Early recognition of methicillin-resistant Staphylococcus aureus surgical site infections using risk and protective factors identified by a group of Italian surgeons through Delphi method.

BACKGROUND: Surgical site infections (SSIs) constitute a major clinical problem in terms of morbidity, mortality, duration of hospital stay, and overall costs. The bacterial pathogens implicated most frequently are Streptococcus pyogenes (S. pyogenes) and Staphylococcus aureus (S. aureus). The incidence of methicillin-resistant S. aureus (MRSA) SSIs is increasing significantly. Since these infections have a significant impact on hospital budgets and patients' health, their diagnosis must be anticipated and therapy improved. The first step should be to evaluate risk factors for MRSA SSIs. METHODS: Through a literature review, we identified possible major and minor risk factors for, and protective factors against MRSA SSIs. We then submitted statements on these factors to 228 Italian surgeons to determine, using the Delphi method, the degree of consensus regarding their importance. The consensus was rated as positive if >80% of the voters agreed with a statement and as negative if >80% of the voters disagreed. In other cases, no consensus was reached. RESULTS: There was positive consensus that sepsis, >2 weeks of hospitalization, age >75 years, colonization by MRSA, and diabetes were major risk factors for MRSA SSIs. Other possible major risk factors, on which a consensus was not reached, e.g., prior antibiotic use, were considered minor risk factors. Other minor risk factors were identified. An adequate antibiotic prophylaxis, laparoscopic technique, and infection committee surveillance were considered protective factors against MRSA SSIs. All these factors might be used to build predictive criteria for identifying SSI due to MRSA. CONCLUSIONS: In order to help to recognize and thus promptly initiate an adequate antibiotic therapy for MRSA SSIs, we designed a gradation of risk and protective factors. Validation, ideally prospective, of this score is now required. In the case of a SSI, if the risk that the infection is caused by MRSA is high, empiric antibiotic therapy should be started after debriding the wound and collecting material for culture.

Focus on the prophylaxis, epidemiology and therapy of methicillin-resistant Staphylococcus aureus surgical site infections and a position paper on associated risk factors: the perspective of an Italian group of surgeons.

BACKGROUND: The aim of this research was to study the epidemiology, microbiology, prophylaxis, and antibiotic therapy of surgical site infections (SSIs), especially those caused by methicillin-resistant Staphylococcus aureus (MRSA), and identify the risk factors for these infections. In Italy SSIs occur in about 5 % of all surgical procedures. They are predominantly caused by staphylococci, and 30 % of them are diagnosed after discharge. In every surgical specialty there are specific procedures more associated with SSIs. METHODS: The authors conducted a systematic review of the literature on SSIs, especially MRSA infections, and used the Delphi method to identify risk factors for these resistant infections. RESULTS: Risk factors associated with MRSA SSIs identified by the Delphi method were: patients from long-term care facilities, recent hospitalization (within the preceding 30 days), Charlson score > 5 points, chronic obstructive pulmonary disease and thoracic surgery, antibiotic therapy with beta-lactams (especially cephalosporins and carbapenem) and/or quinolones in the preceding 30 days, age 75 years or older, current duration of hospitalization >16 days, and surgery with prothesis implantation. Protective factors were adequate antibiotic prophylaxis, laparoscopic surgery and the presence of an active, in-hospital surveillance program for the control of infections. MRSA therapy, especially with agents that enable the patient's rapid discharge from hospital is described. CONCLUSION: The prevention, identification and treatment of SSIs, especially those caused by MRSA, should be implemented in surgical units in order to improve clinical and economic outcomes.

Treatment of gram-positive surgical sepsis: role of the oxazolidinones.

Surgical sepsis is still too frequent (the thirteenth cause of death in the U.S.) with an estimated cost of 5-10 billion dollars. Since the early 1990s antibiotic resistance has become a serious public health problem, with a relevant increase in nosocomial gram-positive infections. The oxazolidinones, a new class of antibiotics acting on bacterial synthesis at a very early stage, were first commercialized in 1987, and linezolid was the first antibiotic in this class registered for clinical use. This new molecule has been shown to be effective in a variety of aerobic and anaerobic infections (both nosocomial and community-acquired), especially those due to gram-positive agents. Linezolid has complete bioavailability in parenteral and oral administration, is well tolerated and shows little toxicity, thus favoring a shortened hospital stay, improving the patient's quality of life and reducing social costs. Oxazolidinones may be considered the first choice in the treatment of resistant gram-positive infections.

Questionnaire survey of perioperative antibiotic prophylaxis in Italian surgical departments.

Correct antibiotic prophylaxis reduces the incidence of postoperative infections. 600 questionnaires on perioperative antibiotic prophylaxis were sent to Italian Surgical Departments. Each questionnaire included a series of 17 multi-choice-questions concerning the specific approach of the department to: organization, type, timing, duration, auditing of prophylaxis. 435 departments (72.5%) responded to the questionnaire; 50 of these were blank, so 385 out of 435 (88.5%) were suitable for statistical evaluation. Results were as follows: 90.5% of departments perform some form of prophylaxis under the control, in 90.5% of cases, of surgeons; 89.3% differentiate antibiotics according to class of operation; 67.4% give the antibiotic preoperatively and prefer i.v. injection (61.0%), mostly in the ward (56.2%); in 33.3% of cases the prophylaxis is standard (more than 2 doses), but 55.8% of Italian surgeons do not give a boost-dose in operations longer than 3 h; 54.2% of patients receive a cephalosporin (mostly III generation), with a rotation of molecules in 53.9% of cases; 71.7% of departments register the incidence of infections, but only 43.2% control the patients 30 days after surgery; finally, 54.2% of departments work together with a bacteriology laboratory active 24 hours, while in 81.7% of cases the hospital has an Infection Committee which meets together usually without a programmed date (60.3%). In conclusion, antibiotic prophylaxis in Italian Surgery Departments appears adequate, even though some problems still remain regarding time-dose-duration-schedule, rotation of molecules, excess of cephalosporins, availability of a 24-h bacteriological laboratory and infection surveillance after discharge.

Antibiotic prophylaxis and treatment of surgical abdominal sepsis.

The incidence of surgical abdominal sepsis is related to the operation, patient and skill of the surgeon, ranging from <2-3% for laparoscopic cholecystectomy to >35-40% in overt peritonitis. Aged, obese, diabetic, neoplastic, acute patients have the highest incidence of sepsis. Antibiotic prophylaxis significantly reduces the incidence of postoperative infections for Class II and II operations. The proper timing (30-60 min before incision), choice of antibiotic (related to possible pathogens) and correct duration are essential. Ultra-short prophylaxis (only one administration) may be effective in most class II procedures and a cephalosporin can be used. Class II operations (colorectal) may require a booster dose soon after surgery or during surgery exceeding 3 h. The most effective regimen may include: ampicillin, clindamycin, I- II- III- or IV-generation cephalosporins, amoxycillin, aminoglycosides, metronidazole have been used alone and in combination. Combination prophylaxis should be active against aerobic and anaerobic bacteria. Treatment of surgical abdominal sepsis may be primary, seconday or tertiary. Surgery should remove the pathologic lesion, and antibiotics reduce the general effects of sepsis and infectious complications. This article presents information on the general rules for correct prophylaxis and treatment.

Monitoring of antimicrobial prophylaxis in general surgery.

The incidence of infections in general surgery is related to different factors. Cost-benefit analysis of antimicrobic prophylaxis is positive, even though incorrect use may be even dangerous (development of resistance and/or superinfections, for instance). The authors report data on a study concerning a total of 316 patients divided into two series, who had antimicrobic prophylaxis before a surgical operation. 274 patients out of 316 (or 86.7%) had an ultra-short (one-shot-only) or short (<24 hours) prophylaxis, 42 (13.3%) standard (>24 hours). The operations performed were classified following class of contamination, i.e. I (clean), II (potentially contaminated), III (contaminated). Antibiotics used were ceftizoxime, cefepime, ceftriaxone, piperacillin and gentamicin in combination. A total of 16 postoperative infections was observed (5%); 11 of these 16 belonged to class III operations. Escherichia coli and Staphylococcus aureus were isolated in most of the infected wounds. The data confirm what is reported in the literature. The authors conclude that a preoperative single-shot 3rd or 4th generation cephalosporin reduces the incidence of wound infections in clean and clean-contaminated surgery.

Short-term prophylaxis with cefuroxime in colorectal surgery for cancer.

A controlled study of short-term prophylaxis with cefuroxime was performed on a group of 52 patients with colorectal neoplasms who underwent elective surgery. The patients were divided into two groups, A and B. Group A received the antibiotic immediately before surgery, intraincisionally and immediately after the end of operation; group B was treated only postoperatively. Each patient received a total of 5,250 mg of cefuroxime. Wound sepsis was demonstrated in 11.5% of cases of group A and 23.0% of group B (P less than 0.01); another type of sepsis was observed in 34% of group A and 11.5% of group B (P less than 0.001). There was no difference in the operative mortality in the two groups.

Operative morbidity after shunt surgery for portal hypertension.

The operative morbidity observed in a consecutive series of 286 patients who underwent shunt surgery for portal hypertension is reported. 149 patients out of 286 (52.1%) had a postoperative complication, which required reoperation in 11 cases (5 intestinal perforations, 2 bleeding peptic ulcers, 1 eventratio, 1 cholestasis, 1 acute pancreatitis, 1 strangulated hernia). 42 patients out of the 149 with complications died of the complication (operative mortality 14.6%). Operative morbidity and mortality appeared higher in patients operated as emergencies. Whereas elective shunts gave better results. The problem involved in preventing and treating the serious complications following shunt surgery for portal hypertension are discussed.

Hepatic staging in operable breast cancer: a reappraisal from a prospective study.

A consecutive series of 100 patients affected by breast cancer and referred for surgical treatment were studied for the eventual spread of the tumour to the liver (echography, carcinoembryonic antigen [CEA], hepatic enzymes). Hepatic echography was positive in five cases: two also had bone and skin metastases at the time of diagnosis, and one was a case of remastectomy (these three patients died rather quickly of the disease); the remaining two patients are free of the disease 24 months after surgery and thus should be considered false-positive cases. Hepatic enzymes were not significant. The same was true for CEA except in nine cases with levels much greater than 20 ng/ml (six of these had early local and/or distant metastases). It is concluded that the usefulness of routine hepatic echography before locoregional treatment of breast cancer is rather limited. CEA much greater than 20 ng/ml may be useful prognostically.

Combined ultrasounds and CEA in preoperative assessment of hepatic metastases from gastrointestinal malignancies.

A consecutive series of 100 patients affected by gastrointestinal malignancies entered a prospective controlled study of liver metastases performed by ultrasound echography, CEA, hepatic enzymes (only alkaline phosphatase (AP) was found to be somehow significant). Laparotomic inspection and palpation were taken as objective control of ultrasound scan. Eighteen out of the 100 patients showed diffuse hepatic metastases at surgery (all controlled histologically). Hepatic echography correctly diagnosed liver metastases in 15 out of these 18 patients (= 83.8% sensitivity); two more cases (hepatic fibroangiomas) were interpreted as metastases (= 89.9% specificity). CEA-RIA assay was pathologic (greater than 10 ng/ml) in all of the 18 patients with liver metastases; 21 out of the 82 without liver metastases were CEA positive (difference of mean values statistically significant at P less than 0.01). The only significant hepatic enzyme was AP, which was pathologic in 12 out of 18 patients with liver metastases. The comparative evaluation of the three tests showed that ultrasound scanning missed three cases of diffuse hepatic metastases, which, however, were CEA positive, while AP could not help to correct such misdiagnosis.

Submucous lipoma of the transverse colon: report of one case.

A case of submucous lipoma of the transverse colon is reported. The patient, a man aged 61, complained of recurrent crampy periumbilical pain. A plain x-ray of the abdomen was negative, while a barium enema showed an intramural filling defect of the transverse colon which was interpreted as a probably degenerated colonic polyp. Laparotomy did not clarify the diagnosis which was readily clear when the lesion was cut, and confirmed by histology.

Side effects of levamisole given to neoplastic patients as adjuvant to surgery: a new case of agranulocytosis.

Side-effects to levamisole given as adjuvant to surgery in a consecutive series of 203 neoplastic patients are reported: Thirty-four patients (16.7%) suffered gastric adverse reactions; 8 (3.9%) allergic; 6 (2.9%) intestinal; 6 (2.9% neurologic; 4 (1.9%) severe hyperthermia (more than 40.5 degrees C); 3 (1.4%) flu-like illness; 1 (0.4% leucopenia; and 1 (0.4%) agranulocytosis. Withdrawal rate was 5.4% or 11 patients. Side effects appeared sex-related (39.0% in females, 17.7% in males; with seven female dropout out of 11), unrelated to other eventual adjuvant treatments, and reappearing at a new challenge with levamisole. The opportunity of very close control of patients taking levamisole for at least the first months is discussed.

Malignant lentigo-melanoma--a comparative histological and electron microscopy study.

We examined, by light and electron microscopy, three cases of malignant lentigo, one of which was in the vertical growth phase. The purpose of our work was to compare the diverse patterns between superficial spreading melanoma and malignant lentigo. The observations suggest the following major findings: 1) the cells of malignant lentigo differ from normal melanocytes, and in the same specimen they differ from one another; 2) in malignant lentigo, melanosomes at stage II-IV are visible; and 3) in spreading melanoma, the melanosomes do not attain complete maturation. These morphological features explain the different behaviour of these two types of tumors.

Cystic lymphangioma of stomach and jejunum: report of one case.

A case of cystic lymphangioma of stomach and jejunum is reported. The patient, a woman aged 58, was referred to the hospital for a melena of 4 days duration, which was interpreted as related to an old history of hypertrophic gastritis and duodenal ulcer. A conservative treatment with transfusions, cimetidine i.v., and gastric washout with antacids was started, but the hemorrhage appeared unresponsive, so an explorative laparotomy was performed. At the operation a soft pliable cystic mass in the anterior wall of the stomach was found; a smaller one was felt in the second jejunal loop. A Billroth II gastroduodenal resection was performed. The diagnosis of nature was only microscopic. At 9 months follow-up the patient is well, free of the disease.

Specific and aspecific immune responsiveness in lung cancer patients: cutaneous delayed hypersensitivity reactions to a lung cancer-associated antigen.

The ability of a lung cancer-associated antigen (LCAA) to provoke specific cutaneous delayed-hypersensitivity reactions has been studied on a group of 59 lung cancer patients. Biological activity of LCAA, monitored by skin testing, was demonstrated in 32% (17 of 53) of lung cancer patients, in 48.0% with limited disease, and in 17.2% with extensive disease. All the responders were in the group of normal reactors to standard recall antigens, if three antigens were used (PPDSK-SD, candida). No correlation was found between biological activity of LCAA and level of immunocompetence evaluated by lymphocyte-blastic transformation with PHA and count of rosette E-forming cells. These studies on the capacity to evoke specific DTH reactions in lung-cancer patients will be extended to the use of assays in vitro in the perspective of a more significant evaluation of immunocompetence levels.

Serial CEA levels in colorectal carcinoma on adjuvant immuno(chemo)therapy--further follow-up. Modulation of adjuvant treatment.

Serial plasma CEA levels have been studied preoperatively (testing A); one day after surgery (B); 10--15 days after surgery (C); 4 (D), 8 (E), 12 (F), 16--18 (G), and 22--24 (H) months after surgery in a series of 45 patients affected by colorectal carcinoma who started soon after surgery a protocol of adjuvant immuno(chemo)therapy with Levamisole and BCG. Postoperative follow-up was from one to 26 months, with 28 patients followed for at least one year. Fourteen patients had recurrences: two of these had false-negative CEA tests, three had persistent high CEA levels after surgery, nine had increasing levels 9--12 months before clinical recurrence; and nine of these 14 patients showed frankly pathologic preoperative plasma CEA levels. Six patients who did not have a recurrence but (both at clinical and instrumental evaluation) who had two consecutive high plasma CEA levels, were put on prophylactic polichemotherapy. The prognostic importance of CEA levels both pre- and postoperatively, the possibility of "modulating" postoperative adjuvant treatments on the basis of CEA levels, and the problem of unexplained fluctuations of plasma CEA levels with the putative metabolic linkages are discussed.

Nonfunctional preaortic paraganglioma: report of one case.

A case of nonfunctional benign preaortic paraganglioma is reported. The patient, a woman aged 50, complained of vague mesogastric pain irradiated posteriorly, occasional nausea and vomiting, related to a tender pulsatile mesogastric mass fixed to the posterior wall of the abdomen. Preoperative diagnostic examinations showed a severe anemia, a severe mechanical impairment of renal function as shown at IVP, a doubt of aortic aneurism at echography, not confirmed by selective arteriography. The mass was removed radically. The diagnosis of nature was only microscopic. Since from 15 days after surgery IVP improved significantly. At three months follow-up the patient is well with no sign of recurrence.