Central line-associated bloodstream infection: is the hospital epidemiology of methicillin-resistant Staphylococcus aureus relevant?

We aimed to evaluate the risk factors, including the hospital epidemiology of methicillin-resistant Staphylococcus aureus (MRSA), for central venous line-associated and laboratory-confirmed bloodstream infections (CLA-BSI and LC-BSI, respectively). The risk factors examined included the age and sex of patients, whether or not they were in the surgery service, the number of days of central line (CL) placement, the monthly number of inpatients and those positive for MRSA, and whether the standard or maximal barrier precautions were observed at CL insertion. As the outcome factors, we selected CLA-BSI and LC-BSI, while precluding repeated isolation within 28 days. Of a total of 22,723 device days in 927 patients with CL placement, we observed 81 CLA-BSIs and 40 LC-BSIs, rates of 3.56 and 1.76 (/1000 device-days), respectively. Logistic regression analysis revealed a single significant factor, CL placement of more than 30 days, with odds ratios of 3.038 [95% confidence interval (CI) 1.733-5.326; P < 0.001] for CLA-BSI and 3.227 (95% CI 1.427-7.299; P = 0.005) for LC-BSI. Both BSIs included MRSA in seven events without temporal clusters. We conclude that the factor of long CL placement outweighs other risk factors, including the hospital epidemiology of MRSA.

Risk factors for central venous catheter-related bloodstream infection: a 1073-patient study.

We intended to evaluate the risk factors for catheter-related bloodstream infection (CR-BSI) with central venous (CV) catheters. For the hub of the CV line, we used three-way stopcocks in the first year of the study and closed needleless connectors (NCs) in the second year. Background factors included the age and sex of patients; the ward; the specialty service; the CV catheter and its days of placement; and the staff compounding the intravenous infusion, i.e., either nurses, who disinfect hands-free, or pharmacists using clean benches. Outcome factors included positive culture from the blood-related samples and the body temperature estimate. Of a total of 29 221 device-days in 1073 patients, positive cultures showed an overall incidence of 2.26 per 1000 device-days. Multivariate analysis showed a higher odds ratio of positive cultures for the ICU (odds ratio [OR], 4.415; 95% confidence interval [CI], 2.054-9.490]) and for CV catheter placement for more than 30 days (OR, 7.529; 95% CI, 4.279-13.247), but no significance for male sex (OR, 1.752; 95% CI, 0.984-3.119) or for pharmacists' compounding (OR, 2.150; 95% CI, 0.974-4.749). Univariate analysis showed no significance for the following factors: age more than 70 years (OR, 0.968; 95% CI 0.561-1.641), the surgery service (OR, 1.029; 95% CI, 0.582-1.818), double-lumen CV catheters (OR, 0.841; 95% CI, 0.465-1.521), or the NC (1.107; 95% CI, 0.673-1.821). We conclude that the theoretical benefit of the NC, the abolished dead space in the hub, contributed little to the outcomes of blood-related culture. The hands-free disinfection may have resulted in comparable odds ratios for the nurses and the pharmacists compounding the infusions.

Laparoscopic rectopexy for recurrent rectal prolapse: a safe and simple procedure without a mesh prosthesis.

Two female patients, 65 and 61 years old, respectively, suffering from a recurrent rectal prolapse underwent laparoscopic rectopexy. Our modified method using an ultrasonically activated scalpel (Harmonic Scalpel) and a laparoscopic suturing device (Endo Stich) both shortened and simplified the operation. The operation times were 140 minutes and 120 minutes, respectively. Neither of the patients demonstrated either intraoperative complications or recurrence of the prolapse during the 24-month follow-up. Our procedure using these new instruments could be performed simply, safely, and in a short time, without the use of a mesh prosthesis.

New therapeutic strategy of open pelvic fracture associated with rectal injury in 43 patients over 60 years of age.

BACKGROUND/AIMS: A diversion of the fecal stream is generally regarded as an integral component of minimizing both the infectious morbidity and mortality associated with an open pelvic fracture. However, the efficacy of the fecal diversion in elderly has yet to be clearly elucidated. We performed a formal retrospective comparison between the elderly patients who underwent diversion and those who did not. METHODOLOGY: Forty-three consecutive patients who were over 60 years of age and suffered a pelvic fracture associated with rectal injury. The use of fecal diversion was used to delineate the comparison groups: group 1, underwent diversion; group 2, did not undergo diversion. The 2 groups were compared based on the outcome variables and patient demographics. RESULTS: The diverted patients were more severely injured as demonstrated by a higher ISS (p < 0.05). The length of hospital stay was also significantly greater for the diverted patients than for the non-diverted patients (p < 0.05). The number of abdominal injuries (p < 0.05) and the number of total diagnoses (p < 0.05) were also significantly greater for the diverted patients than for the non-diverted patients. There was a significant difference in the distribution of intraabdominal fecal contamination (p < 0.05). No significant difference was observed in the distribution of fracture stability, fracture patterns, wound location, or wound severity between the diverted and non-diverted groups. On the other hand, the chi 2 test for trend (Mantel-Haenszel) for fecal diversion and the Gustilo grade produced a P value of 0.04. A primary repair with end-colostomy was performed in 7 of 23 patients and a resection with an end-colostomy was performed in 16 of 23 patients in group 1. On the other hand, a primary repair was performed in 3 of 20 patients and a resection with anastomosis was performed in 17 of 20 patients in group 2. By the third postoperative month, no significant difference was seen in the survival rate: 61% in group I versus 65% in group 2 (P = 0.40). By the first postoperative month, the survival rate was significantly lower in group 1 than in group 2 (P = 0.04). CONCLUSIONS: Diversion should not be regarded as an absolutely safe intervention for open pelvic fracture associated with rectal injury. However, if a failure of the primary repair or resection with anastomosis once occurs, then the patient's condition could change suddenly or worsen. Elderly patients especially have a poor physiological reserve, and thus a failure to perform a primary repair or resection with anastomosis can quickly lead to patient mortality. There may be some bias when selecting fecal diversion or not based on each surgeon's subjective judgment. In our cases, diversions tended to be done in severe cases. If surgeons encounter a pelvic fracture with severe rectal injury, then aggressive fecal diversion may thus be the procedure of choice in emergency elderly cases.

Results of endotoxin absorption after a subtotal resection of the small intestine and a right hemicolectomy for severe superior mesenteric ischemia.

BACKGROUND/AIMS: The purpose of this study is to analyze the results of endotoxin absorption therapy after a subtotal resection of the small intestine and a right hemicolectomy for severe superior mesenteric ischemia. METHODOLOGY: From April 1980 through August 1999, 82 patients with severe superior mesenteric ischemia were operated on an emergency basis, and they were divided into two groups. Group 1 (n = 51), did not undergo postoperative endotoxin absorption therapy, while group 2 (n = 31), underwent this therapy. The two groups were compared based on the outcome variables. RESULTS: When the number of risk factors was 1 or 2, the mortality rate in group 2 was significantly lower than in group 1 (p < 0.05). For postoperative lung or liver failure, the mortality rate was significantly higher in group 1 than in group 2. For an intraabdominal abscess, the mortality rate was significantly higher in group 1 than in group 2. Twenty-two of the thirty-one patients in group 2 survived. In the surviving cases, this therapy significantly decreased the intravenous concentration of endotoxin (p = 0.04). As for the fatalities (n = 9), no significant change in the concentration of endotoxin before or after endotoxin absorption was recognized. By the first postoperative month, the survival rate was significantly lower in group 1 than in group 2 (58.8% vs. 71.0%, P = 0.04). CONCLUSIONS: In conclusion, we may now safely say that both stoma and a resection are recommended while endotoxin absorption using blood filtration may also be an effective additional therapy for post-operative septic shock.

New insight for management of blunt splenic trauma: significant differences between young and elderly.

BACKGROUND/AIMS: Although highly successful in children and young patients, the non-operative management of blunt splenic injury in the elderly has yet to be clearly studied. The purpose of this study was to determine whether or not a relationship exists among the mechanism of injury, the grade of splenic injury, the associated injuries, and whether patterns of injury differ between the young group (younger than 60 years old) and the elderly group (60 years and older than 60 years). METHODOLOGY: One hundred and sixty-seven patients (116 young patients including 30 early deaths and 51 elderly patients including 20 early deaths) with blunt splenic injury were admitted to our clinic from 1983 to 1997. Computed tomography scans were interpreted in a blind fashion. In addition, the Injury Severity Score, Glasgow Coma Scale, blunt splenic injury grade, length of hospital stay, length of intensive care unit stay, survival, number of abdominal injuries and number of total diagnoses were investigated in both the young and elderly groups. The different types of management for blunt splenic injury were also studied. RESULTS: Higher injury severity scores, lower Glasgow Coma Scales, and higher mortality all indicated that the elderly were more severely injured than the young patients. The rate of non-operative treatment was also significantly greater for young patients than for elderly patients (62.8 vs. 32.3%, P < 0.05) and the rate of a splenectomy was significantly less for the young patients than for the elderly patients (29.1 vs. 51.6%, P < 0.05). Regarding infectious complications, the rates of pneumonia (14.0 vs. 23.1%, P < 0.05), subphrenic abscess (9.3 vs. 23.1%, P < 0.05), and urosepsis (7.0 vs. 23.1%, P < 0.05) was significantly greater for the elderly patients than for the young patients. The overall failure of non-operative management was 5.2% in the young patients and 9.8% in the elderly patients. CONCLUSIONS: The final selection of splenic management decision was individualized for each patient and based on multiple variables. For persistent hemodynamic instability or unresolved concerns for other individual pathologic conditions, aggressive management is recommended. In the absence of these two important conditions, the variables that predicted a need for operative intervention include an Injury Severity Score above 20 in younger and elderly patients; an American Association for the Surgery of Trauma splenic grade above III in elderly; a large hemoperitoneum on an initial computed tomography scan; the presence of active extravasation on an initial computed tomography scan; and high-energy mechanisms. In conclusion, selecting the optimal non-operative management of blunt splenic injury in elderly patients remains difficult. An aggressive initial operation is thus recommended because the specific fragility of the spleen and the decreased physiologic reserve in elderly patients is difficult to estimate, especially at small hospitals where performing emergency splenic angiography and treating embolisms is difficult.

Anatomic resection for severe blunt liver trauma in 100 patients: significant differences between young and elderly.

The liver is the organ most commonly injured during blunt abdominal trauma. As our society ages, emergency surgery for active elderly patients increases, but data on aggressive emergency hepatic resection remain scarce in the literature. The purpose of this study was to determine whether the elderly (70 years of age or older) can tolerate major liver injury and subsequent hepatic resection. We investigated 100 patients who were treated by an anatomic resection for severe blunt liver trauma (29 elderly patients who were 70 years of age or older and 71 young patients who were younger than 70 years of age) in a retrospective study. The elderly patients were more severely injured as demonstrated by a higher Injury Severity Score, a lower Glascow Coma Scale, and lower survival (80.3% vs. 65.5%; p < 0.05). The total number of associated injuries was greater in elderly patients. Motor vehicle accidents were responsible for 71.8% of the injuries in the young group, and the predominant mechanism in the elderly patients was also motor vehicle accidents (51.7%). The 71 anatomic hepatic resections performed on the young patients included right hemihepatectomy (n = 45), left lateral segment resection (n = 14), bisegmentectomy (n = 5), and others. The 29 anatomic hepatic resections performed for the elderly patients were right hemihepatectomy (n = 15), left lateral segment resection (n = 5), left hemihepatectomy (n = 4), and others. Pneumonia, subphrenic abscess, and urosepsis occurred at a significantly higher frequency in elderly patients than in young patients. Our data clearly indicated that (1) the mechanism of injury, grade of associated intraabdominal injuries, distribution of surgical procedures, and complications differ significantly between young and elderly patients; and (2) the survival rate (65.5%) in elderly patients may be sufficient to consider anatomic hepatic resection to be a useful, safe procedure.

Therapeutic strategy of emergency surgery for colon cancer in 71 patients over 70 years of age in Japan.

BACKGROUND/AIMS: The prognosis for colon cancer is poorest in cases of emergency situation in the elderly not only in Japan, but worldwide. The aim was to design a therapeutic approach used for colon cancer in the elderly. METHODOLOGY: Seventy-one patients, who were all older than 70 years, with colon carcinoma in an emergency situation were examined. Lethality, surgical procedure, risk of comorbidity, multiple organ system failure and the effect of endotoxin absorption were examined. RESULTS: Any increase in comorbidity was associated with a higher clinical lethality in the lungs, heart, kidney, and diabetes. The highest postoperative mortality rate was recorded in patients who underwent primary resection after perforation, while the lowest postoperative mortality rate was recorded in patients who underwent primary resection after obstruction. Postoperative failure of the lungs and heart and renal failure were associated with a significantly higher mortality rate. Twenty-five septic patients received an endotoxin adsorption due to blood filtration and 8 patients survived. Of the eight survivors, the endotoxin concentration was significantly decreased by an endotoxin absorption. CONCLUSIONS: In cases of ileus, the resection may be performed positively. In cases of perforation, we may safely say now that stoma and resection is to be recommended. Endotoxin absorption due to blood filtration may be an effective additional therapy for post-operative septic shock.