Robert G. Sawyer

Knowledge, awareness, and attitude towards infection prevention and management among surgeons: identifying the surgeon champion

Despite evidence supporting the effectiveness of best practices of infection prevention and management, many surgeons worldwide fail to implement them. Evidence-based practices tend to be underused in routine practice. Surgeons with knowledge in surgical infections should provide feedback to prescribers and integrate best practices among surgeons and implement changes within their team. Identifying a local opinion leader to serve as a champion within the surgical department may be important. The “surgeon champion” can integrate best clinical practices of infection prevention and management, drive behavior change in their colleagues, and interact with both infection control teams in promoting antimicrobial stewardship.

The Significance of Interleukin-6 in the Early Detection of Surgical Site Infections after Definitive Operation for Gastrointestinal Fistulae

BACKGROUNDnSurgical site infections (SSIs) are among the most common complications after definitive treatment for intestinal fistulae. Serum inflammatory markers including white blood cell count (WBC), C-reactive protein (CRP), interleukin-6 (IL-6), as well as procalcitonin (PCT) have been used to help diagnosis post-operative complications.nnnOBJECTIVEnThe goal of this study was to assess the clinical value of inflammatory markers, specifically IL-6, in predicting SSIs after intestinal fistulae resection.nnnMETHODSnA total of 184 consecutive patients who underwent elective intestinal fistula resection were enrolled prospectively. All patients were screened to exclude patients with existing clinical infection. Plasma IL-6 concentrations, serum PCT, and CRP concentrations were measured pre-operatively and on post-operative days one, three, and seven. The predictive value of each laboratory marker for SSI was calculated.nnnRESULTSnThe incidence of SSI after elective intestinal fistula resection was 26.7%. Interleukin-6, PCT, and CRP concentrations were higher in patients with SSIs compared with patients without. In contrast, there was no statistical difference for WBC counts between the two groups. Receiver operating characteristic curves demonstrated that IL-6 had the highest diagnostic effectiveness for post-operative SSI on post-operative day one, with an area under the curve of 0.77, and a sensitivity of 85.7% and specificity of 63.9%.nnnCONCLUSIONnA concentration of IL-6 above 95.6u2009ng/L on post-operative day one and 52.5u2009ng/L on post-operative day three, and a concentration of PCT exceeding 0.61u2009mcg/L predict the occurrence of SSI after definitive operations for gastrointestinal fistulae.

Short-Course Antimicrobial Therapy Does Not Increase Treatment Failure Rate in Patients with Intra-Abdominal Infection Involving Fungal Organisms

BACKGROUNDnFungi frequently are isolated in intra-abdominal infections (IAI). The Study to Optimize Peritoneal Infection Therapy (STOP-IT) recently suggested short-course treatment for patients with IAI. It remains unclear whether the presence of fungi in IAI affects the optimal duration of Antimicrobial therapy. We hypothesized that a shorter treatment course in IAI with fungal organisms would be associated with a higher rate of treatment failure.nnnMETHODSnPatients enrolled in the STOP-IT trial were stratified according to the presence or absence of a fungal isolate. They were analyzed as a subgroup based on original randomization to either the control group or an experimental group that received a four-day course of Antimicrobial therapy and by comparison with those without a fungal component to their infection. Descriptive comparisons were performed using a χ2, Fisher exact, or Kruskal-Wallis test as appropriate. The primary outcome was a composite of recurrent IAI, surgical site infection, and death.nnnRESULTSnA total of 411 patients in the study (79%) had available culture data, of which 58 (14%) had positive fungal cultures. The most common organisms were Candida albicans and C. glabrata. The treatment failure rate was equivalent in the experimental and control arms (29.6% vs. 22.6%; pu2009=u20090.54). Patients with fungal isolates were more likely to have malignant disease (25.9% vs. 9.6%; pu2009=u20090.0004) and coronary artery disease (22% vs. 12%; pu2009=u20090.04), but were otherwise similar to those without fungal isolates. Patients with fungal isolates had more hospital days (median 10 vs. 7; pu2009<u20090.0001) and more days to resumption of enteral intake (median 5 vs. 3; pu2009=u20090.0006), but there was no difference in the composite outcome.nnnCONCLUSIONSnPatients with IAI involving fungal organisms randomized to a shorter course of Antimicrobial therapy had no difference in the rate of treatment failure. These results suggest that the presence of fungi in IAI may not indicate independently the need for a longer course of Antimicrobial therapy.

Plasma metabolomics pilot study suggests age and sex-based differences in the metabolic response to traumatic injury

INTRODUCTIONnAge and sex affect outcomes from trauma. Older patients tend to be under-triaged, consume more healthcare resources, and experience worse outcomes relative to younger patients. Sex has also been associated with different outcomes, with women experiencing better outcomes than men. While baseline metabolism differs with both age and sex, no study has examined how these differences affect the response to trauma. We used high-throughput metabolomics to assess metabolic differences associated with blunt trauma according to age and sex.nnnMETHODSnMetabolic profiles were constructed using nuclear magnetic resonance spectroscopy for trauma patients age 21-40u2009years (nu2009=u200920, 55% male) and >65 years (nu2009=u200922, 41% male) from plasma samples obtained on Day 1 and Day 3 of each patients hospital stay. These were compared to profiles constructed from plasma obtained from healthy controls of the same age (21-40: nu2009=u200923, 61% male; 65+: nu2009=u200926, 50% male). Differences in metabolic profiles were assessed with partial least squares discriminant analysis.nnnRESULTSnTrauma elicits an overwhelming global stress response that includes more subtle differences in metabolism related to age and gender. Significant differences due to normal aging were also identified. Many of the metabolites measured were present in similar levels in healthy controls age 65+ as they were in trauma patients of all ages. Sex-based differences in metabolism were observed in younger trauma patients on Day 3 but not in older patients.nnnCONCLUSIONSnDifferences in energy metabolism and oxidative stress were implicated in the response to trauma in all patients. Older trauma patients may enter the trauma state with pre-existing oxidative stress and energy deficits that complicate recovery. Sex-based differences in recovery from trauma support the large body of work demonstrating the role of sex in recovery from trauma.

Volume-based feeding improves nutritional adequacy in surgical patients

BACKGROUNDnCritically ill surgical patients often receive inadequate enteral nutrition using traditional rate-based feeding methods. An alternative strategy is volume-based feeding, in which feeding rates are adjusted to deliver a goal volume per day.nnnMETHODSnThis prospective quality improvement study in a single surgical, trauma, and burn ICU compared volume-based feeding to rate-based feeding in a before-and-after design. Outcomes included calories and protein delivered, length of stay, infection, and mortality.nnnRESULTSnA total of 50 patients received volume-based feeding and 49 rate-based feeding. The volume-based group received a higher proportion of goal calories (84.5% vs. 73.4%; pu202f=u202f0.005) and protein (86.2% vs. 77.4%; pu202f=u202f0.01), as well as increased total daily calories (1604 vs. 1356u202fkcal; pu202f=u202f0.02). There was no difference in length of stay, mortality, aspiration, or gastrointestinal intolerance.nnnCONCLUSIONSnVolume-based feeding improved nutritional intake in critically ill surgical patients, although this study was underpowered to determine differences in clinical outcomes.

The emerging role of stimulator of interferons genes signaling in sepsis: Inflammation, autophagy, and cell death

Stimulator of interferons genes (STING) is an adaptor protein that plays a critical role in the secretion of type I interferons and pro‐inflammatory cytokines in response to cytosolic nucleic acid. Recent research indicates the involvement of the STING pathway in uncontrolled inflammation, sepsis, and shock. STING signaling is significantly up‐regulated in human sepsis, and STING agonists are suggested to contribute to the pathogenesis of sepsis and shock. Nevertheless, little is known about the consequences of activated STING‐mediated signaling during sepsis. It has been shown that aberrant activation of the STING‐dependent way can result in increased inflammation, type I interferons responses, and cell death (including apoptosis, necroptosis, and pyroptosis). In addition, autophagy modulation has been demonstrated to protect against multiple organs injuries in animal sepsis model. However, impaired autophagy may contribute to the aberrant activation of STING signaling, leading to uncontrolled inflammation and cell death. Here we present a comprehensive review of recent advances in the understanding of STING signaling, focusing on the regulatory mechanisms and the roles of this pathway in sepsis.