Duration of antimicrobial treatment for complicated intra-abdominal infections after definitive source control: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma

Recent studies have evaluated outcomes associated with duration of antimicrobial treatment for complicated intra-abdominal infections (cIAI). The goal of this guideline was to help clinicians better define appropriate antimicrobial duration in patients who have undergone definitive source control for cIAI. A working group of Eastern Association for the Surgery of Trauma (EAST) performed a systematic review and meta-analyses of the available data pertaining to the duration of antibiotics after definitive source control of cIAI in adult patients. Only studies that compared patients treated with short vs. long duration antibiotic regimens were included. The critical outcomes of interest were selected by the group. Noninferiority of short compared with long duration of antimicrobial treatment was defined as an indicator for a potential recommendation in favor of shorter antibiotics course. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of the evidence and to formulate recommendations. Sixteen studies were included. The short duration ranged from 1 dose to ≤10 days, with an average of 4 days, and the long duration ranged >1 day to 28 days, with an average of 8 days. There were no differences between short and long duration of antibiotics in terms of mortality (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.56-1.44), rate of surgical site infection (OR, 0.88; 95% CI, 0.56-1.38); persistent/recurrent abscess (OR, 0.76; 95% CI, 0.45-1.29); unplanned interventions (OR, 0.53; 95% CI, 0.12-2.26); hospital length of stay (mean difference, -2.62 days; CI, -7.08 to 1.83 days); or readmissions (OR, 0.92; 95% CI, 0.50-1.69). The level of evidence was assessed as very low. The group made a recommendation for shorter (four or less days) versus longer duration (eight or more days) of antimicrobial treatment in adult patients with cIAIs who had definitive source control.

Duration of antimicrobial treatment for complicated intra-abdominal infections after definitive source control: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Recent studies have evaluated outcomes associated with duration of antimicrobial treatment for complicated intra-abdominal infections (cIAI). The goal of this guideline was to help clinicians better define appropriate antimicrobial duration in patients who have undergone definitive source control for cIAI. METHODS: A working group of Eastern Association for the Surgery of Trauma (EAST) performed a systematic review and meta-analyses of the available data pertaining to the duration of antibiotics after definitive source control of cIAI in adult patients. Only studies that compared patients treated with short vs. long duration antibiotic regimens were included. The critical outcomes of interest were selected by the group. Noninferiority of short compared with long duration of antimicrobial treatment was defined as an indicator for a potential recommendation in favor of shorter antibiotics course. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of the evidence and to formulate recommendations. RESULTS: Sixteen studies were included. The short duration ranged from 1 dose to ≤10 days, with an average of 4 days, and the long duration ranged >1 day to 28 days, with an average of 8 days. There were no differences between short and long duration of antibiotics in terms of mortality (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.56-1.44), rate of surgical site infection (OR, 0.88; 95% CI, 0.56-1.38); persistent/recurrent abscess (OR, 0.76; 95% CI, 0.45-1.29); unplanned interventions (OR, 0.53; 95% CI, 0.12-2.26); hospital length of stay (mean difference, -2.62 days; CI, -7.08 to 1.83 days); or readmissions (OR, 0.92; 95% CI, 0.50-1.69). The level of evidence was assessed as very low. CONCLUSION: The group made a recommendation for shorter (four or less days) versus longer duration (eight or more days) of antimicrobial treatment in adult patients with cIAIs who had definitive source control. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level III.

Re-Admission in Patients with Necrotizing Soft Tissue Infections: Continuity of Care Matters.

Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressive infections with high mortality and complication rates. The incidence of NSTIs has been increasing steadily whereas mortality has decreased; survivors have a high risk of re-hospitalization. We hypothesized that re-admission to the index hospital where the first admission occurred would be associated with better clinical outcomes compared with re-admission to a non-index hospital. Patients and Methods: We identified patients from the 2017 Nationwide Readmissions Database with an index admission for NSTIs and examined all-cause re-admissions within 90 days of discharge. We noted whether re-admission occurred at the index or a non-index hospital. Survey-weighted logistic regression identified factors associated with death at the first re-admission and re-admission to index hospital. We also compared patient outcomes between patients admitted to index versus non-index hospitals. Results: We identified 27,051 NSTI survivors, of whom 6,954 (25.7%) had an unplanned re-admission within 90 days. A large proportion of re-admission occurred at non-index hospitals (28.3%; n = 1,966). Factors associated with non-index re-admission included prolonged index length of stay, discharge to short-term hospital, and leaving against medical advice. Patients re-admitted to index hospitals had a lower mortality rate (4.7% vs. 6.7%; p = 0.003), lower admission costs (in $1000; 45 [23-88] vs. 50 [24-104]; p = 0.004) and higher discharge rate to home (55.7% vs. 48.6%; p < 0.001). Conclusions: More than one-quarter of re-admissions among NSTI survivors were to non-index hospitals. Continuity of care is important because re-admission to the index hospital was associated with better patient outcomes.

Management of simple and retained hemothorax: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Traumatic hemothorax poses diagnostic and therapeutic challenges both acutely and chronically. A working group of the Eastern Association for the Surgery of Trauma convened to formulate a practice management guideline for traumatic hemothorax. METHODS: We formulated four questions: whether tube thoracostomy vs observation be performed, should pigtail catheter versus thoracostomy tube be placed to drain hemothorax, should thrombolytic therapy be attempted versus immediate thoracoscopic assisted drainage (VATS) in retained hemothorax (rHTX), and should early VATS (≤4 days) versus late VATS (>4 days) be performed? A systematic review was undertaken from articles identified in multiple databases. RESULTS: A total of 6391 articles were identified, 14 were selected for guideline construction. Most articles were retrospective with very low-quality evidence. We performed meta-analysis for some of the outcomes for three of the questions. CONCLUSIONS: For traumatic hemothorax we conditionally recommend pigtail catheters, in hemodynamically stable patients. In patients with rHTX, we conditionally recommend VATS rather than attempting thrombolytic therapy and recommend that it should be performed early (≤4 days).

Grade of injury, not initial management, is associated with unplanned interventions in liver injury.

INTRODUCTION: Risk factors for complications after liver injury do not distinguish between patients undergoing selective non-operative management (sNOM) vs operative management (OM) as the initial treatment strategy. Our objective was to identify risk factors for complications requiring an unplanned intervention following sNOM or OM. We hypothesized that patient undergoing sNOM will have fewer unplanned interventions. METHODS: Adults presenting to a level I trauma center with grade III or higher liver injury over a period of 6 years were reviewed. Patient and injury factors, initial management strategy, subsequent complications and interventions were obtained. Bivariate analysis was performed between patients undergoing sNOM vs OM to determine factors associated with unplanned interventions, defined as intervention >48 h after injury. Logistic regression was performed to identify independent risk factors for unplanned interventions. RESULTS: 191 patients were identified: 105 (55%) grade III, 64 (34%) grade IV, and 22 (12%) grade V injury; 136 (71%) underwent sNOM and 55 (29%) underwent OM. 21 (15%) patients required an unplanned intervention: 26 percutaneous drainage, 10 ERCP, and 3 angiography; 12 had multiple procedures. Male gender, younger age, higher ISS, higher grade of injury, firearm mechanism, and initial OM (all p < 0.05) were associated with unplanned interventions. Firearm mechanism and injury grade IV and V, but not initial OM, were independent risk factors for an unplanned intervention. CONCLUSIONS: Grade of liver injury, not the initial mode of treatment, was significantly associated with requiring an unplanned intervention for liver-related complications. Surveillance at 7-10 days, or prior to discharge, in the high-risk group may be able to capture those requiring unplanned intervention and readmission.

Beta-blockers and Traumatic Brain Injury: A Systematic Review, Meta-analysis, and Eastern Association for the Surgery of Trauma Guideline.

OBJECTIVE: To determine if beta-(ß)-blockers improve outcomes after acute traumatic brain injury (TBI). BACKGROUND: There have been no new inpatient pharmacologic therapies to improve TBI outcomes in a half-century. Treatment of TBI patients with ß-blockers offers a potentially beneficial approach. METHODS: Using MEDLINE, EMBASE, and CENTRAL databases, eligible articles for our systematic review and meta-analysis (PROSPERO CRD42016048547) included adult (age ≥ 16 years) blunt trauma patients admitted with TBI. The exposure of interest was ß-blocker administration initiated during the hospitalization. Outcomes were mortality, functional measures, quality of life, cardiopulmonary morbidity (e.g., hypotension, bradycardia, bronchospasm, and/or congestive heart failure). Data were analyzed using a random-effects model, and represented by pooled odds ratio (OR) with 95% confidence intervals (CI) and statistical heterogeneity (I). RESULTS: Data were extracted from 9 included studies encompassing 2005 unique TBI patients with ß-blocker treatment and 6240 unique controls. Exposure to ß-blockers after TBI was associated with a reduction of in-hospital mortality (pooled OR 0.39, 95% CI: 0.27-0.56; I = 65%, P < 0.00001). None of the included studies examined functional outcome or quality of life measures, and cardiopulmonary adverse events were rarely reported. No clear evidence of reporting bias was identified. CONCLUSIONS: In adults with acute TBI, observational studies reveal a significant mortality advantage with ß-blockers; however, quality of evidence is very low. We conditionally recommend the use of in-hospital ß-blockers. However, we recommend further high-quality trials to answer questions about the mechanisms of action, effectiveness on subgroups, dose-response, length of therapy, functional outcome, and quality of life after ß-blocker use for TBI.

Selective nonoperative management of abdominal gunshot wounds with isolated solid organ injury.

OBJECTIVE: To review selective nonoperative management (SNOM) of gunshot wound (GSW) patients with isolated abdominal solid organ injury. METHODS: Patients who sustained isolated solid organ injury secondary to GSW from 2003 to 2014 were studied. The use of SNOM over time was analyzed, and comparisons of initial SNOM and operative management (OM) groups were performed. RESULTS: Of 127 patients, 63 (50%) underwent SNOM. There were no significant differences between the early/late or SNOM/OM groups in demographics, physiologic presentation, or Injury Severity Score. SNOM increased from the early to late cohorts (31%-67%, p < 0.001), without any change in outcomes. SNOM patients had shorter hospital stays (5.8 vs. 10.0 days, p < 0.001), received fewer PRBCs (0.8 vs. 4 units, p < 0.001), and suffered fewer complications (13% vs. 28%, p < 0.05) than the OM group. CONCLUSION: An increase in SNOM vs. OM was associated with equivalent outcomes. Patients undergoing SNOM received fewer PRBCs and had shorter LOS.

Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Traumatic injury to the pancreas is rare but is associated with significant morbidity and mortality, including fistula, sepsis, and death. There are currently no practice management guidelines for the medical and surgical management of traumatic pancreatic injuries. The overall objective of this article is to provide evidence-based recommendations for the physician who is presented with traumatic injury to the pancreas. METHODS: The MEDLINE database using PubMed was searched to identify English language articles published from January 1965 to December 2014 regarding adult patients with pancreatic injuries. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to formulate evidence-based recommendations. RESULTS: Three hundred nineteen articles were identified. Of these, 52 articles underwent full text review, and 37 were selected for guideline construction. CONCLUSION: Patients with grade I/II injuries tend to have fewer complications; for these, we conditionally recommend nonoperative or nonresectional management. For grade III/IV injuries identified on computed tomography or at operation, we conditionally recommend pancreatic resection. We conditionally recommend against the routine use of octreotide for postoperative pancreatic fistula prophylaxis. No recommendations could be made regarding the following two topics: optimal surgical management of grade V injuries, and the need for routine splenectomy with distal pancreatectomy. LEVEL OF EVIDENCE: Systematic review, level III.

Management of penetrating extraperitoneal rectal injuries: An Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: The management of penetrating rectal trauma invokes a complex decision tree that advocates the principles of proximal diversion (diversion) of the fecal stream, irrigation of stool from the distal rectum, and presacral drainage based on data from World War II and the Vietnam War. This guideline seeks to define the initial operative management principles for nondestructive extraperitoneal rectal injuries. METHODS: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding penetrating rectal trauma from January 1900 to July 2014. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included the management principles of diversion, irrigation of stool from the distal rectum, and presacral drainage using the GRADE methodology. RESULTS: A total of 306 articles were screened leading to a full-text review of 56 articles. Eighteen articles were used to formulate the recommendations of this guideline. CONCLUSION: This guideline consists of three conditional evidence-based recommendations. First, we conditionally recommend proximal diversion for management of these injuries. Second, we conditionally recommend the avoidance of routine presacral drains and distal rectal washout in the management of these injuries.