Incidence and perioperative risk factors for surgical site infections in neurosurgery: prospective observational study

Background Surgical site infections (SSI) represent a burden on the health care system especially in developing countries with significant morbidity and mortality. In Egypt, especially in our institution, there is no registry for the SSI rate or the contributing factors with no clear guidelines regarding the regimen of perioperative antibiotic prophylaxis. Our study was conducted to assess the local practice and to calculate the rate and risk factors of SSI. Patients and methods A prospective registry was established at the Neurosurgery Department, Demerdash teaching hospital Ain Shams University, Cairo, Egypt. All patients who underwent elective neurosurgical procedures were included in this study. Trauma patients were excluded. Patients were followed-up for incident SSI for 1 month postoperatively. SSIs were identified based on CDC criteria and a standardized data collection form predictor variables including patient characteristics, preoperative, intraoperative, and postoperative factors along with the pattern of antimicrobial prophylaxis. Results The study included 248 patients with 1-month postoperative follow-up. An SSI rate of 19% was recorded being mainly in patients below 10 years of age. Postoperative CSF leak was noticed to be the most significant risk factor of SSI in our study (p value < 0.01). Sixty five percent of culture results showed infection with gram-negative bacilli with the predominance of Acinetobacter. Conclusion Prolonged use of perioperative antibiotics does not seem to have an added benefit in SSI prevention. Tailoring of the used antibiotic regimen is highly recommended according to the latest antimicrobial prophylaxis guidelines and the local culture and sensitivity results.

Changes in the gut bacterial communities in colon cancer surgery patients: an observational study

Background Colon surgery has been shown to modulate the intestinal microbiota. Our objective was to characterize these changes using state-of-the-art next generation sequencing techniques. Methods We performed a single-centre prospective observational cohort study to evaluate the changes in the gut microbiota, i.e., taxon distribution, before and after elective oncologic colon surgery in adult patients with different antimicrobial prophylaxis regimens (standard prophylaxis with cefuroxime/metronidazole versus carbapenems for extended-spectrum beta-lactamase-producing Enterobacterales [ESBL-E] carriers). We obtained rectal samples on the day of surgery, intraoperative luminal samples, and rectal or stoma samples 3 days after surgery. We performed metataxonomic analysis based on sequencing of the bacterial 16S rRNA gene marker. Similarities and differences between bacterial communities were assessed using Bray–Curtis similarity, visualised using principal coordinates analysis and statistically tested by PERMANOVA. Comparison of taxa relative abundance was performed using ANCOM. Results We included 27 patients between March 27, 2019 and September 17, 2019. The median age was 63.6 years (IQR 56.4–76.3) and 44% were females. Most (81%) patients received standard perioperative prophylaxis as they were not ESBL carriers. There was no significant association between ESBL carriage and differences in gut microbiome. We observed large and significant increases in the genus Enterococcus between the preoperative/intraoperative samples and the postoperative sample, mainly driven by Enterococcus faecalis. There were significant differences in the postoperative microbiome between patients who received standard prophylaxis and carbapenems, specifically in the family Erysipelotrichaceae. Conclusion This hypothesis-generating study showed rapid changes in the rectal microbiota following colon cancer surgery.

Cellulitis in patients with chronic lower-limb lymphedema due to HIV-related Kaposi sarcoma

Objective Chronic Lower Limb Lymphedema (CL-LL) secondary to Kaposi sarcoma (KS) has not been recognized as a risk factor for cellulitis. The aim was to describe the clinical spectrum and use of antimicrobial prophylaxis in patients with cellulitis and CL-LL due to KS. Methods HIV patients with KS, CL-LL, and at least one episode of cellulitis seen at the AIDS Cancer Clinic at INCan in Mexico from 2004 to 2019 were included. Demographic and clinical data were obtained from medical records. Results Thirty-nine men all with CL-LL were included. Clinical factors associated with cellulitis were groin and/or lymph-node KS infiltration (69.2%), onychomycosis and/or tinea pedis (44.7%), ulcerated lesions (38.4%), and obesity (2.5%). Eighteen (46.1%) were hospitalized in the first episode and eight (20.5%) in recurrence. Six (25.3%) died, two of toxic shock syndrome (TSS), and one of septic shock. Fourteen (35.8%) had at least one recurrent episode of cellulitis. Twenty-five (64.1%) received prophylaxis. Patients without prophylaxis had significantly more unfavorable outcomes (hospitalization and recurrences) than those with prophylaxis. Conclusions CL-LL due to KS is a risk factor for cellulitis and severe complications in patients with a long life expectancy. Antimicrobial prophylaxis needs to be explored as it could prevent complications.

One day versus three days’ antibiotic prophylaxis in joint arthroplasty. A prospective randomized controlled trial

Objectives: The objectives of the study was to compare the effectiveness of 1 day versus 3 days post-operative antibiotic prophylaxis in decreasing surgical site infection (SSI) rate after arthroplasty surgery. Methods: A prospective, randomized controlled trial was conducted over 1 year, in Cairo University Hospitals. The study included adult patients, who were scheduled for arthroplasty. Sixty patients were divided into two groups, 30 patients in each. The first group of patients received cefazolin for 1 day postoperatively (1-day group) and the other group for 3 days postoperatively (3-days group). Patients were randomized using the sealed opaque envelope method. Results: There were 32 females and 28 males. The mean patient age was 52 years (range 20–85 years). Wound infection developed in four cases (one case from the 1-day group and three cases from the 3-days group). All infections occurred within the early post-operative period, and completely resolved after proper management. Correlating the SSI to the type of surgery, operative time, the associated medical co-morbidities, and the duration of antimicrobial prophylaxis was not statistically significant. Conclusion: This study suggests that there is no significant difference in the prevalence of SSI between 1 day and 3 days of antimicrobial prophylaxis after primary joint arthroplasty within the average post-operative follow-up period of 3 months.

Acanthoamoeba Keratitis Induced by a Therapeutic, Soft Contact Lens: Diagnosis via Gram Staining

Purpose: We report two cases of Acanthamoeba keratitis diagnosed by Gram staining in patients who had recently worn therapeutic, soft contact lenses and had no history of lens use for visual correction.Case summary: The first patient was initially diagnosed with suspected mixed bacterial or fungal keratitis before a final diagnosis of Acanthamoeba keratitis was confirmed by Gram staining of a corneal smear. The second patient was initially diagnosed with a persistent epithelial defect caused by an earlier lid injury inflicted by a metallic foreign body, and then with a suspected mixed infection combined with herpetic uveitis. The patient was finally diagnosed with Acanthamoeba keratitis by Gram staining of a corneal smear. Both cases were treated with polyhexamethylene biguanide and chlorhexidine.Conclusions: Therapeutic, soft contact lenses are used to enhance corneal, epithelial wound healing in conjunction with antimicrobial prophylaxis. However, application of such a lens to a diseased cornea may predispose to the development of microbial keratitis caused by microorganisms resistant to the usual, prophylactic, antimicrobial eye drops. Therapeutic, soft contact lenses are associated with a risk of Acanthamoeba keratitis; early diagnosis is important. Gram staining of a corneal smear is useful in this context. Acanthamoeba is not eradicated by empirical broad-spectrum antimicrobials.

Antimicrobial Prophylaxis and Anticoagulation Therapy in Pediatric ECMO: A Survey Study

OBJECTIVE The purpose was to characterize antimicrobial and anticoagulation therapies used in health systems with children receiving extracorporeal membrane oxygenation (ECMO). METHODS An anonymous electronic survey assessing health system demographics and antimicrobial and anticoagulation therapies during ECMO was distributed to the American College of Clinical Pharmacy Pediatric Practice and Research Network and the Pediatric Pharmacy Association Critical Care Special Interest Group. The primary objective was to identify the number of respondents using antimicrobial prophylaxis for ECMO cannulation and ECMO runs. Secondary objectives included the first- and second-line anticoagulants and anticoagulation laboratory parameters. Additionally, the antimicrobial regimens and the dosing and administration of antithrombin III (AT III) with systemic anticoagulation were collected. Descriptive statistics were employed. RESULTS The questionnaire was completed by 38 respondents from 33 health systems; respondents practiced in the pediatric ICU (n = 20; 52.6%), cardiovascular ICU (n = 14; 36.8%), and neonatal ICU (n = 4; 10.5%). Twenty-eight (73.6%) respondents use antimicrobial prophylaxis during ECMO cannulation or ECMO runs, with most units using cefazolin monotherapy. Thirty-five (92.1%) respondents use heparin as the first-line anticoagulant and used a variety of laboratory tests including anti-factor Xa, activated clotting time, and activated partial thromboplastin time. The most common second-line anticoagulant was bivalirudin (n = 24; 63.2%). Thirty-six (94.7%) respondents use AT III with heparin, with most patients receiving AT III dosing calculated based on a formula for the desired AT III concentration. CONCLUSIONS The majority of respondents use antimicrobial prophylaxis, but variations in the regimens were noted. Heparin was the most common anticoagulant, but variations in laboratory monitoring and concomitant use of AT III were found.

The Risk-Benefit Ratio of Leech Therapy: A Single-Center Retrospective Study

Background: Venous congestion in transplanted or replanted tissues remains a common and challenging complication of plastic and reconstructive surgery. The local application of medicinal leeches is effective in reducing postoperative venous congestion in skin flaps and restoring normal blood flow. However, leech therapy is associated with a number of risks, including infections; in order to digest blood, leeches have a symbiotic relationship with Aeromonas species in their gut. Aeromonas infections are associated with a dramatic decrease in flap salvage rates. This is why prophylactic antibiotic treatment and external decontamination of the leeches are widely recommended. Methods: We performed a single retrospective study of patients having undergone leech therapy between January 1st, 2010, and December 31st, 2018, at Amiens-Picardie University Hospital, France. Each patient’s medical history, clinical data, laboratory results, prophylactic antibiotic use, and complications were recorded.Results: A total of 37 patients (mean age: 47) had undergone leech therapy after reconstructive surgery. Antimicrobial prophylaxis was documented in 32 (84.6%) patients. However, there are no guidelines on the choice of prophylactic antibiotic treatment. Twenty-four of the 37 (64.8 %) patients had anemia (mean hemoglobin level: 8.5 (6-11.1) g/dL), and 13 of the 24 (54%) required a transfusion. Thirteen of the 37 patients (35.1%) had a post-operative infection mainly due to Aeromonas spp. (76.9%). Leech therapy was effective in 23 of the 37 patients (62%) overall and in 2 of the 10 patients (20%) with an Aeromonas infection. The association between Aeromonas infection and flap salvage failure was highly significant (p = 0.005).Conclusions: The results of the study emphasized that clinical bacteriologists and surgeons should be aware that leeches are potential sources of infection.