of the covid-19 pandemic: A single center experience

Elective operations were significantly reduced in order to eliminate, as much as possible, the risks of SARS -CoV-2 virus infection for both patients and medical personnel and to leave the clinical facilities and intensive care available for access to COVID patients. We looked at the total number of patients treated for skin cancer surgery at both hospitals from the March 23, 2020 till the May 28, 2020, the demographic characteristics, the medical comorbidities, the pathologies operated on in day surgery regimens of care and the surgical outcomes. With regards to the site, more than one third of the patients were treated at a private hospital setting. Among the surgery complications identified there was one graft failure following excision of scalp lesion which histology confirmed regressed keratoacanthoma. Moreover, three infections associated with the lesions excised occurred and were treated with antibiotics. With regards to morbidity there was only one covid-19 infection among the patients that attended for skin cancer surgery and two deaths. The utilization of Covid-free locations, other than NHS hospitals, for elective surgery improved the efficiency of the service and together with the practical steps in theatre management and minimizing footfall, allowed the successful continuation of care during the pandemic.Copyright © 2021

Primary Human Herpes Virus-6 Causing Recalcitrant Pyrexia after Pilocytic Astrocytoma Resection.

INTRODUCTION: Human herpes virus-6 (HHV-6) is a ubiquitous virus but can lead to deleterious clinical manifestations due to its predilection for the pediatric central nervous system. Despite significant literature describing its common clinical course, it is rarely considered as a causative agent in CSF pleocytosis in the setting of craniotomy and external ventricular drainage device. Identification of a primary HHV-6 infection allowed for timely treatment with an antiviral agent along with earlier discontinuation of antibiotic regimen and expedited placement of a ventriculoperitoneal shunt. CASE PRESENTATION: A two-year-old girl presented with 3 months of progressive gait disturbance and intranuclear ophthalmoplegia. Following craniotomy for removal of 4th ventricular pilocytic astrocytoma and decompression of hydrocephalus, she suffered a prolonged clinical course due to persistent fevers and worsening CSF leukocytosis despite multiple antibiotic regimens. The patient was admitted to the hospital during the COVID-19 pandemic and isolated with her parents in the intensive care unit with strict infection control measures. FilmArray Meningitis/Encephalitis (FAME) panel ultimately detected HHV-6. Clinical confirmation of HHV-6-induced meningitis was proposed given improvement in CSF leukocytosis and fever reduction following the initiation of antiviral medications. Pathologic analysis of brain tumor tissue failed to show HHV-6 genome positivity, suggesting a primary peripheral etiology of infection. CONCLUSION: Here, we present the first known case of HHV-6 infection detected by FAME following intracranial tumor resection. We propose a modified algorithm for persistent fever of unknown origin which may decrease symptomatic sequelae, minimize additional procedures, and shorten length of ICU stay.

SYSTEMATIC LITERATURE REVIEW on the SCREENING and PROPHYLAXIS of CHRONIC and OPPORTUNISTIC INFECTIONS

Background: Opportunistic and chronic infections can arise in the context of treatment used for Autoimmune Rheumatic Diseases (ARDs). Although it is recognized that screening procedures and prophylactic measures must be followed, clinical practice is largely heterogeneous, with relevant recommendations not currently developed or disparately located across the literature. Objectives: To conduct a systematic literature review (SLR) focusing on the screening and prophylaxis of opportunistic and chronic infections in ARDs. This is preparatory work done by members of the respective EULAR task force (TF). Methods: Following the EULAR standardised operating procedures, we conducted an SLR with the following 5 search domains;1) Infection: infectious agents identifed by a scoping review and expert opinion (TF members), 2) Rheumatic Diseases: all ARDs, 3) Immunosuppression: all immunosuppressives/immunomodulators used in rheumatology, 4) Screening: general and specifc (e.g mantoux test) terms, 5) Prophylaxis: general and specifc (e.g trimethop-rim) terms. Articles were retrieved having the terms from domains 1 AND 2 AND 3, plus terms from domains 4 OR 5. Databases searched: Pubmed, Embase, Cochrane. Exclusion criteria: post-operative infections, pediatric ARDs, not ARDs (e.g septic arthritis), not concerning screening or prophylaxis, Covid-19 studies, articles concerning vaccinations and non-Εnglish literature. Quality of studies included was assessed as follows: Newcastle Ottawa scale for non-randomized controlled trials (RCTs), RoB-Cochrane tool for RCTs, AMSTAR2 for SLRs. Results: 5641 studies were initially retrieved (Figure 1). After title and screening and removal of duplicates, 568 full-text articles were assessed for eligibility. Finally, 293 articles were included in the SLR. Most studies were of medium quality. Reasons for exclusion are shown in Figure 1. Results categorized as per type of microbe, are as follows: For Tuberculosis;evidence suggests that tuberculin skin test (TST) is affected by treatment with glucocorticoids and conventional synthetic DMARDs (csDMARDs) and its performance is inferior to interferon gamma release assay (IGRA). Agreement between TST and IGRA is moderate to low. Conversion of TST/IGRA occurs in about 10-15% of patients treated with biologic DMARDs (bDMARDs). Various prophylactic schemes have been used for latent TB, including isoniazide for 9 months, rifampicin for 4 months, isoniazide/rifampicin for 3-4 months. For hepatitis B (HBV): there is evidence that risk of reactivation is increased in patients positive for hepatitis B surface antigen. These patients should be referred for HBV treatment. Patients who are positive for anti-HBcore antibodies, are at low risk for reactivation when treated with glucocorticoids, cDMARDs and bDMARDs but should be monitored periodically with liver function tests and HBV-viral load. Patients treated with rituximab display higher risk for HBV reactivation especially when anti-HBs titers are low. Risk for reactivation in hepatitis C RNA positive patients, treated with bDMARDs is low. However, all patients should be referred for antiviral treatment and monitored periodically. For pneumocystis jirovecii: prophylaxis with trimeth-oprim/sulfamethoxazole (alternatively with atovaquone or pentamidine) should be considered in patients treated with prednisolone: 15-30mg/day for more than 4 weeks. Few data exist for screening and prophylaxis from viruses like E B V, CMV and Varicella Zoster Virus. Expert opinion supports the screening of rare bugs like histoplasma and trypanosoma in patients considered to be at high risk (e.g living in endemic areas). Conclusion: The risk of chronic and opportunistic infections should be considered in all patients prior to treatment with immunosuppressives/immunomod-ulators. Different screening and prophylaxis approaches are described in the literature, partly determined by individual patient and disease characteristics. Collaboration between different disciplines is important.

Impact of order sentence implementation on outpatient antibiotic prescribing for urinary tract infection and skin and soft tissue infection

Introduction: Due to the high volume of outpatient antibiotic prescribing, the Joint Commission now requires antimicrobial stewardship program (ASP) expansion to ambulatory practice settings. Unfortunately, ASP resources in these settings are scarce. The purpose of this study was to determine whether the implementation of antibiotic order sentences alongside education would improve antibiotic prescribing for urinary tract infections (UTI) and skin and soft tissue infections (SSTI). Objectives: The primary objective was to compare the proportion of total guideline-concordant antibiotic prescribing before (pre-ASP) vs after (post-ASP) implementing order sentences. Guideline concordance was defined as antibiotic selection, dosing, and duration in accordance with the health system's empiric guidelines. Secondary objectives included comparing patient-centered outcomes, such as infection-related revisits and Clostridiodes difficile infections between groups. Methods: This retrospective, quasi-experimental study evaluated adult patients treated for uncomplicated UTI or SSTI at an outpatient Family Medicine office between 1 February 2020 and 1 January 2021. The institution's stewardship team provided in-person education and set prescribing order sentence “favorites” for providers. Patients were excluded who were diagnosed with a complicated UTI, treated only with topical antibiotics, were pregnant, or received care via telephone encounter. Results: Two hundred sixty patients were included in this study (pre-ASP n = 139, post-ASP n = 121). Total antibiotic appropriateness improved significantly from 24.5% to 39.7% after implementation of order sentences and education (P =.008). Significant improvement was seen for appropriate drug selection (52.5% vs 66.9%, P =.018) and duration (47.5% vs 68.6%, P =.001). There were no differences observed in patient-centered outcomes between groups. Conclusion: Implementing stewardship-focused order sentences significantly improved outpatient antibiotic prescribing for UTI and SSTI. Tailoring antibiotic order sentences may be a useful tool for ASP expansion into the outpatient setting with limited resources to allocate to stewardship efforts.

Analysis of patient outcomes after urological surgery during the second and third waves of SARS-CoV-2 pandemic in a high incidence area.

OBJECTIVE: To analyze surgical safety through postoperative COVID-19 incidence and mortality at the urology department of a tertiary hospital located in Madrid (Spain). METHODS: Observational, prospective study including all patients undergoing urological surgery from 1st March 2020 to 28th February 2021. According to the hospital organization and local epidemiological situation we delimitate three epidemic waves. A set of screening and protective measures was applied from 4th May onwards. Demographic, baseline, surgical and perioperative variables, as well as postoperative outcomes, were collected. Telephone follow-up was performed at least 3 weeks after hospital discharge. RESULTS: 940 urological surgeries were performed, 12 of them had to be rescheduled due to active or recent SARS-CoV-2 infection identified by the screening protocol. Thirty-one patients developed COVID-19 (3.3% incidence) and 7 died (22.6% mortality). The average time to onset of symptoms was 62.6 days after discharge, being 25 cases attributable to community transmission. The remaining 6 cases, due to in-hospital transmission, had worse outcomes. Five of them were identified during the first wave, especially when no preoperative PCR was obtained. In contrast, during the second and third waves, fewer and milder cases were diagnosed, with just 1 in-hospital transmission among 857 urological patients. CONCLUSIONS: After implementing complete protective measures, postoperative in-hospital COVID-19 cases almost disappeared, even during the second and third waves. Most of the cases were due to community transmission and thus driven by the general epidemiological situation. While hospitals follow recommendations to avoid COVID-19 infection, urological surgery remains safe and can be maintained.

Post-ureteroscopy febrile urinary tract infections are linked to pre-operative stent dwell time: Results from three European endourology centres

Introduction & Objectives: Indwelling ureteric stents are valuable devices used in emergency drainage of upper urinary tract obstruction due to ureteric stones. However, stents can cause significant morbidity with infections, encrustations and blockages. In the study we look at the outcomes of pre-operative stent dwell time on infectious complications following ureteroscopy and laser fragmentation (URSL). Materials & Methods: Data was retrospectively collected for outcomes of URSL from 3 European endourology centres for patients with preoperative indwelling ureteric stents. We included data for patient details, stone demographics, operative details, stone free rate (SFR), outcomes and complications between 2011 and 2020. Patients were divided into two groups based on the stent dwell time: group 1 (<6 months) and group 2 (≥6 months). Descriptive statistics were used to determine the rate of early post-operative infectious complications (defined as the presence of fever?) and ICU access. Binomial logistic regression analysis were used to explore the relationship between stent dwelling time and post-operative early infectious complications. (SPSS v.24). Results: There were 501 patients undergoing URSL in the study period, with 429 and 72 patients in groups 1 and 2 respectively (Table 1). The mean age and operative time in groups 1 and 2 were 71±30 years and 64±22 years, and 51±28 minutes and 59±31 minutes respectively. Infectious complications and ICU admissions were seen in 32 (8%) and 3 (0.7%), and 22 (31%) and 1 (1.4%) in groups 1 and 2 respectively. Stent dwell time of ≥6 months carried significantly higher risk for febrile UTI post URSL (RR=5.45, 95% CI: 2.94-10.10, p<0.001). (Table Presented) Conclusions: Although the overall risk of infectious complication rates from URSL were low, longer indwelling stent time significantly increases the risk of post-operative infections, of which a small proportion of patients end up in ICU. We would recommend having the stent dwell time as short as possible and not to exceed a 6 months’ time period, and our findings will help prioritise these patients in the post-COVID era.

Does use of intra-operative PPE affect post-operative infection rates in hip fracture patients?

Aim: COVID-19 has required significant change to theatre protocol. Regional guidelines dictate full PPE must be donned for all procedures where aerosol generating procedures (AGP) occur. Additionally, no one may enter or leave theatre whilst an operation is in progress, or until 20 minutes after an AGP. We hypothesized that adopting these protocols may lead to a reduction in post-operative infection in hip fracture patients. Method: Multicentre retrospective cohort study comparing post-operative infection and return to theatre rates (<30-days post-op) from 18/ 03/20 to 27/04/20 with respective period in 2019. COVID-19 was considered endemic in Northern Ireland from 18/03/20. Patients were identified from the Fracture Outcomes Research Department database and relevant inpatient episode reviewed via Electronic Care Record. Results: 464 patients were included- 261(2020) and 203(2019). In 2019, 4 patients (1.5%) returned to theatre within 30-days, however only one was due to wound dehiscence. In 2020, 1 patient (0.5%) returned to theatre for traumatic wound dehiscence, however they had no documented infection. Conclusions: There was no difference in post-operative complication rate requiring return to theatre within 30 days between cohorts. Whilst PPE can be considered important for protection of patients and staff against COVID-19, it may not have significant effect on post-operative infection rates.

Barriers to same-day discharge after percutaneous nephrolithotomy

Introduction & Objective: The COVID-19 pandemic has provided an impetus to reconsider traditional urologic practices and adapt to the unprecedented healthcare burden. Reducing length of stay after minimally invasive procedures is now more important than ever. Using percutaneous nephrolithotomy (PCNL) as a model, we sought to evaluate clinical barriers to same-day discharge in order to better understand the feasibility of outpatient surgery. Methods: Prospective data collected from 500 inpatient PCNLs performed at our institution between 2016 and 2020 was analyzed via the Registry for Surgery of the Kidney and Ureter (ReSKU). Preadmissions and aborted procedures were excluded. We analyzed issues and complications that warranted postoperative admission. Major categories included infection, bleeding, and excessive pain, which was defined as either a documented pain complication or administration of intravenous opioids within 24 hours after discharge from the recovery room. Multivariate statistics were used to assess risk factors for each outcome. Results: Excessive pain was the most common postoperative issue (40.9%). ASA score was inversely correlated with odds of having increased pain (OR 0.64, 95% CI 0.42-0.98) and was the only statistically significant predictor in our multivariate model that included dilated tract number, diameter, and location. The postoperative SIRS/sepsis rate within 7 days was 9.7%, and higher ASA score (OR 3.6, 95% CI 1.8-7.6) and incomplete stone clearance (OR 2.7, 95% CI 1.2-6.3) were significant predictors. Age, sex, body mass index (BMI), stone burden, and positive preoperative urine cultures were not associated with overall infection rate. In patients who had a postoperative infection, 34.1% of infections were detected intraoperatively or in the recovery room, and 48.8% were associated with the nephrostomy tube removal process on postoperative day 1. Patients who had a postoperative double-J stent rather than a nephrostomy tube had a lower overall infection rate (1.8%, p = 0.047). Finally, only 1.9% of patients had a bleeding complication, and 1.1% required a blood transfusion. Conclusions: Pain is the major barrier to same-day discharge after PCNL. Bleeding is infrequent and most infections can be recognized perioperatively or avoided with alternative tube management strategies. Rigorous patient selection for same-day discharge does not appear to be necessary. Optimizing pain control may be the key to performing outpatient surgery on a large scale.

COVID-19 in patients recovering from cardiac surgery: A surprising mild disease course.

BACKGROUND: We describe the baseline, operative, and postoperative features of a group of 18 patients who contracted the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection in a rehabilitation facility after cardiac surgery, and present some potential explanations for the surprisingly benign course of the COVID-19 in this cohort. METHODS: All patients were operated on an urgent or emergency basis (acute aortic syndrome, 3; refractory heart failure, 12; and endocarditis, 3) during the first lockdown period of the COVID-19 pandemic. The mean age was 70 years, and 12 patients were male. After the diagnosis of COVID-19, patients were treated according to the most recent recommendations. Eleven asymptomatic patients were discharged home or to a COVID-19 hotel and underwent close monitoring. Patients with fever, dyspnea, or a significant rise of the polymerase chain reaction levels were hospitalized, three received antivirals, three azithromicyne, and five hydroxychloroquine. Nasal swabs were repeated on a weekly basis, and all patients were quarantined until the collection of two consecutive negative samples. RESULTS: Diversely from other observations on perioperative COVID-19 reporting mortality rates of 30%-40%, the COVID-19 had a benign course in our cohort: only seven patients required hospitalization, and one required short intensive care unit admission. There were no deaths, and at the latest follow-up, all patients had been discharged home. COMMENT: Our data show that the SARS-CoV2 infection after cardiac surgery may have a benign course. Further studies are needed to investigate the relationship between the timing of the infection, some potentially protective therapies (e.g., anticoagulants), and the course of the COVID-19.

Urological surgery during SARS-CoV-2 pandemic. Descriptive analysis of the experience in a Urology Department across the pandemic phases. / Cirugía urológica durante la pandemia por SARS-CoV-2. Análisis descriptivo de la experiencia en un Servicio de Urología durante distintas fases epidemiológicas.

INTRODUCTION: The SARS-CoV-2 pandemic has changed the urological practice around the world. Our objective is to describe the outcomes presented by patients undergoing surgery in the urology department of a tertiary hospital, across the pandemic phases. METHODS: Observational, cohort study including all patients undergoing surgery from March 1 to May 14. According to the hospital organization, we identified three periods: there were no changes during the first two weeks (1st. period), the following seven weeks, when only urgent interventions were carried out after performance of nasopharyngeal swab test (2nd. period), and finally, elective surgery was resumed on May 4, after the implementation of a multidisciplinary screening protocol (3rd. period). Demographic, baseline, surgical and perioperative variables, as well as postoperative outcomes, were obtained in a retrospective (periods 1 and 2) and prospective (period 3) manner. Telephone follow-up was initiated at least 3 weeks after hospital discharge. RESULTS: 103 urological surgeries were performed, and 11 patients were diagnosed with COVID-19, 8 of them within the 1st. PERIOD: The diagnosis was already known in 1 patient, while the other 10 developed the disease in an average of 25 days after the intervention and 16,6 days after discharge. Of seven transplant patients, four got the infection. Three deaths were recorded due to the disease: a 69-year-old woman transplanted and two men over 80 with comorbidities and high anesthetic risk who underwent drainage of retroperitoneal abscess and retrograde intrarenal surgery, respectively. CONCLUSIONS: SARS-CoV-2 infection mainly affected renal transplant recipients or elderly patients with high anesthetic risk, during the first 2 weeks of the pandemic. After implementing preoperative PCR tests and a comprehensive screening protocol, cases were substantially reduced, and safe surgical procedures were achieved.