This chapter provides insight into current management strategies for the placenta accreta spectrum (PAS). PAS is one of the most morbid conditions of pregnancy, with significant maternal hemorrhage and surgical morbidity risks, and its increasing incidence. Here, we review the available data to help guide the clinical management of PAS, from time of diagnosis through delivery and postpartum care, while acknowledging the many areas of continued uncertainty. The evidence is strong for the importance of team-based, patient-centered, and multidisciplinary care for patients with PAS. However, much else remains uncertain and is predominantly guided by expert opinion. Ultimately, we aim to provide a current understanding of available literature and to emphasize that continued research is paramount to explore management and surgical approaches to move toward optimization of patient outcomes, including the patient experience.

In neurosurgery, cefazolin (CFZ) is typically recommended at a dose of 2-gram within 60 minutes prior to surgical incision. However, due to the reported poor cerebrospinal fluid (CSF) penetration of CFZ, we conducted a population pharmacokinetic study to assess the adequacy of a 2-gram CFZ dosing regimen against the most common pathogens found in neurosurgical patients. If necessary, alternative CFZ dosing strategies were identified to achieve effective CSF concentrations. Adult patients undergoing neurosurgery were considered for inclusion in a prospective, observational, single-center study. After intravenous administration of CFZ 2-gram, blood and CSF samples were collected to determine CFZ concentrations. Population pharmacokinetic modeling of CFZ was performed using a non-linear mixed-effects approach and different dosing regimens were evaluated pharmacodynamically via Monte Carlo simulations. A total of 147 plasma and 42 CSF samples from 23 patients were analyzed. The median CFZ concentrations in plasma and CSF were 140.5 and 7.8 mg/L, respectively. The final model selected was a two-compartment model with an additional CSF compartment without covariates. The standard 2 g CFZ dose was inadequate in most cases. In contrast, intermittent administration of 1 g every hour following an initial bolus of 4-5 g, or continuous infusion at a rate of 1.625 g/h after a 6 g bolus provided better target attainment. The standard 2 g CFZ dose for neurosurgical antibiotic prophylaxis should be reassessed. The alternative dosing regimens proposed in this study warrant evaluation in future clinical trials.

Piperacillin/tazobactam and metronidazole are two commonly antimicrobials used to prevent and treat infections after liver transplantation in pediatric patients. However, under the recommended dose, it may lead to insufficient antimicrobial treatment and poor efficacy. To achieve antimicrobial therapy based on pharmacokinetic strategies, a rapid and highly sensitive ultra-high performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method was developed to measure the plasma concentrations of piperacillin, tazobactam, and metronidazole in pediatric liver transplant recipients. Sample separation was achieved using an Acquity UPLC CSH C18 column (2.1 × 50 mm, 1.7 μm) with gradient elution. The mobile phase consisted of ammonia solution-formic acid-water (0.5:1:1000, v/v/v) and methanol-acetonitrile (1:1, v/v). The plasma concentration range was 0.20-100.00 μg/mL, with good linear range. The intra- and inter-day precisions were less than 13.4 %, and the accuracy ranged from 90.0 % to 109.0 %. The selectivity, carryover, dilution integrity, matrix effect, recovery, and stability met the requirements of the relevant guidelines. The established UPLC-MS/MS method was successfully applied to measure the concentrations of piperacillin, tazobactam, and metronidazole in the plasma of pediatric liver transplant patients. The results showed that according to the recommended dosing regimen, piperacillin/tazobactam reached the effective therapeutic target of 50 %T > MIC in only 4 h. The maximum plasma concentration (Cmax) of metronidazole ranged from 9.46 to 28 μg/mL, with an average Cmax of 16.59 μg/mL, which did not achieve the ideal Cmax/MIC ratio of 8-10.

Thyroidectomy is a clean surgery, with the presentation of postoperative infections being uncommon and an exceedingly rare incidence of postoperative sepsis.A female patient in her early 80s became acutely unwell following total thyroidectomy within the immediate postoperative period, with features suggestive of sepsis. She developed new-onset atrial fibrillation (AF), and her care was escalated to the intensive treatment unit (ITU) on the same day postoperatively. While in the ITU, she deteriorated with multiorgan failure (MOF). There was no evidence of a surgical site infection (SSI).Beta haemolytic lancefield Group A Streptococcus (GAS) was isolated from positive blood cultures, confirming the diagnosis of streptococcal toxic shock syndrome (TSS). She was treated with targeted antibiotics and intravenous immunoglobulin (IG) and received supportive care for MOF.In our case, sepsis developed in the immediate postoperative period of total thyroidectomy. A high index of suspicion and prompt treatment are required to minimise the risks of morbidity and mortality.

Proper antimicrobial prophylaxis is critical for reducing the risk of infection during interventional procedures. Brachytherapy, a highly effective radiation therapy for various malignancies, allows for precise radiation delivery; however, the use of foreign material as instrumentation for brachytherapy potentially increases the risk of infection. Understanding infectious complications and proper antimicrobial use in this case is essential for successful outcomes and patient safety. The aim of this review is to provide insights and summarize existing information on the infectious complications of brachytherapy in prostate, breast and gynaecological (cervical and endometrial) cancer, as well as on the potential benefit, if any, of administering antimicrobial prophylaxis. Infectious complication rates in prostate, breast and gynaecological cancer brachytherapy remain low with diverse prophylactic regimens, emphasizing the need to identify risk factors for tailored practices. The choice of the antimicrobial regimen, type of device and modality influences the probability of infectious complications. There is minimal overlap of existing brachytherapy guidelines with surgical prophylaxis guidelines. Infectious outcomes and antimicrobial resistance are underreported, and guidance for antimicrobial-resistant organisms is scarce. When indicated, prophylaxis for less than 24 h is efficient. More studies oriented towards antimicrobial prophylaxis on this specific population are needed.

The prevalence of obesity and morbid obesity in the U.S. has reached record levels, with over 50% of adults affected. Obese patients undergoing total joint arthroplasty (TJA) face increased post-operative complications, yet studies on optimizing outcomes for this population are limited. The COVID-19 pandemic accelerated the shift towards same-day discharge (SDD) for TJA, but the impact on morbidly obese patients remains understudied. This study aims to fill this gap by examining outcomes and costs for morbidly obese patients undergoing SDD TJA.

This study is a retrospective review of the PearlDiver Mariner Database. Based on the procedure and their body mass index (BMI), the patients were divided into 4 SDD groups: Total knee arthroplasty (TKA)-BMI > 40, TKA-BMI < 40, total hip arthroplasty (THA)-BMI > 40, and THA-BMI < 40. The two TKA groups were matched based on age, gender, and the Charlson comorbidity index (CCI). The THA groups were matched similarly. Outcomes at 30 and 90 days post-operatively were compared between the groups.

5588 patients were included in each TKA group, and 1675 patients in each THA group. When compared to individuals with a BMI of less than 40, patients with morbid obesity receiving SDD TKA had greater incidence of deep vein thrombosis (DVT) (p < 0.05), urinary tract infection (UTI) (p < 0.05), readmissions (p < 0.05), superficial surgical site infection (SSSI) (p < 0.05), and higher costs (p < 0.05). Regarding SDD THA, patients with morbid obesity had greater incidence of DVT (p < 0.05), UTI (p < 0.05), emergency department visits (p < 0.05), readmissions (p < 0.05), intensive care unit admission (p < 0.05), prosthetic joint infection (p < 0.05), SSSI (p < 0.05), and higher costs (p < 0.05).

This study highlights the considerable challenges faced by morbidly obese patients undergoing SDD TJA. Patient optimization prior to undergoing total joint replacement may benefit morbidly obese patients undergoing same day discharge. Further research is needed.

This study reports trends in the epidemiology of surgical site infections (SSI) complicating coronary artery bypass graft (CABG) surgery and describes changes in surgical antimicrobial prophylaxis (SAP) compliance and causative pathogens over time.

Data on CABG procedures from 2010 to 2023 submitted to the Victorian healthcare-associated infection surveillance coordinating centre were analyzed. Trends in the SSI rate and choice, timing and duration of SAP were modelled using Poisson regression. The most common pathogens causing SSI and their change over time were assessed.

32,446 CABG procedures were reported during the study period. Sternal SSI rate decreased from 2.7 per 100 procedures in 2010 to 1.6 per 100 procedures in 2023, representing a 15% annual decrease when the model was adjusted for the number of years of participation in surveillance. This decrease was most marked during the first decade (IRR 0.70 [95% CI 0.64, 0.76]) followed by stable rates between 2020 and 2023 (IRR 1.08 [95% CI 0.93, 1.27]). Compliance with SAP choice was consistently above 98%, while compliance with timing increased by an average of 1% per year to 83%, and compliance with duration fluctuated between 75% and 86%. The most frequent pathogens responsible for SSI were Staphylococcus aureus, Serratia marcescens, Staphylococcus epidermidis, and Klebsiella pneumoniae. The proportion of sternal and donor site SSIs involving Gram-negative pathogens increased from 38% to 59%.

This analysis of 14 years of surveillance data for SSI complicating CABG procedures highlighted a reduction in rates of SSI, high rates of compliance with antimicrobial choice for SAP, and predominance of S. aureus as a causative pathogen of SSI in our region. Notably, we observed Gram-negative pathogens, particularly S. marcescens, to be responsible for a larger proportion of SSIs over recent years.

Study DesignRetrospective analysis of randomized controlled trial.ObjectivesSurgical site infection (SSI) after spine surgery has severe negative health and financial consequences. Surgical antibiotic prophylaxis (SAP) is a routinely used method to prevent SSIs in the spine patient population. The most commonly used antibiotic is cefazolin, with vancomycin often being substituted in the case of penicillin or cephalosporin allergy. Vancomycin as SAP has been associated with increased SSI in the joint replacement literature, but this is not yet well defined in the spinal surgery population. The purpose of this study was to determine whether vancomycin SAP compared to cefazolin SAP is associated with increased risk of SSI.Methods535 patients, aged 16 years or older, underwent elective multi-level open posterior spinal fusion surgery at the thoracic, thoracolumbar, or lumbar levels. Demographic and operative characteristics as well as post-operative outcomes were compared between the following groups: (1) noninfected-cefazolin, (2) noninfected-vancomycin, (3) infected-cefazolin, and (4) infected-vancomycin. Primary outcomes were superficial and complicated (deep and organ/space) infections.ResultsThe following risk factors for SSI were identified in a logistic regression analysis: vancomycin (OR 2.498, 95% CI, 1.085-5.73, P = 0.031), increasing operating time (OR 1.006, 95% CI, 1.001-1.010 P = 0.010), weight (OR 1.020, 95% CI 1.006-1.034, P = 0.005), revision procedure (OR 2.343, 95% CI 1.283-4.277, P = 0.006), and depression (OR 2.366, 95% CI 1.284-4.360, P = 0.006).ConclusionsIn open posterior approach spinal fusion surgery, vancomycin SAP is associated with increased risk of infection compared to cefazolin SAP.

The human gut microbiome represents a complex ecosystem comprising numerous microorganisms critical to basic physiological processes. The gut microbiome's composition and functionality influence surgical outcomes following orthopedic procedures. The purpose of this study was to evaluate the gut microbiota on critical aspects of orthopedic surgical outcomes. A comprehensive literature search was conducted via PubMed, the Cumulative Index for Nursing and Allied Health Literature (CINAHL), Google Scholar, Cochrane Library, Medline, and Web of Science. A total of 18 research articles of the 599 retrieved results were included in this study. Significant correlations were identified between microbial composition and surgical outcomes, including infection rates, inflammatory responses, and postoperative complications. Bacterial genera like Alistipes and Helicobacter increased postoperative cognitive dysfunction (POCD) risk, while short-chain fatty acid (SCFA)-producing bacteria showed negative correlations with inflammatory markers. Probiotic interventions reduced POCD incidence from 16.4% to 5.1% and modulated inflammatory responses. Additionally, bacterial composition was associated with critical surgical parameters such as bone healing, infection rate, and recovery trajectory. Inflammation, healing processes, and recovery trajectories are influenced by microbial composition in surgical settings. Targeted interventions, such as probiotics, show promise in reducing surgical risks and improving patient recovery.

Comprehensive antimicrobial use (AMU) data are essential to promote effective antimicrobial stewardship. However, qualitative information on AMUs in Japanese hospitals is limited.

This study aimed to provide an overview of AMU for inpatients in Japanese hospitals.

A multicentre point-prevalence survey was conducted across Aichi Prefecture in 2020, collecting patient demographics, underlying conditions, indications of AMU (for treatment of community-acquired infections [CAIs]/healthcare-associated infections [HAIs], surgical prophylaxis [SP], medical prophylaxis [MP] and others), treated infections, and antimicrobial stewardship team (AST) intervention.

Among the 10,199 patients from 27 hospitals included in this study, A total of 3,738 antimicrobials were prescribed to 3,024 patients (29.6%; 95% confidence interval: 28.8-30.5). Of these, 1,510 (40.4%) antimicrobials were prescribed for CAI treatment, 815 (21.8%) for HAI treatment, 745 (19.9%) for SP, and 639 (17.1%) for MP. SP administration over 2 days was observed in 31.2% of the cases. The top three prescribed antimicrobials were cefazolin (12.0%, 450), ceftriaxone (9.2%, 343), and oral trimethoprim-sulfamethoxazole (8.7%, 327). Antimicrobial use per 1,000 patients was highest in extra-large hospitals (472) and lowest in small hospitals (264). Ceftriaxone was most commonly prescribed for CAIs, while meropenem was typical for HAIs. AST intervention rates were 15.0% and 22.5% in CAIs and HAIs, respectively.

This study provides comprehensive AMU information from a region in Japan, highlighting variations linked to hospital size, frequent prescriptions of broad-spectrum antimicrobials for HAIs, high prescription rate of trimethoprim-sulfamethoxazole as MP, and prolonged SAP.

The prevalence of obesity is rapidly increasing worldwide, however there is a notable gap in understanding how obesity affects the pharmacokinetics of drugs and how dosing should be adjusted in obese population. The goals of this work were to evaluate plasma pharmacokinetics and tissue disposition of piperacillin, cefazolin, and cefoxitin in a rat model of diet-induced obesity compared to a lean cohort. Male Long-Evans rats were fed high-fat or control diets for 23 weeks. Various measures of body size and composition were collected. The animals were administered a mixture containing 50 mg/kg cefoxitin, 50 mg/kg cefazolin, and 120 mg/kg piperacillin. Plasma and tissues were collected and analyzed using a validated LC-MS/MS method. Whole-body physiologically-based pharmacokinetic (PBPK) models were develop to capture the biodistribution of these drugs in lean and obese cohorts. Most plasma and tissue concentrations were comparable between lean and obese rats after dosing based on mg/kg of total body weight; however, in some tissues concentration was consistently higher in obese animals. PBPKs successfully captured biodistribution of three drugs and both cohorts; however, cohort-specific (lean or obese) parameters were required for liver (for cefoxitin and cefazolin) and spleen (for all three drugs) for capturing the data.The results support the necessity of using mg/kg dosing for obese rats to achieve drug exposure comparable to that of lean rats. In the future, these models could be extended to predict plasma pharmacokinetics and tissue disposition of cefoxitin, cefazolin, and piperacillin in humans by incorporating interspecies scaling approaches.

The purpose of this study was to evaluate antimicrobial prophylaxis regimens for genital gender affirmation surgery in the prevention of surgical site infections and other infectious complications and to provide a descriptive report of what was observed when using the study sites' recommended regimens.

This retrospective observational study was completed at 2 urban academic medical centers between June 1, 2020, and June 30, 2023. All data were collected through retrospective chart review. The primary outcome of this study was the prevalence of surgical site infections within 30 days following genital gender affirmation surgery completed by a single surgeon at 2 health centers. Secondary outcomes included the prevalence of surgical site infections within 6 months of surgery, potential relationships of demographic data and type of surgery with the development of postoperative infection, and relationships of antibiotics, dose, and number of subsequent doses with the development of postoperative infection.

A total of 146 surgeries (124 patients) were included in the final analysis. Surgical site infection occurred within 30 days postoperatively in 4 patients (3%), most commonly noted on the first follow-up visit within 1 month of surgery. Another 2 infections occurred within 6 months postoperatively, resulting in a total of 6 patients (4%) with surgical site infections during the study period.

This study observed an acceptable prevalence of surgical site infections within both 30 days and 6 months of genital gender affirmation surgery. This outcome supports the use of narrow gram-positive and gram-negative coverage (ie, cefazolin) for clean and clean-contaminated procedures without entry into the gastrointestinal (GI) or gastroduodenal (GU) tracts, with the addition of anaerobic coverage (ie, metronidazole) for clean-contaminated procedures with entry into the GI or GU tract, as clinically appropriate options.

This study addresses the critical need for timely and accurate diagnosis of early postoperative infection (EPI) following cardiac surgery. EPI significantly impacts patient outcomes and healthcare costs, making its early detection vital.

To develop, validate, and clinically implement a machine-learning-based model for diagnosing EPI post-cardiac surgery, enhancing postoperative care.

In this multi-center cohort study spanning 2020 to 2022, data from four medical centers involved 2001 participants. Of these, 1400 were used for trainingand 601 for validation. Several machines-learning algorithms, including XGBoost, random forest, support vector machines, least absolute shrinkage and selection operator, and single-layer neural networks, were applied to develop predictive models. These were compared against a traditional logistic regression model. The model with the highest area under the receiver operating characteristic curve (AUROC) was deemed optimal. Implemented across four centers since 1 January 2023, a retrospective real-world study assessed its clinical applicability. Among 400 patients with an estimated EPI risk above 10%, identified by the optimal model, 55 followed its antibiotic upgrade recommendations (DEICS group). The remaining 345 patients upgraded antibiotics empirically, with 55 in the control group, matched 1:1 with the DEICS group. Clinical utility was evaluated through antibiotic use density (AUD), hospital costs, and ICU stay duration.

The XGBoost model achieved the highest performance with an AUROC of 0.96 (95% CI: 0.93-0.98). The calibration curve exhibited strong agreement with Brier scores of 0.02. According to the XGBoost model, the DEICS group significantly demonstrated reduced AUD ( P < 0.01) in the matched cohort, along with decreased ICU stay time (median: 5 vs. 6 days, P = 0.01) and hospital costs (median: ¥150 000 vs. median: ¥200 000, P = 0.01) in the EPI cohort.

The successful implementation of the XGBoost model facilitates accurate EPI diagnosis, improves postoperative recovery, and lowers hospital costs.

To assess practice patterns regarding antibiotics prophylaxis in otologic surgery in the United States.

Cross-sectional study.

Tertiary care center.

Members of American Neurotology Society (ANS).

Nationwide survey.

Prevalence of antibiotic prescribing among surgeons performing the following six ear surgical procedures: cochlear implantation, tympanoplasty with a clean ear, tympanoplasty with active drainage, cholesteatoma surgery without evidence of infection, cholesteatoma surgery with evidence of infection, and stapedectomy.

Seventy-three surgeons completed the survey (15.21% response rate). Twenty-seven percent had more than 25 years in experience, and 18% had 0 to 5 years of experience. Antibiotic prescribing practices varied by procedure: cochlear implantation (64.4%, median 5 d), tympanoplasty (clean ear: 23.3%, median 5 d; active drainage: 53.4%, median 7 d), cholesteatoma surgery (no infection: 30.1%, median 7 d; with infection: 58.9%, median 7 d), and stapedectomy (34.2%, mean 5 d). Cephalosporins were preferred for noninfected procedures, whereas amoxicillin dominated for active infections.

Prophylactic oral antibiotics varies for ear surgery, with higher usage for procedures with active infection and a preference for cephalosporins in noninfected cases. These findings underscore the need for the development and dissemination of standardized, evidence-based recommendations.

Consensus guidelines from the Infectious Disease Society of America recommend against antimicrobial prophylaxis in the operative management of uncomplicated cholelithiasis; however, these guidelines were derived entirely from the adult surgical population.

To compare surgical site infection (SSI) outcomes between children undergoing cholecystectomy who received prophylaxis and those who did not.

This was a cohort study using data from 141 hospitals participating in the National Surgical Quality Improvement Program-Pediatric. Patients younger than 18 years who underwent cholecystectomy for uncomplicated cholelithiasis from January 2021 to December 2022 were identified. Exclusion criteria included diagnoses of acute cholecystitis, pancreatitis, choledocholithiasis, hematologic disorders, and emergent procedures.

Administration of prophylactic antibiotics before incision.

The main outcomes were 30-day postoperative SSI and readmission. Propensity score weighting on the likelihood of receiving prophylaxis was used to balance groups on case acuity, duration of surgery, hospital discharge diagnosis, and patient characteristics. The association between outcomes and the use of prophylaxis was estimated using logistic regression models, weighted by the inverse probability of treatment with a random effect by hospital to control for hospital-level clustering. A secondary analysis was performed exploring the association between broad-spectrum prophylaxis and outcomes.

Of 2234 children who met criteria for inclusion (median age, 15.3 years; 19.7% male [399 of 2025]), 2025 (90.6%) received prophylaxis (utilization rates ranged from 0% to 100% among hospitals). Cefazolin was the most commonly used antibiotic (69.2% [1401 of 2025]), and 559 of 2025 patients (27.6%) received extended-spectrum prophylaxis (compared with cefazolin). In the propensity-weighted cohort, SSI rates were lower for children who received prophylaxis compared with those who did not (18.0 of 2016 [0.9%] vs 7.8 of 212 [3.7%]; adjusted odds ratio [AOR], 0.28; 95% CI, 0.11-0.70), and rates were similar between children receiving cefazolin and those receiving more extended-spectrum antibiotics in a secondary propensity-weighted analysis (13.9 of 1399 [1.0%] vs 2.9 of 558 [0.5%]; AOR, 0.54; 95% CI, 0.15-1.95).

The results of this study support prophylaxis use for children undergoing nonemergent cholecystectomy; however, use of extended-spectrum antibiotics was not associated with superior outcomes compared with cefazolin alone. Opportunities to optimize infection prevention or antimicrobial stewardship were identified in more than one-third of all children undergoing cholecystectomy.

Access to effective medicines (e.g. antibiotics) is a fundamental human right. However, in contrast to high-income countries (HICs), many low- and middle-income countries (LMICs) lack appropriate and effective antibiotics. This is a paradox, and an inequitable scenario, as LMICs can have significantly higher burdens of infectious diseases than HICs and especially require appropriate antibiotics. Inequitable access to appropriate antibiotics results in patients being treated with substandard antibiotics, treatment failure, the emergence of antimicrobial resistance (AMR) and, inevitably, morbidity and mortality. Factors that hinder access to appropriate antibiotics in LMICs include: poor political will, weak health systems, complex bureaucratic protocols, poor implementation of National Action Plans on AMR, inadequate expertise in regulatory science, unfavourable macroeconomic policies and a poor investment climate. Clearly, multisectoral, collaborative approaches are required to effectively mitigate inequitable access to appropriate antibiotics in LMICs. Also, efforts (such as the African Medicines Regulatory Harmonization Initiative and the African Medicines Agency) to streamline bureaucratic processes and improve the registration and entry of appropriate antibiotics into LMICs are required. This review discusses factors responsible for inequitable access to appropriate antibiotics in LMICs, and makes recommendations to mitigate the problem. With rising rates of AMR, a dwindling antibiotic pipeline, and the dangers of a post-antibiotic era, it is clear that the time to act is now, as inequitable access to appropriate antibiotics in LMICs reduces the quality of healthcare, and threatens the achievement of Universal Health Coverage and, ultimately, the Sustainable Development Goals.

Studies have shown an association between a reported penicillin allergy and an increased risk of surgical site infection. The risk is due to avoidance of cephalosporins and to the use of alternative classes of antibiotics in surgical prophylaxis. The aim of this study was to examine the safety of using cephalosporins in patients with a penicillin allergy label.

Patients with a primary or revision hip or knee arthroplasty in a tertiary care hospital between March 2020 and February 2023 were identified (n = 14,939). Information on prophylactic antibiotics, pre-existing antibiotic allergy labels before the operation, and all recorded new antibiotic allergy labels within 2 weeks after the operation was gathered. The prophylactic antibiotic use in patients with and without a penicillin allergy label was compared. In addition, all new antibiotic allergy labels recorded after the operation were verified from the electronic health records.

A total of 1,435 (9.6%) patients had a previous penicillin allergy label. The majority of patients (14,838 of 14,939; 99.3%) received cephalosporin prophylaxis, as did most of the patients with a label of penicillin allergy (1,395 of 1,435; 97.2%). Six perioperative allergic reactions were recorded; none of these were anaphylactic reactions. In 5 cases, the allergic reaction occurred in patients receiving cefuroxime, none of whom had a previous penicillin allergy.

This study found cephalosporin antibiotic prophylaxis to be safe in patients with a pre-existing penicillin allergy label.

To investigate the genomic epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) endophthalmitis and correlate it with the presenting clinical features and outcomes.

Nine patients presenting with MRSA endophthalmitis from 2014 to 2022 were included. Phenotypic and genomic tests were used for strain characterization. Demographics, clinical presentation, treatment and outcomes were reviewed.

The MRSA population was dominated by multidrug-resistant (MDR) strains within the clonal complex 5 (CC5) carrying an SCCmec type II genetic element (USA100-like strains). These strains carried genes that confer resistance to five antibiotic classes, in addition to mutations in topoisomerase genes (gyrA and parC) that resulted in resistance to all fluoroquinolones tested. Patients were mostly male (56%), with a median age of 82.7 years, and most had no recent history of extensive healthcare exposure. All cases were exogenous following ocular surgery (67%) or intravitreal injection (33%). The main exam findings were visual acuity ≤ hand motion, hypopyon (89%), and vitreous opacity (89%). Five patients (56%) showed improvement in visual acuity at 1 month following presentation, three (33%) at 3 months, and two (22%) at 6 months. Complications included evisceration (n = 1) and phthisis (n = 1). Patients who had pars plana vitrectomy within 48 hours of presentation had better clinical outcomes compared to those who did not.

Exogenous MRSA endophthalmitis is caused by MDR strains that resemble the hospital-acquired lineage USA100. These strains cause severe endophthalmitis in patients with no recent hospital/healthcare exposure.

Surgical site infection (SSI) remains a significant global health concern, including in Indonesia. The administration of prophylactic antibiotics plays a pivotal role in the prevention and the reduction in mortality rates associated with SSIs. Prophylactic antibiotic use is recommended in surgical procedures that are at risk of infection, including in clean surgical operations that last more than three hours and clean-contaminated surgeries. The objective of this study was to analyze the quantity of prophylactic antibiotic consumption and to compare the consumption of antibiotics between neurosurgery (clean surgery) and appendectomy (clean-contaminated surgery).

Data in this observational study were obtained from the medical records of patients who underwent neurosurgery and appendectomy at two hospitals in Surabaya: one private and one public hospital. The quantity of antibiotic consumption will be analyzed descriptively and presented as a defined daily dose (DDD) per 100 bed days.

Research findings revealed a higher quantity of antibiotic consumption in elective neurosurgery, representing 47.43 DDD/100 bed-days, in comparison to 21.26 DDD/100 bed-days and 76.34 DDD/100 bed-days in elective and emergency appendectomy, respectively. The most frequently used antibiotics were broad-spectrum antibiotics, which included cefixime (36.91 DDD/100 bed-days) and ceftriaxone (5.45 DDD/100 bed-days) in elective neurosurgery; and ceftriaxone (14.94 vs 50.86 DDD/100 bed-days) and metronidazole (5.75 vs 19.16 DDD/100 bed-days) in elective and emergency appendectomy, respectively.

The consumption of prophylaxis antibiotics remains a significant concern. In order to develop strategies to prevent bacterial resistance through an antibiotic stewardship program, it is essential to evaluate antibiotic consumption and monitor trends over time.

Cefazolin is used as a prophylactic antibiotic to reduce surgical site infections (SSIs). Obesity has been identified as a risk factor for SSIs. Cefazolin dosing recommendations and guidelines are currently inconsistent for obese patients. As plasma and target-site exposure might differ, pharmacokinetic data from the sites of SSIs are essential to evaluate treatment efficacy: these data can be obtained via tissue microdialysis. This analysis was designed to evaluate the need for dosing adaptations in obese patients for surgical prophylaxis.

Data from 15 obese (BMImedian = 52.6 kg m-2) and 15 age- and sex-matched nonobese patients (BMImedian = 26.0 kg m-2) who received 2 g cefazolin i.v. infusion for infection prophylaxis were included in the analysis. Pharmacokinetic data from plasma and interstitial space fluid (ISF) of adipose tissue were obtained and analysed simultaneously using nonlinear mixed-effects modelling. Dosing regimens were evaluated by calculating the probability of target attainment (PTA) and the cumulative fraction of response (CFR) for plasma and ISF using unbound cefazolin concentration above minimum inhibitory concentration 100% of the time as target (fT>MIC = 100%). Dosing regimens were considered adequate when PTA and CFR were ≥90%.

Evaluation of cefazolin doses of 1 and 2 g with redosing at either 3 or 4 h by PTA and CFR in plasma and ISF found 2 g cefazolin with redosing at 4 h to be the most suitable dosing regimen for both obese and nonobese patients (PTA >90% and CFR >90% for both).

This model-based analysis, using fT>MIC = 100% as a target, showed that cefazolin dosing adaptations are not required for surgical prophylaxis in obese patients.

In terms of perioperative infections, arthroplasty for obese patients represents a high-risk procedure. Correct antibiotic prophylaxis is a central pillar of infection prophylaxis. Studies showed increased infection rates if an antibiotic other than cefazolin was administered for prophylaxis. In patients with anamnestic penicillin allergy, an existing allergy is extremely rare, and the presence of cross-allergies to cephalosporins is similarly rare. Consequently, every effort should be made to administer a first- or second generation cephalosporin such as cefazolin.

Whether the dosage of antibiotic prophylaxis should be adjusted to the body weight remains unclear due to the limited data available: case series showed increased infection rates when cefazolin was underdosed and recommended increasing the dose to 3 g if the body weight exceeds 120 kg. However, no studies with a higher level of evidence exist. Published studies on the effective antibiotic levels in the tissue remain contradictory with regard to possible weight-dependent dose adjustments. Similarly, there is insufficient data on whether local intraoperative antibiotic prophylaxis may be useful in obese patients. By contrast, there is no evidence for a positive benefit of double prophylaxis with two different antibiotics or prolonged postoperative antibiotic prophylaxis in obesity.

In summary, the data on antibiotic prophylaxis is generally insufficient, especially when focussing on possible dose adjustments in obesity. The well-timed administration of a cephalosporin such as cefazolin represents the golden standard in orthopedics and trauma surgery. A possible dose adjustment to 3 g for a body weight over 120 kg appears reasonable considering the low costs and the broad therapeutic window and is therefore recommended in the current AWMF S3 guideline.

To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management.

Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines.

After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient's unique characteristics.

The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

To investigate the influence of surgical antimicrobial prophylaxis (SAP) on complication rates and surgical site infections (SSI) in horses undergoing sutured castration in a hospital setting.

Retrospective chart review of a convenience sample.

A total of 220 colts and stallions admitted for sutured castration.

Medical records of sutured castration were assessed for patient characteristics, perioperative and postoperative medications, and postoperative complications within 6 weeks after surgery. The effect of these variables on the occurrence of complications was analyzed using χ2 tests, and the association between SAP use and SSI probability was evaluated.

The median age of horses included in the study was 3 years (range 1-14 years), and the overall complication rate was 10.0% (22/220). Surgical antimicrobial prophylaxis was administered to 62% of the patients (136/220). There were no differences in the overall complication rates, with a 7.1% (6/84) complication rate among horses without SAP (SAP-) and an 11.8% (16/136) rate in those receiving SAP (SAP+) (p = .36). There was no association between the use of SAP and the probability of SSI, with an incidence of 3.6% in SAP- and 4.4% in SAP+ (3/84 and 6/136 respectively) (p = 1.0).

Administering SAP did not influence the overall complication rate or the SSI rate following sutured castrations in a hospital setting.

These findings prompt a reconsideration of the use of SAP for sutured castrations under aseptic conditions. The results may also serve as a basis for future randomized controlled trials.

Surgical site infections (SSIs) are a major yet preventable cause of poor post-operative clinical outcomes, prolonged ICU/hospital stay, increased antibiotic consumption and added cost of therapy. Low- and Middle-income Countries (LMICs) have disproportionately higher rates of SSIs as compared to high-income countries despite various national and international guidelines in place as multipronged, combined interventions are seldom used. The IMPRESS project aims to respond to this urgent need to identify and evaluate the quality improvement measures contextualized to the logistic constraints of LMIC settings such as India.

We adopt a multi-center longitudinal mixed-methods study to be conducted over a period of 2 years in various phases. Phase 1 will be formative research with the objective of identifying knowledge gaps and baseline data collection. Phase II will involve co-development of multipronged interventions addressing identified barriers. Phase III will focus on the deployment of the selected multipronged interventions. Phase IV will be the post-intervention phase to evaluate the impact of the interventions. The study has been prospectively registered with CTRI and is supported by a funding grant from the Indian Council of Medical Research, New Delhi. The Institutional Ethics Committee approval has been obtained from all the sites involved in the study.

An antimicrobial stewardship program (ASP) is crucial for reducing inappropriate antimicrobial use, improving patient outcomes, and combating increasing antimicrobial resistance. However, data on the implementation of enhanced ASP networks in Asia are limited.

This quasi-experimental study evaluated an ASP collaborative network across four hospitals in Thailand (two university hospitals, a tertiary care center, and a private hospital) during 2021 and 2022. Baseline ASP activities were assessed using gap analysis surveys. Effectiveness was measured through antibiotic consumption (daily defined dose, [DDD] per 1,000 patient-days), appropriateness of antibiotic use, and the incidence of multidrug-resistant organisms (MDROs).

The enhanced ASP network addressed key challenges, leading to significant improvements in ASP implementation. Notable achievements included an increase in the overall appropriateness of target antibiotic use (86.5% vs. 74.4 %, p < 0.05) and a reduction in target antibiotic consumptions in all hospitals. The incidence of MDROs, including carbapenem-resistant Acinetobacter baumannii (30.22 vs. 6.08 per 1,000 patient-days, p < 0.05) and methicillin-resistant Staphylococcus aureus (1.90 vs. 0.46 per 1,000 patient-days, p < 0.05), declined significantly in one hospital. The incidence of multidrug-resistant pathogens declined after the implementation of the enhanced ASP in two hospitals.

The enhanced networking program in this study significantly improved ASP implementation across diverse hospital settings in Thailand. It addressed challenges such as insufficient financial support. Notable improvements were observed in the appropriateness of antibiotic use and overall antibiotic consumption, potentially contributing to the reduction in multidrug-resistant pathogens. These findings highlight the effectiveness of a collaborative ASP network in Asia.

The Surgical Infection Society (SIS) guidelines recommend against the use of surgical antibiotic prophylaxis (SAP) for low-risk patients undergoing elective laparoscopic cholecystectomies.

Using National Surgical Quality Improvement Program (NSQIP) data, 5440 pediatric patients were identified who underwent laparoscopic cholecystectomy from 2021 to 2022. Patients who had immunodeficiency, active malignancy, American Society of Anesthesiologists (ASA) physical status classification 3-5, procedure indicated for infection, emergent procedure, received intravenous antibiotics before the prophylaxis window, or missing SAP data were excluded.

3959 patients were included in the analysis. Among these patients, 3570 (90.2 %) received SAP. Overall incidence of 30-day superficial incisional surgical site infection (SSI), deep incisional SSI, and organ space SSI were 0.9 %, 0.0 %, and 0.1 %, respectively. The incidence of superficial incisional SSI was significantly higher in the patients who did not receive SAP (SAP 0.8 %, no SAP 2.1 %; p = 0.024). The incidence of organ space SSI was also significantly higher in the patients who did not receive SAP (SAP 0.1 %, no SAP 0.8 %; p = 0.008). There was no difference in the incidence of C. diff colitis (SAP 0.1 %, no SAP 0.0 %; p = 1.000). Multivariable modeling, controlling for Hispanic ethnicity, age, and gender, demonstrated patients that received SAP were significantly less likely to have any postoperative SSI compared to patients who did not receive SAP (OR = 0.35).

Hospitals are not currently compliant with SIS guidelines regarding omission of antibiotic prophylaxis for low-risk patients undergoing elective laparoscopic cholecystectomies. The authors advocate for additional studies and reassessment of current guidelines for pediatric patients given the above findings.

Retrospective comparative study.

III.

Appropriate antibiotic prophylaxis is essential for preventing surgical site infections (SSI); however, the clinical benefit of intraoperative redosing remains unclear and controversial owing to insufficient reliable evidence. Therefore, we performed a systematic review and meta-analysis to assess the effectiveness of prophylactic antibiotic redosing in lengthy surgical procedures.

We systematically searched the PubMed, Cochrane Library, Web of Science, and Ichushi-Web databases for articles published until 31 December, 2023. We compared the incidence of SSI between patients receiving and not receiving intraoperative redosing of antibiotics in surgeries lasting ≥3 h. Subgroup analyses were conducted across study characteristics. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel random effects model. The risk of bias was assessed using the ROBINS-I.

Overall, seven observational studies involving 4,671 patients were included. Intraoperative antibiotic redosing significantly reduced the risk of SSI compared with non-redosing (OR = 0.65, 95% CI = 0.45-0.94, p = 0.02). Subgroup analyses showed that intraoperative redosing decreased SSI risk in studies with a minimum 4-h operative time, no postoperative antibiotic continuation, and a moderate risk of bias. However, the statistical heterogeneity of the analyses was high among the studies.

Intraoperative redosing with prophylactic antibiotics during lengthy surgeries may be associated with a lower risk of SSI than non-redosing. Therefore, we recommend intraoperative redosing for surgeries lasting beyond 3-4 h to reduce the risk of infection. Further research is required to clarify the optimal redosing interval, which should be prioritized in future studies.

To determine if the use of 0.05% chlorhexidine gluconate (CHG) irrigation solution during cesarean delivery (CD) can reduce the post-cesarean surgical site infection (SSI) rate when compared to standard practices without CHG irrigation.

A single-center retrospective observational study was performed at a community hospital in Toledo, Ohio. Control and treatment periods were defined, and patients in the treatment group received irrigation with CHG solution during CD, while the control group did not. An electronic medical record review was conducted to note additional perioperative procedures that affect SSI rates. Patients were evaluated for infection at standard postoperative appointments using the CDC criteria, and the hospital system's department of infection prevention provided records of all documented SSIs in both groups. Characteristics of the deliveries and SSIs of each group were compared using the chi-square or Fisher's exact two-tailed tests.

Data were available for 351 deliveries after the implementation of the CHG protocol, and 432 deliveries were used as the control group. No significant difference in rates of infection was found between the two groups (p = 0.68). There were significantly more endometritis infections diagnosed in the treatment group compared to the control group (four (1.1%) versus zero; p = 0.04). Compared to the controls, the treatment group had fewer deliveries with the use of silver dressing, more deliveries with a negative pressure dressing, and more deliveries with a diagnosis of pregestational or gestational diabetes (p < 0.05). There were no other differences between the groups, including the use of abdominal and vaginal prep, BMI > 35, and perioperative antibiotics.

This single center retrospective observational study revealed no difference in post-cesarean SSI rates when performing intra-abdominal and subcutaneous irrigation with CHG solution. A significant increase in endometritis was observed with the use of CHG irrigation; however, further studies are required to determine the benefit or harm of antimicrobial irrigation in CDs.

Beta-lactam prophylaxis is the first-line preoperative antibiotic in open abdominal wall reconstruction. However, of the 11% patients reporting a penicillin allergy (PA), most receive second-line, non-β-lactam prophylaxis. Previously, abdominal wall reconstruction research from our institution demonstrated increased wound complications, readmissions, and reoperations with non-β-lactam prophylaxis. Therefore, a collaborative quality improvement initiative was developed with the infectious disease service, and a penicillin allergy protocol was instituted that stratified patients' risk of allergic reaction with a goal to increase β-lactam prophylaxis use. The effect of the penicillin allergy protocol on open abdominal wall reconstruction outcomes was prospectively evaluated.

Patients with penicillin allergy undergoing open abdominal wall reconstruction were identified and grouped according to penicillin allergy protocol implementation. Pre-penicillin allergy protocol underwent open abdominal wall reconstruction before January 1, 2020, predominantly receiving non-β-lactam prophylaxis; post-penicillin allergy protocol underwent open abdominal wall reconstruction between January 1, 2020-November 1, 2023, predominantly receiving β-lactam prophylaxis. Incidence of surgical site infection was the primary outcome. Standard and inferential statistical analyses were performed.

Of 315 patients with penicillin allergy, 250 underwent open abdominal wall reconstruction pre-penicillin allergy protocol and 65 post-penicillin allergy protocol. Pre- and post-penicillin allergy protocol were similar in allergic reaction severity history, sex, race, age, diabetes, American Society of Anesthesiologists score, hernia defect size, and mesh type (P > .05). Post-penicillin allergy protocol had lower body mass index (33.4 ± 7.9 vs 29.8 ± 5.3 kg/m2; P = .002) and fewer active smokers (12.4% vs 1.5%; P = .019). Expectedly, post-penicillin allergy protocol received more β-lactam prophylaxis (22.8% vs 83.1%; P < .001) and no antibiotic-induced allergic reactions. Post-penicillin allergy protocol had significantly fewer surgical site infections (24.4% vs 3.1%; P < .001), wound breakdown (16.0% vs 3.1%; P = .004), reoperations (19.2% vs 0.0%; P < .001), and readmissions (25.3% vs 9.2%; P = .006) but no statistically significant reduction in recurrence (8.4% vs 1.5%; P = .057).

The penicillin allergy protocol safely increased the number of patients with penicillin allergy undergoing open abdominal wall reconstruction receiving β-lactam prophylaxis and decreased the rate of surgical site infections, wound complications, reoperations, and readmissions. These data supported the systemwide implementation of the penicillin allergy protocol for both general and orthopedic surgery, which has been incorporated into the electronic medical record of 13 hospitals within the system.

Antimicrobial resistance (AMR) is a significant global health concern, with improper antibiotic use contributing to its rise. Tanzania initiated an AMR action plan in 2017, but comprehensive surveillance and stewardship efforts remain limited. This study focused on evaluating antibiotic use, particularly surgical prophylaxis, in a rural Tanzanian hospital.

The study was conducted at Haydom Lutheran Hospital in Tanzania in May 2023, using a cross-sectional point prevalence survey. Antibiotic use in all patients admitted for >24 h and those undergoing surgery was recorded, including type, dose, indication and duration. Quality indicators for surgical prophylaxis were assessed.

Among 199 inpatients, 55% received antibiotics, with surgical prophylaxis accounting for 23% of prescriptions. Notably, none of the patients who received surgical prophylaxis received a single-dose regimen, and 67% exceeded the recommended 24-h duration. A combination of ampicillin-cloxacillin plus metronidazole was the most commonly prescribed combination for surgical prophylaxis (41% of prescriptions). Thirty-three percent of the antibiotics prescribed for surgical prophylaxis were classified as 'Not recommended' by the World Health Organization. Furthermore, 90% of surgical prophylaxis prescriptions lacked documented rationale, and 83% of prescriptions lacked stop/review dates in medical records.

This study reveals a high prevalence of prolonged antibiotic use for surgical prophylaxis, frequent use of antibiotics classified as 'Not recommended', and a lack of adequate documentation, which deviates from international standards. These practices highlight the urgent need for contextualized national guidelines, large-scale implementation projects of evidence-based interventions, and local initiatives in antibiotic stewardship, particularly in low-resource settings.

The administration of prophylactic antibiotics in obstetrics and gynecology represents a pivotal intervention with a major contribution to the prevention of maternal and neonatal infectious morbidity.

The aim of this study was to review and compare the most recently published guidelines on prophylactic antibiotic use in obstetric and gynecologic procedures.

A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynaecologists of Canada, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists on antibiotic prophylaxis was carried out.

There is a consensus among the reviewed guidelines regarding the importance of antibiotic prophylaxis prior to cesarean delivery, hysterectomy, colporrhaphy and surgical-induced abortions, the optimal choice of antibiotics, and the timing of administration, as well as the indications for increased and additional doses. First-generation cephalosporins are unanimously recommended as first-line antibiotics. All the reviewed guidelines recommend antibiotic prophylaxis in case of preterm prelabor rupture of membranes, whereas they discourage routine antibiotic use in case of active preterm labor with intact membranes or cervical cerclage placement. There is also an overall agreement that antibiotic prophylaxis should not be given for hysteroscopic and laparoscopic procedures with no entry into the bowel or the vagina, endometrial biopsy, intrauterine device insertion, or cervical tissue excision surgeries. Moreover, all the guidelines agree that women undergoing hysterosalpingography should receive a course of antibiotics only when the fallopian tubes are abnormal or there is a history of pelvic inflammatory disease. In contrast, inconsistency was identified on the need of antibiotic prophylaxis in case of obstetric anal sphincter injuries, operative vaginal delivery, and early pregnancy loss. Finally, American College of Obstetricians and Gynecologists states that antibiotics should not be routinely offered for oocyte retrieval and embryo transfer.

Infectious complications following both obstetric and gynecological procedures are significant contributors of morbidity and mortality, rendering their prevention using antibiotic prophylaxis a crucial aspect of preoperative care. Nevertheless, antibiotic overuse should be avoided. Thus, it seems of paramount importance to develop consistent international practice protocols for the appropriate use of antibiotics in everyday practice to minimize their adverse effects and maximize their associated benefits.

Infection is a rare complication of percutaneous renal biopsy (RB). However, the questionnaire included in the Kidney Biopsy Guidebook 2020 in Japan revealed that antibiotic prophylaxis (AP) was administered at about 60% of hospitals. The objective of this study was to evaluate whether it is possible to omit AP for RB.

Patients aged ≥ 15 years were eligible. Three hundred and sixty-four patients were recruited at 6 hospitals. The patients were randomly assigned to receive either a single dose of intravenous cefazolin or no antibiotic prophylaxis. The primary outcome was the percentage of patients that exhibited positive urine cultures 3 or 4 days after the RB. The secondary outcomes were the percentage of patients who were diagnosed with pyelonephritis, puncture site infections (PSI), or an infection other than pyelonephritis or PSI within 30 days, and cefazolin-induced side effects.

With regard to the primary outcome, there was no statistically significant difference between the cefazolin group and the no AP group (2.9% versus 5.1%, p = 0.416). With regard to the secondary outcomes, only one patient (who belonged to no AP group) developed pyelonephritis. This patient underwent urinary catheterization. No PSI occurred. There were no significant intergroup differences in any secondary outcomes.

This study revealed the incidence of post-percutaneous RB infections was minimal. Although the outcomes of this study did not lead to the conclusion that it is unnecessary to use AP for RB, the obtained data suggest that the effects of such AP may not be clinically significant.

This retrospective monocentric study aims to describe the characteristics of neurosurgical site infections (n-SSI) in neurooncological pediatric patients. The primary goal was to assess infection rates and identify common pathogens in this population.

We considered pediatric patients (0-18 years) who underwent neurosurgery for brain tumors at Meyer Children's Hospital in Florence between January 1, 2017, and December 31, 2021. Children with suspected/confirmed n-SSI were included. Data were retrospectively collected from patients' medical records, and covered tumor and surgery type, presence of foreign bodies, microbiological findings, and treatment. Infections were classified into categories according to literature. Statistical analysis was performed using GraphPad Prism. A p value of < 0.05 was considered significant.

Of 352 children undergoing neurosurgery, 43 (12.22%) had suspected/confirmed n-SSI, with a confirmed infection rate of 4%. The most frequent n-SSI was postoperative meningitis (37.2%), followed by wound infections (25.6%). A foreign body was present in 74.4% of cases. The most prevalent pathogens were Staphylococcus aureus (40%) and coagulase-negative staphylococci (33%). Lumbar puncture (LP) performed before antibiotics significantly increased pathogen isolation (p = 0.01). Most patients (95.3%) had fever, and 53.5% had CSF leakage. Antibiotic therapy was administered in all cases, and 65.1% required therapy adjustment. No significant correlation was found between foreign body and clinical symptoms or microbiological positivity.

The study reveals a high rate of n-SSI, emphasizing the importance of early diagnostic measures like LP to improve microbiological diagnosis and optimize antimicrobial treatment. The most frequent pathogen was S. aureus; however, the absence of methicillin-resistant strains is notable. These findings highlight the role of a multidisciplinary approach in managing n-SSI and the potential for n-SSI to delay adjuvant cancer treatments.

To compare the efficacy of clindamycin versus cefazolin in preventing periprosthetic joint infection (PJI) in patients undergoing hip hemiarthroplasty (HA) for femoral neck fractures.

This retrospective cohort study included 1,139 patients aged ≥ 65 years who underwent HA for femoral neck fractures between January 2017 and October 2023. Patients received either Cefazolin + Gentamicin (n = 1001) or Clindamycin + Gentamicin (n = 138). Propensity score matching was performed at a 6:1 ratio, resulting in 828 patients in the cefazolin group and 138 in the clindamycin group. PJI rates, causative organisms, and mortality were compared. Multivariate logistic regression adjusted for potential confounders.

The PJI rate was significantly higher in the clindamycin group compared to the cefazolin group (7.2% vs. 3.5%, p = 0.042). Multivariate analysis confirmed that clindamycin prophylaxis was independently associated with increased PJI risk (adjusted OR = 2.41, 95% CI: 1.16-4.99, p = 0.018). Other independent risk factors for PJI included age (adjusted OR = 1.03 per year, 95% CI: 1.01-1.05, p = 0.045), diabetes mellitus (adjusted OR = 1.76, 95% CI: 1.10-2.81, p = 0.018), and surgery duration (adjusted OR = 1.07 per minute, 95% CI: 1.01-1.16, p = 0.035). Staphylococcus aureus was the most common pathogen, with no significant differences in bacterial distribution between the groups. No significant differences were found in 30-day or 1-year mortality rates.

Clindamycin prophylaxis in hip hemiarthroplasty for femoral neck fractures is associated with a significantly higher risk of PJI compared to cefazolin. These findings support the preferential use of cefazolin in patients without contraindications and demonstrate the critical need for accurate assessment of reported beta-lactam allergies. Results suggest potential benefit from pre-operative allergy evaluation when feasible, as alternative prophylaxis choices may carry increased infection risk. Further research is needed to explore alternative prophylactic strategies for patients with beta-lactam allergies.

To identify risk factors for methicillin-susceptible (MSSA) and methicillin-resistant S. aureus (MRSA) nasal carriage and surgical site infection (SSI) among patients undergoing fracture fixation procedures who were included in a quality improvement protocol involving screening patients for S. aureus nasal carriage and treating carriers with intranasal mupirocin and chlorhexidine bathing.

Retrospective cohort study.

Level 1 trauma center.

1,254 adults who underwent operative fixation of 1,298 extremity or pelvis fractures between 8/1/2014 - 7/31/2017.

We calculated rates of S. aureus nasal carriage and SSI. We used multivariable stepwise logistic regression and selected the final models based on Akaike information criterion.

Of the 1,040 screened first procedures, 262 (25.19%) were performed on S. aureus nasal carriers: 211 (20.29%) on MSSA carriers and 51 (4.90%) on MRSA carriers. Long-term care facility residence (odds ratio [OR] 3.38; 95% confidence interval [CI] 1.17-9.76) was associated with MRSA nasal carriage. After adjusting for statistically and clinically significant variables, MRSA carriage was significantly associated with any SSI (OR 4.58; 95% CI 1.63-12.88), S. aureus SSI (OR 10.11; 95% CI 3.25-31.42), and MRSA SSI (OR 27.25; 95% CI 5.33-139.24), whereas MSSA carriage was not. Among S. aureus carriers, any chlorhexidine use was documented for 232 (88.55%), and any intranasal mupirocin was documented for 85 (40.28%) MSSA carriers and 33 (64.71%) MRSA carriers.

MRSA carriage was associated with a significant risk of SSI after operative fracture fixation. Many carriers did not undergo decolonization, suggesting that a simplified decolonization protocol is needed.

The role of enhanced recovery after surgery (ERAS) in cytoreductive surgery and/or Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is evolving, with promising results that improve patient outcomes. This consensus exercise was carried out to address and standardize components of the ERAS protocol pertinent to the Indian context.

The modified Delphi method was employed with two rounds of voting. All fifty invited specialists agreed to vote. There were 30 questions addressing the key elements of ERAS protocols. They were broadly distributed across four sections: Prehabilitation, Preoperative, Intraoperative, and Postoperative elements. A consensus was achieved if any one option received > 70 % votes (strong consensus > 90 %). If consensus was not achieved in round 1, the question was moved to round 2.

After rounds I and II, 48/50 (95.8%) of invited panelists voted for the questions. The highest rate of 'skipped question' was 6% in both rounds. A consensus was obtained for 28/30 (93.33%) questions, and strong consensus was obtained for 5/30 (16.6%) questions. No consensus was obtained for two questions. Some of the panelists' recommendations contradicted the standard ERAS guidelines, such as using intraperitoneal drains in all patients and mechanical bowel preparation for left-sided colonic or rectal resections.

Despite some limitations, this consensus exercise represents a significant step toward advancement and pioneering efforts to improve patient outcomes by implementing and standardizing ERAS protocols in CRS and/or HIPEC tailored for India.