Neoadjuvant Chemotherapy Is Associated with Lower Lymph Node Counts in Colon Cancer.

Adequate lymphadenectomy is associated with improved survival in patients who undergo oncologic resection of colorectal cancer and has been identified as a quality metric. Neoadjuvant chemotherapy has been found to be associated with collection of <12 lymph nodes in patients with rectal cancer. The purpose of this study was to evaluate patient and operative risk factors for inadequate lymph node retrieval during oncologic colectomy. The 2014 American College of Surgeons National Surgical Quality Improvement Program Participant Use File data set for oncologic colectomy (n = 9077) was analyzed. Patient- and operation-related factors were assessed by univariate and multivariate regression analyses to determine factors associated with the number of lymph nodes collected. Adequate lymphadenectomy was defined by collection of >12 lymph nodes. Of 9077 patients with a diagnosis of colon cancer who underwent colectomy, a minimum of 12 lymph nodes was harvested in 7897 (87%). Significant factors independently associated with inadequate lymphadenectomy included preoperative chemotherapy, emergent surgery, and T1 tumors (all P < 0.05). A large majority of patients who undergo colectomy for colon cancer have at least 12 lymph nodes collected. Preoperative chemotherapy is a major risk factor for inadequate lymph node retrieval. Recognition of factors associated with inadequate lymphadenectomy may improve colectomy lymph node yield and survival in patients with colon cancer.

Recent Anti-Microbial Exposure Is Associated with More Complications after Elective Surgery.

BACKGROUND: Recent anti-microbial exposure has been associated with poor outcomes after infection in a mixed population. We hypothesized that recent anti-microbial exposure would be associated with poor outcomes of elective surgery. METHODS: From August 2015 to August 2016, all elective surgical patients were questioned prospectively about anti-microbial exposure during the prior three months. Multivariable models were used to calculate risk-adjusted odds ratios for anti-microbial exposure controlling for surgeon influence. Primary outcomes were any serious complication, any complication, any infection, and surgical site infection. Secondary outcomes were length of stay, C. difficile infection, and death. A separate analysis of patients excluding those having colorectal surgery who had undergone an oral antibiotic bowel preparation also was performed. RESULTS: Ninety-four percent of eligible patients (n = 1,538) answered the exposure question, with a three-month anti-microbial exposure rate of 34.1%. Colorectal surgery patients had the highest exposure rate, whereas hernia patients had the lowest. Exposed patients had higher rates of any complication, any infection, and surgical site infection, as well as a median two-day longer hospital stay. There were no differences in C. difficile infection or death between the groups. After risk adjustment, anti-microbial exposure was independently associated with any serious complication for all patients as well as with complications and infection in patients having an operation other than colorectal surgery. CONCLUSION: Recent anti-microbial exposure is associated with more complications of elective surgery. Anti-microbial drug-induced alterations in microbiome-related inflammatory responses may play a role, highlighting an opportunity for pre-surgical intervention in this at-risk population.

Open Surgical Incisions After Colorectal Surgery Improve Quality Metrics, But Do Patients Benefit?

BACKGROUND: Surgical site infection is a frequent cause of morbidity after colorectal resection and is a quality measure for hospitals and surgeons. In an effort to reduce the risk of postoperative infections, many wounds are left open at the time of surgery for secondary or delayed primary wound closure. OBJECTIVE: The purpose of this study was to evaluate the impact of delayed wound closure on the rate of surgical infections and resource use. DESIGN: This retrospective propensity-matched study compared colorectal surgery patients with wounds left open with a cohort of patients with primary skin closure. SETTINGS: The American College of Surgeons National Quality Improvement Program Participant Use file for 2014 was queried. PATIENTS: A total of 50,212 patients who underwent elective or emergent colectomy, proctectomy, and stoma creation were included. MAIN OUTCOME MEASURES: Rates of postoperative infections and discharge to medical facilities were measured. RESULTS: Surgical wounds were left open in 2.9% of colorectal cases (n = 1466). Patients with skin left open were broadly higher risk, as evidenced by a significantly higher median estimated probability of 30-day mortality (3.40% vs 0.45%; p < 0.0001). After propensity matching (n = 1382 per group), there were no significant differences between baseline characteristics. Within the matched cohort, there were no differences in the rates of 30-day mortality, deep or organ space infection, or sepsis (all p > 0.05). Resource use was higher for patients with incisions left open, including longer length of stay (11 vs 10 d; p = 0.006) and higher rates of discharge to a facility (34% vs 27%; p < 0.001). LIMITATIONS: This study was limited by its retrospective design and a large data set with a bias toward academic institutions. CONCLUSIONS: In a well-matched colorectal cohort, secondary or delayed wound closure eliminates superficial surgical infections, but there was no decrease in deep or organ space infections. In addition, attention should be given to the possibility for increased resource use associated with open surgical incisions. See Video Abstract at http://links.lww.com/DCR/A560.

Decreased portal vein velocity is predictive of the development of portal vein thrombosis: A matched case-control study.

BACKGROUND & AIMS: Portal vein thrombosis (PVT) in cirrhosis may lead to hepatic decompensation and increased mortality. We aimed to investigate if decreased portal vein (PV) velocity is associated with future PVT. METHODS: Data on adult patients with cirrhosis and PVT between January 1, 2005 and July 30, 2015 were obtained. Cases with PVT were matched by age, gender and Model for End-stage Liver Disease (MELD) score to corresponding controls without PVT. Cox proportional hazards models, receiver operator curves and Kaplan Meier curves were constructed. RESULTS: One hundred subjects (50 matched pairs) with mean age 53.8±13.1 y and MELD score 14.9±5.5 were included in our analysis. Sixty-four percent were male and 76% were Child-Turcotte-Pugh Class A or B. Baseline characteristics (prior to development of PVT) were similar, except for baseline PV velocity (16.9 cm/s, 95% CI 13.9-20.0 PVT vs 25.0, 95% CI 21.8-28.8 no PVT, P<.001). 30 PVT subjects had PV velocity <15 cm/s compared to five without PVT (P<.001). On adjusted multivariable analysis, PV velocity was the strongest independent risk factor predicting PVT development (HR 0.86, 95% CI 0.80-0.93). The predictive value for PVT development was greatest for flow <15 cm/s (c-statistic 0.77). PV velocity <15 cm/s had a highly significant association with future PVT (HR 6.00, 95% CI 2.20-16.40, P=<.001). CONCLUSIONS: Decreased PV velocity is associated with increased risk of future PVT. Patients with cirrhosis and decreased PV velocity are a high-risk subgroup that warrants further investigation with prospective study.

Wound Concerns and Healthcare Consumption of Resources after Colorectal Surgery: An Opportunity for Innovation?

BACKGROUND: Significant portions of patients undergoing colorectal surgical procedures have minor incision disturbances, yet very few meet definitions for surgical site infection (SSI). We sought to investigate the natural history of incision disturbances with a focus on the patient experience and resource utilization. We hypothesize that patients who have an incision disturbance consume frequent healthcare resources in the post-operative period despite the fact that most never receive a diagnosis of SSI. METHODS: A 24-month prospective observational study was undertaken at an academic institution. Patients undergoing elective colorectal operation by two board-certified colorectal surgeons were followed prospectively for 90 days. Incisions were photographed serially and clinically characterized beginning as early as post-operative day two and at follow-up visits. The primary outcome was patient concern for an incision disturbance. Three surgeons reviewed clinical data and photographs to determine the presence of an incisional surgical infection, and diagnosis required agreement from two of three surgeons. RESULTS: There were 171 patients included; 31 (15%) sought evaluation from a healthcare provider for concerns related to their incision including 46 telephone calls, six emergency department visits, seven primary care visits, 10 home health and 40 surgical clinic visits. Incision erythema and drainage were the most common sources of patient concern. Mean body mass index was higher in patients with concern for incision disturbances (34 vs. 28 kg/m2, p < 0.0001). Ultimately, 8% (14/171) received a diagnosis of SSI by study criteria while only 2% (4/171) were captured as having an SSI by the institutional National Surgical Quality Improvement Program database (p < 0.0001). CONCLUSIONS: Patients undergoing colorectal surgical procedures commonly are concerned with post-operative incision disturbance, yet few are associated with a diagnosis of SSI, and in-person evaluation yields frequent utilization of healthcare resources. This presents an opportunity for secure electronic communication with the surgical team and the patient to potentially reduce consumption of healthcare resources.

Treatment of stage I non-small cell lung cancer: What's trending?

OBJECTIVES: Stage I non-small cell lung cancer traditionally is treated with lobectomy. Sublobar resection and stereotactic body radiation therapy provide alternative treatments for higher-risk groups. The purpose of this study was to determine the national treatment trends for stage I lung cancer. METHODS: The National Cancer Database was queried for patients with clinical stage I non-small cell lung cancer between 1998 and 2012. Patients were compared across treatment groups, and trends in treatment and disease were evaluated over the 15-year time period. RESULTS: The National Cancer Database contained 369,931 patients with clinical stage I non-small cell lung cancer. After removing patients who received chemotherapy as a first course of treatment and patients with pathologic stage IV, 357,490 patients were analyzed. The first recorded cases of stereotactic body radiation therapy are in 2003 and rapidly increased to 6.6% (2063) of all patients treated in 2012. The number of diagnoses of stage I non-small cell lung cancer steadily increased over the 15-year period, whereas the rate of lobectomy decreased from 55% in 1998 to 50% in 2012 (P < .001). Most of the decrease in lobectomy can be explained by the increase in the rate of sublobar resection from 12% to 17% (P < .001). The percentage of untreated patients remained stable at approximately 7% (P = .283). CONCLUSIONS: Although the number of stage I non-small cell lung cancer cases continues to increase, lobectomy rates are decreasing while sublobar resection and stereotactic body radiation therapy rates are increasing. Although the increasing popularity of alternative therapies to lobectomy for treatment of stage I non-small cell lung cancer should allow more patients to undergo treatment, we did not observe this trend in the data.

Aggressive Antimicrobial Initiation for Suspected Intensive Care Unit-Acquired Infection Is Associated with Decreased Long-Term Survival after Critical Illness.

BACKGROUND: The long-term significance of early and prolonged antibiotic use in critically ill patients is yet to be described. Several studies suggest that antimicrobial exposure may have as yet unrecognized long-term effects on clinically meaningful outcomes. Our group previously conducted a quasi-experimental, before and after observational cohort study of hemodynamically stable surgical patients suspected of having an intensive care unit-acquired infection. This study demonstrated that aggressive initiation of antimicrobial therapy was associated with increased 30-day deaths. In a follow-up survival analysis, we hypothesized that aggressive antimicrobial treatment would not be a significant predictor of long-term death. METHODS: Survival data for the 201 patients included in the initial study were obtained from our clinical data repository. Univariable analysis, Kaplan-Meier, and Cox proportional hazards models were used. Survival was evaluated at one and four years. Age, gender, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and co-morbidities were chosen a priori for potential inclusion in the model. Variables that met the model assumptions after testing were included in the final model. RESULTS: Follow-up data were available for 190 patients (95 in each group) representing 94.5% of the initial cohort. Twenty-four (25.3%) patients in the aggressive group had initial APACHE II scores of less than 15 compared with 13 (13.7%) patients in the conservative group (p = 0.04). There was a trend toward higher deaths in the aggressive group at four years (41.1% vs. 30.5%; p = 0.13). Kaplan-Meier analysis demonstrated a difference in survival at one year but not at four years. The Cox proportional hazards model showed a higher long-term death for patients in the aggressive antimicrobial group at both one and four years (hazard rate: 2.26 and 1.70, respectively). CONCLUSION: Aggressive initiation of antimicrobial therapy is independently associated with decreased long-term survival after critical illness. While further work is needed to confirm these findings, waiting for evidence of infection before initiation of antibiotic agents may be beneficial.

Reducing Readmissions While Shortening Length of Stay: The Positive Impact of an Enhanced Recovery Protocol in Colorectal Surgery.

BACKGROUND: Hospital readmission rates are an increasingly important quality metric since enactment of the 2012 Hospital Readmissions Reduction Program. The proliferation of enhanced recovery protocols and earlier discharge raises concerns for increased readmission rates. OBJECTIVE: We evaluated the effect of enhanced recovery on readmissions and identified risk factors for readmission. DESIGN: This study involved implementation of a multidisciplinary enhanced recovery protocol. SETTINGS: It was conducted at a large academic medical center PATIENTS:: All patients undergoing elective colorectal surgery between 2011 and 2015 at our center were included. MAIN OUTCOME MEASURES: This cohort study compared patients before and after enhanced recovery initiation, looking at 30-day readmission as the primary outcome. A multivariable logistic regression model identified predictors of 30-day readmission. Kaplan-Meier analysis identified differences in time to readmission. RESULTS: A total of 707 patients underwent colorectal procedures between 2011 and 2015, including 383 patients before enhanced recovery protocol was implemented and 324 patients after enhanced protocol was implemented. Length of stay decreased from a median 5 days to a median 4 days before and after enhanced recovery implementation (p < 0.0001). Thirty-day readmission decreased from 19% (72/383) in the pre-enhanced recovery pathway to 12% (38/324) in the enhanced recovery pathway (p = 0.009). Twenty-one percent (21/99) of patients who underwent ileostomy were readmitted before enhanced recovery implementation compared with 19% (18/93) of patients who underwent ileostomy after enhanced recovery implementation (p = 0.16). Multivariable logistic regression identified ileostomy as increasing the risk of readmission (p = 0.04), whereas enhanced recovery protocol decreased the risk of readmission (p = 0.006). LIMITATIONS: The study is limited because it was conducted at a single institution and used a before-and-after study design. CONCLUSIONS: These data suggest that use of a standardized enhanced recovery protocol significantly reduces length of stay and readmission rates in an elective colorectal surgery population. However, the presence of an ileostomy maintains a high association with readmission, serving as a significant burden to patients and providers alike. Ongoing efforts are needed to further improve the management of patients undergoing ileostomy in the outpatient setting after discharge to prevent readmissions.

Relationship of a Second Professional Degree to Research Productivity of General Surgery Residents.

OBJECTIVE: Many general surgery residents interrupt clinical training for research pursuits or advanced degrees during dedicated research time (DRT). We hypothesize that time required to obtain a second degree during DRT decreases resident publication productivity. DESIGN, SETTING, AND PARTICIPANTS: All consecutive categorical general surgery residents at the University of Virginia in Charlottesville, VA, graduating in 2007 to 2016 were evaluated. PubMed queries identified journal publications for residents during and after DRT, limited to 1 year postgraduation. DRT varied between 1 and 3 years and was standardized by dividing publication number by DRT plus remaining clinical years and 1 postgraduation year. Median publications were compared between residents by receipt of a second degree. RESULTS: Thirty-six residents were eligible for analysis. Of these, 8 obtained a Master's in Clinical Research, 3 received Master of Public Health, and 1 completed a Doctorate of Philosophy. Publications ranged from 2 to 76 for degree residents and 1 to 36 for nondegree residents. For the 12 degree residents, median publication number per year was 3.8 (interquartile range: 2.3, 5.2) compared to 2.6 (interquartile range: 1.6, 3.5) in residents not pursuing a postdoctoral degree (p = 0.04). There was no significant difference in median number of first and second author publications by degree status. CONCLUSION: More publications per year were seen among residents earning a second degree, with a statistically significant difference between residents obtaining postdoctoral degrees during DRT compared with their counterparts. Our study demonstrates that residents pursuing a second degree are not hindered in their publication productivity despite the time investment required by the degree program. Additional research is needed to determine whether formal research training through a second degree corresponds to sustained scholarly productivity beyond residency.

Enhanced Recovery Implementation in Major Gynecologic Surgeries: Effect of Care Standardization.

OBJECTIVE: To examine implementing an enhanced recovery after surgery (ERAS) protocol for women undergoing major gynecologic surgery at an academic institution and compare surgical outcomes before and after implementation. METHODS: Two ERAS protocols were developed: a full pathway using regional anesthesia for open procedures and a light pathway without regional anesthesia for vaginal and minimally invasive procedures. Enhanced recovery after surgery pathways included extensive preoperative counseling, carbohydrate loading and oral fluids before surgery, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, and immediate postoperative feeding and ambulation. A before-and-after study design was used to compare clinical outcomes, costs, and patient satisfaction. Complications and risk-adjusted length of stay were drawn from the American College of Surgeons' National Surgical Quality Improvement Program database. RESULTS: On the ERAS full protocol, 136 patients were compared with 211 historical controls and the median length of stay was reduced (2.0 compared with 3.0 days; P=.007) despite an increase in National Surgical Quality Improvement Program-predicted length of stay (2.5 compared with 2.0 days; P=.009). Reductions were seen in median intraoperative morphine equivalents (0.3 compared with 12.7 mg; P<.001), intraoperative (285 compared with 1,250 mL; P<.001) and total intravenous fluids (-917.5 compared with 1,410 mL; P<.001), immediate postoperative pain scores (3.7 compared with 5.0; P<.001), and total complications (21.3% compared with 40.2%; P=.004). On the ERAS light protocol, 249 patients were compared with 324 historical controls and demonstrated decreased intraoperative and postoperative morphine equivalents (0.0 compared with 13.0 mg; P<.001 and 15.0 compared with 23.6 mg; P<.001) and decreased intraoperative and overall net intravenous fluids (P<.001). Patient satisfaction scores showed a marked and significant improvement on focus questions regarding pain control, nurses keeping patients informed, and staff teamwork; 30-day total hospital costs were significantly decreased in both ERAS groups. CONCLUSION: Implementation of ERAS protocols in gynecologic surgery was associated with a substantial decrease in intravenous fluids and morphine administration coupled with reduction in length of stay for open procedures combined with improved patient satisfaction and decreased hospital costs.

Hepatocyte growth factor, hepatocyte growth factor activator and arginine in a rat fulminant colitis model.

INTRODUCTION: Dextran sodium sulfate (DSS) is commonly used to induce a murine fulminant colitis model. Hepatocyte growth factor (HGF) has been shown to decrease the symptoms of inflammatory bowel disease (IBD) but the effect of its activator, HGFA, is not well characterized. Arginine reduces effects of oxidative stress but its effect on IBD is not well known. The primary aim is to determine whether HGF and HGFA, or arginine will decrease IBD symptoms such as pain and diarrhea in a DSS-induced fulminant colitis murine model. METHODS: A severe colitis was induced in young, male Fischer 344 rats with 4% (w/v) DSS oral solution for seven days; rats were sacrificed on day 10. Rats were divided into five groups of 8 animals: control, HGF (700 mcg/kg/dose), HGF and HGFA (10 mcg/dose), HGF and arginine, and high dose HGF (2800 mcg/kg/dose). Main clinical outcomes were pain, diarrhea and weight loss. Blinded pathologists scored the terminal ileum and distal colon. RESULTS: DSS reliably induced severe active colitis in 90% of animals (n = 36/40). There were no differences in injury scores between control and treatment animals. HGF led to 1.38 fewer days in pain (p = 0.036), while arginine led to 1.88 fewer days of diarrhea (P = 0.017) compared to controls. 88% of HGFA-treated rats started regaining weight (P < 0.001). DISCUSSION/CONCLUSION: Although treatment was unable to reverse fulminant disease, HGF and arginine were associated with decreased days of pain and diarrhea. These clinical interventions may reduce associated symptoms for severe IBD patients, even when urgent surgical intervention remains the only viable option.

Operative Start Time Does Not Affect Post-Operative Infection Risk.

BACKGROUND: Surgical care is delivered 24 h a day at most institutions. Alarmingly, some authors have found that certain operative start times are associated with greater morbidity and mortality rates. This effect has been noted in both the public and private sector. Although some of these differences may be related to process, they may also be caused by the human circadian rhythm and corresponding changes in host defenses. We hypothesized that the time of day of an operation would impact the frequency of certain post-operative outcomes significantly. METHODS: Cases at a single tertiary-care center reported to the American College of Surgeons National Surgical Quality Improvement Program over a 10-year period were identified. Operative start times were divided into six-hour blocks, with 6 am to noon serving as the reference. Standard univariable techniques were applied. Multivariable logistic regression with mixed effects modeling then was used to determine the relation between operative start times and infectious outcomes, controlling for surgeon clustering. Statistical significance was set at p < 0.01. RESULTS: A total of 21,985 cases were identified, of which 2,764 (12.6%) were emergency procedures. Overall, 9.7% (n = 2,142) of patients experienced some post-operative infectious complication. Seventy percent of these infections (n = 1,506) were surgical site infections. On univariable analysis considering all cases, nighttime and evening operations had higher rates of post-operative infections than those in performed during the day (9.1% from 6 am to noon; 9.7% from noon to 6 pm; 14.8% from 6 pm to midnight; and 14.4% from midnight to 6 am; p < 0.001). On multivariable analysis, operative start time was not associated with the risk of post-operative infection, even when emergency cases were considered independently. CONCLUSION: Our data suggest that operative start times have no correlation with post-operative infectious complications. Further work is required to identify the source of the time-dependent outcome variability observed in previous studies.

Obesity Is Not Associated with Antimicrobial Treatment Failure for Intra-Abdominal Infection.

BACKGROUND: Obesity and commonly associated comorbidities are known risk factors for the development of infections. However, the intensity and duration of antimicrobial treatment are rarely conditioned on body mass index (BMI). In particular, the influence of obesity on failure of antimicrobial treatment for intra-abdominal infection (IAI) remains unknown. We hypothesized that obesity is associated with recurrent infectious complications in patients treated for IAI. METHODS: Five hundred eighteen patients randomized to treatment in the Surgical Infection Society Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial were evaluated. Patients were stratified by obese (BMI ≥30) versus non-obese (BMI≥30) status. Descriptive comparisons were performed using Chi-square test, Fisher exact test, or Wilcoxon rank-sum tests as appropriate. Multivariable logistic regression using a priori selected variables was performed to assess the independent association between obesity and treatment failure in patients with IAI. RESULTS: Overall, 198 (38.3%) of patients were obese (BMI ≥30) versus 319 (61.7%) who were non-obese. Mean antibiotic d and total hospital d were similar between both groups. Unadjusted outcomes of surgical site infection (9.1% vs. 6.9%, p = 0.36), recurrent intra-abdominal infection (16.2% vs. 13.8, p = 0.46), death (1.0% vs. 0.9%, p = 1.0), and a composite of all complications (25.3% vs. 19.8%, p = 0.14) were also similar between both groups. After controlling for appropriate demographics, comorbidities, severity of illness, treatment group, and duration of antimicrobial therapy, obesity was not independently associated with treatment failure (c-statistic: 0.64). CONCLUSIONS: Obesity is not associated with antimicrobial treatment failure among patients with IAI. These results suggest that obesity may not independently influence the need for longer duration of antimicrobial therapy in treatment of IAI versus non-obese patients.

Top Guns: The "Maverick" and "Goose" of Empiric Therapy.

BACKGROUND: Vancomycin and piperacillin-tazobactam are commonly used first guns in the empiric management of critically ill patients. Current studies suggest an increased prevalence of acute kidney injury with concomitant use, however, these studies are few and limited by small sample size. The purpose of this study was to compare the prevalence of nephrotoxicity after treatment with vancomycin alone and concomitant vancomycin and piperacillin-tazobactam treatment at our institution. HYPOTHESIS: Concomitant vancomycin and piperacillin-tazobactam-treated patients will experience greater prevalence of nephrotoxicity compared with vancomycin-only treated patients. METHODS: This was a retrospective cohort of patients treated with vancomycin for gram-positive or mixed infections in our facility from 2005 to 2009 who were not receiving hemodialysis at the time of admission. Included patients were stratified by treatment with vancomycin, vancomycin/piperacillin-tazobactam, or vancomycin/an alternative gram-negative rod (GNR) antibiotic. p values for categorical variables were computed using χ(2) while continuous variables were computed using Kruskal-Wallis. Variables deemed statistically significant (< 0.05) were included in the multivariable, log-binomial regression model. Relative risk (RR) and 95% confidence intervals (CI), and p values were computed using a generalized estimating equation (GEE) approach with robust standard errors (i.e., Huber White "sandwich variance" estimates) to accommodate a correlated data structure corresponding to multiple episodes of infection per individual. RESULTS: A total of 530 patients with 1,007 episodes of infection, were treated with vancomycin (150 patients/302 episodes of infection), vancomycin/piperacillin-tazobactam (213 patients/372 episodes of infection), or vancomycin/GNR alternative (167 patients/333 episodes of infection). Patient demographics, comorbidities, sites of infection, and organisms of infection were compared among groups. After adjusting for statistically significant variables, neither vancomycin/piperacillin-tazobactam (RR = 1.1, 95% CI = 0.99-1.2; p = 0.073) nor vancomycin/GNR alternative (RR = 1.1, 95% CI = 0.98-1.2; p = 0.097) were found to be associated with an increased risk for nephrotoxicity compared with vancomycin alone. CONCLUSION: A difference in nephrotoxicity was not observed between vancomycin and vancomycin/piperacillin-tazobactam-treated patients at our institution. Concomitant use as empiric therapy is appropriate, although larger sample sizes are needed to analyze closely this relation among at-risk subsets of this population.

Do Polymicrobial Intra-Abdominal Infections Have Worse Outcomes than Monomicrobial Intra-Abdominal Infections?

BACKGROUND: Numerous studies have demonstrated microorganism interaction through signaling molecules, some of which are recognized by other bacterial species. This interspecies synergy can prove detrimental to the human host in polymicrobial infections. We hypothesized that polymicrobial intra-abdominal infections (IAI) have worse outcomes than monomicrobial infections. METHODS: Data from the Study to Optimize Peritoneal Infection Therapy (STOP-IT), a prospective, multicenter, randomized controlled trial, were reviewed for all occurrences of IAI having culture results available. Patients in STOP-IT had been randomized to receive four days of antibiotics vs. antibiotics until two days after clinical symptom resolution. Patients with polymicrobial and monomicrobial infections were compared by univariable analysis using the Wilcoxon rank sum, χ(2), and Fisher exact tests. RESULTS: Culture results were available for 336 of 518 patients (65%). The durations of antibiotic therapy in polymicrobial (n = 225) and monomicrobial IAI (n = 111) were equal (p = 0.78). Univariable analysis demonstrated similar demographics in the two populations. The 37 patients (11%) with inflammatory bowel disease were more likely to have polymicrobial IAI (p = 0.05). Polymicrobial infections were not associated with a higher risk of surgical site infection, recurrent IAI, or death. CONCLUSION: Contrary to our hypothesis, polymicrobial IAI do not have worse outcomes than monomicrobial infections. These results suggest polymicrobial IAI can be treated the same as monomicrobial IAI.

Portal vein thrombosis, mortality and hepatic decompensation in patients with cirrhosis: A meta-analysis.

AIM: To determine the clinical impact of portal vein thrombosis in terms of both mortality and hepatic decompensations (variceal hemorrhage, ascites, portosystemic encephalopathy) in adult patients with cirrhosis. METHODS: We identified original articles reported through February 2015 in MEDLINE, Scopus, Science Citation Index, AMED, the Cochrane Library, and relevant examples available in the grey literature. Two independent reviewers screened all citations for inclusion criteria and extracted summary data. Random effects odds ratios were calculated to obtain aggregate estimates of effect size across included studies, with 95%CI. RESULTS: A total of 226 citations were identified and reviewed, and 3 studies with 2436 participants were included in the meta-analysis of summary effect. Patients with portal vein thrombosis had an increased risk of mortality (OR = 1.62, 95%CI: 1.11-2.36, P = 0.01). Portal vein thrombosis was associated with an increased risk of ascites (OR = 2.52, 95%CI: 1.63-3.89, P < 0.001). There was insufficient data available to determine the pooled effect on other markers of decompensation including gastroesophageal variceal bleeding or hepatic encephalopathy. CONCLUSION: Portal vein thrombosis appears to increase mortality and ascites, however, the relatively small number of included studies limits more generalizable conclusions. More trials with a direct comparison group are needed.

Vancomycin-Associated Nephrotoxicity: The Obesity Factor.

BACKGROUND: Current recommendations suggest that vancomycin dosing utilize actual rather than ideal body weight in obese patients. Thus, obese patients may be at greater risk for nephrotoxicity. The purpose of this study was to compare the incidence of nephrotoxicity in vancomycin-treated obese and lean patients at our institution, where unadjusted, actual body weight-based dosing (capped at 2 g per dose twice daily) is used. We expected obese patients to experience a greater incidence of nephrotoxicity than lean patients. METHODS: This study examined a retrospective cohort of patients treated with vancomycin for gram-positive or mixed infections in our facility from 2005-2009 who were not receiving hemodialysis at the time of admission. Patients were stratified by body mass index (BMI; obese ≥30 kg/m(2) vs. lean <30 kg/m(2)). Relative risk (RR), 95% confidence intervals (CIs), and p values were computed using a generalized estimating equation to accommodate a correlated data structure corresponding to multiple episodes of infection per individual. Multivariable analysis was performed. RESULTS: A total of 530 patients (207 obese; 323 lean) with 1,007 episodes of infection were treated with vancomycin. Patient demographics, co-morbidities, sites of infection, and infecting organisms were similar in the two groups. Female gender (p=0.042), diabetes mellitus (DM) (p=0.018), and hypertension (HTN) (p=0.0009) were more often associated with obesity, whereas allografts (p=0.022) and peripheral vascular disease (p=0.036) were more often present in lean patients. The Acute Physiology and Chronic Health Evaluation II score >21 was the only variable associated with nephrotoxicity (p=0.039). After adjusting for statistically significant variables, obesity was found not to be associated with a greater risk of nephrotoxicity (RR=0.98; 95% CI=0.93-1.04; p=0.59). CONCLUSION: No difference in nephrotoxicity was observed between lean and obese patients treated with vancomycin at our institution.

Advances in Intra-abdominal Sepsis: What Is New?

We have reviewed the literature regarding recent advances in the management of intra-abdominal sepsis, with a focus on antimicrobial agents, duration of therapy, and source control. Several important developments in these areas are discussed in this review. The introduction of a new antimicrobial agent-ceftolozane/tazobactam-marks the first novel agent for treating intra-abdominal infections in a number of years, and its indications for use and supporting evidence are reviewed here. In addition, we discuss recent evidence that clarifies the importance of early source control for intra-abdominal infection and new data that suggests that an abbreviated course of antimicrobial therapy for intra-abdominal infection is equally effective as prolonged therapy.

Rate of lower-extremity ultrasonography in trauma patients is associated with rate of deep venous thrombosis but not pulmonary embolism.

BACKGROUND: Disparate lower-extremity ultrasonography (LUS) screening practices among trauma institutions reflecta lack of consensus regarding screening indications and whether screening improves outcomes. We hypothesized that LUS screening for deep-vein thrombosis (DVT) is not associated with a reduced incidence of pulmonary embolism (PE). METHODS: The 2012 ACS National Trauma Data Bank Research Data Set was queried to identify 442,108 patients treated at institutions reporting at least one LUS and at least one DVT. Institutions performing LUS on more than 2% of admitted patients were designated high-screening facilities and remaining institutions were designated low-screening facilities. Patient characteristics and risk factors were used to develop a logistic regression model to assess the independent associations between LUS and DVT and between LUS and PE. RESULTS: Overall, DVT and PE were reported in 0.94% and 0.37% of the study population, respectively. DVT and PE were reported more commonly in designated high-screening than low-screening facilities (DVT: 1.12% vs 0.72%, P < .0001; PE: 0.40% vs 0.33%, P = .0004). Multivariable logistic regression demonstrated that LUS was associated independently with DVT (odds ratio 1.43, confidence interval 1.34-1.53) but not PE (odds ratio 1.01, confidence interval 0.92-1.12) (c-statistic 0.86 and 0.85, respectively). Sensitivity analyses performed at various rates for designating HS facilities did not alter the significance of these relationships. CONCLUSION: LUS in trauma patients is not associated with a change in the incidence of PE. Aggressive LUS DVT screening protocols appear to detect many clinically insignificant DVTs for which subsequent therapeutic intervention may be unnecessary, and the use of these protocols should be questioned.