Treating abdominal surgical site infection using NPWT in Abdominal Tuberculosis Patient: A case report

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Authors:
Perwira Widianto

Body of Abstract:
Background: Negative pressure wound therapy (NPWT) for abdominal surgical site infection (SSI) is becoming increasingly common, although enterocutaneous fistula (ECF) has been reported as a com plication after abdominal tuberculosis surgery. To avoid ECF, we used computed tomography (CT) abdominal to evaluate the relationship between the wound and the intestine, and then safely treated the abdominal SSI with NPWT.
Case Presentation: a 30-year-old man following a laparoscopic appendectomy for acute appendicitis case. Six days after surgery, we diagnosed ECF. We performed ileostomy because there is leak in terminal ileum 20 cm oral ileocecal valve, pathology result was abdominal tuberculosis. There is also deep SSI, because the wound was deep and the pus resembled enteric fluid Accordingly, we performed NPWT. SSI was cured and the wound was well granulated. Twenty days after surgery, the patient was discharged. Eventually, the wound was completely epithelialized
DISCUSSION: Although successful NPWT has been reported for open abdominal wounds, ECF is a common complication. ECF can be prevented by separating the wound from the intestine by the omentum or muscle fascia, protecting the intestinal serosa during surgery, and applying low vacuum pressure. The relationships among the wound, the fascia, and the intestine must be evaluated before abdominal SSI treatment
CONCLUSION: We report a case of successful NPWT for abdominal SSI in tuberculosis patient

Preventing Surgical Site Infections with Intradermal Antibiotics.

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Authors:
Christian Potter, Dow Stough MD, Tom Ashfield

Body of Abstract:
Intra-Incisional Delivery
The delivery of microdoses of incisional antibiotics to reduce the rate of surgical site infections has been documented in the literature for over 40 years.3,4,5 There is now robust evidence and published meta-analysis to change treatment guidelines in this area. A meta-analysis demonstrated significantly less surgical site infections versus placebo in a study by Mourad.1There are multiple antibiotics involving a variety of classes which potentially could be distributed by the intra-incisional route.
The benefits of a direct deposit of antibiotics into the surgical area include the following:
1. The administration of the preoperative antibiotics can be tailored to the onset of the surgical procedure. Specifically, the intra-incisional antibiotic can be given with a lidocaine diluent 10 to 15 minutes prior to the surgical procedure. The uncertainty of the oral and intravenous routes can be eliminated.
2. The nausea associated with oral administration of antibiotics is no longer a concern.
3. The major organ systems of the body, including the CNS, are not exposed to large amounts of unneeded antibiotics along with the associated adverse events.
4. The normal gastrointestinal microbiota is not altered detrimentally. The emergence of colitis due to Clostridium should be minimized by an intra-incisional approach.
5. Higher tissue levels with greater efficacy are possible with intra-incisional delivery compared to other routes.
6. There is less risk to the patient of medical errors and mishaps involving IV access, mixing of antibiotic solutions, and proper calculation of the intravenous rate of delivery.
7. The development of resistant organisms will be minimized with the intra-incisional route.
8. Compliance issues with oral antibiotics will be eliminated.
9. There is a theoretical possibility to decrease systemic drug interactions by the intra-incisional approach.
10. Current antibiotic recommendations are based primarily on efficacy and safety not on cost. Cost savings could be an additional benefit realized through the intra-incisional route of antibiotic delivery.
11. There is an emerging trend reported by the National Nosocomial Infections Surveillance System (NNIS), that demonstrates gram-negative bacilli decreased from 56% to 33% over the last 25 years. Gram-positive bacteria have increased in prevalence. Surgical site infections caused by staph aureus have increased by 30%. The resistant strains of staph and MRSA, compromise almost 50% of this group. The antibiotics needed to treat this MRSA, are often those that cannot be given orally, and therefore intravenous treatment is recommended. The intra-incisional route offers the advantage of soft tissue antibiotic delivery for the treatment or prevention of MRSA without the requirement for IV access.

Surgical Management and Post operative Morbidity in Abdominal Tuberculosis Patients

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Authors:
Perwira Widianto

Body of Abstract:
Background: The adequacy of tuberculosis treatment before abdominal surgery is a dilemma faced by surgeons who aims for low risk of morbidity. In addition, there is no morbidity data post abdominal operation in abdominal Tuberculosis (TB) patients at Persahabatan Central General Hospital.
Method: This study is a descriptive-analytic cross-sectional study done in Persahabatan Central General Hospital using total sampling method, a total of 110 subjects with abdominal TB and had undergone abdominal operation and was admitted from January 2019 to November 2024, that fulfilled the criteria of this study. Bivariate and multivariate analysis using SPSS was done to analyse the correlation between TB treatment adequacy and postoperative morbidity and mortality.
Results: 75 subjects (68%) did not receive adequate preoperative TB treatment. There are 2 significant morbidities in this study (fistula enterocutaneous, surgical site infection), only surgical site infection (SSI) has significant correlation with TB treatment adequacy (p=0.048). There is no significant correlation with postoperative mortality (p=0.564). Compared to elective surgery, emergency surgery has higher morbidity (OR = 1.62; 95% CI 0.58 – 4.53) and SSI (OR = 2.02; 95% CI 0.63 – 6.46)
incidence.
Conclusion: Adequate preoperative TB treatment lowers the postoperative morbidity such as surgical site infection. Morbidity and SSI are more likely to happen in emergency surgery than elective surgery. Both adequacy of antituberculosis treatment and surgery type are independent risk factors for morbidity. Anti-tuberculous therapy remains main stay of treatment after the surgery as early as possible surgical interference in acute abdominal tuberculosis is important to decrease the prevalence of morbidity and mortality in the patients.

The Impact of a Novel Microbicidal Elastomeric Liquid Polymer (Preventogen) on Surgical Site Infections in Patient Undergoing Surgery

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Authors:
Christy Chai, Hachem Bey, Raymond Lopez, Samir Awad

Body of Abstract:
Background: Surgical site infections (SSI) are the most common hospital acquired infection accounting for 20% with increase in morbidity, mortality and cost. In vitro, Preventogen, a novel elastomeric microbicidal liquid polymer has been shown to actively kill pathogens such as MDRO and Non-MDRO gram positive & negative bacteria, and various fungi on contact through cell lysis; drying within 30 seconds to create a flexible see through film barrier that continues to protect the surgical site for 5-7 days. Previous reports have demonstrated a significant decrease in external fixator pin site infections [Pema, doi:10.15761/CMID.1000177].

Hypothesis: Our objective was to evaluate the impact of Preventogen on SSI rates in patients undergoing general and surgical oncologic procedures. We hypothesized that Preventogen would decrease the risk of SSIs.

Methods: A retrospective review of a prospective data base of patients undergoing elective surgery at a tertiary academic hospital was performed from 7-1-2022 to 10-1-2024. Age, gender, comorbidities (HTN, CHF, COPD, DM, Tobacco, AKI, Ascites, sepsis, functional status, cancer), demographics and procedure CPT codes were collected. Cases were stratified for clean and clean contaminated (CC). For each patient the expected SSI risk was calculated using the validated ACS NSQIP risk calculator (https://riskcalculator.facs.org/RiskCalculator/index.jsp). All patients underwent preoperative decontamination with Chlorhexidine wipes day prior and on day of surgery; all had surgery site appropriate prophylactic antibiotics prior to incision; and all had Chloraprep as the skin prep. Preventogen was applied as the dressing after skin closure. SSIs at 30 days were collected and the Observed to Expected (O/E) ratio was calculated. Statistical analysis was performed using Chi square with p<0.05 as significant. Results: A total of 76 cases were evaluated, 51% (39) clean, 49% (37) CC. Overall, the mean age was 61+/-2 years, and BMI 30.4+/-0.65. 61% male, 40% DM, 12% smokers and 10% AKI. Overall the ACS NSQIP calculated SSI risk was 4.13% with no observed 30-day surgical site infections [Expected=4.13, Observed=0, O/E ratio=0, 95%CI (0,0.73), p=0.032]. Conclusions: The use of Preventogen in patients undergoing surgery resulted in a significant reduction of SSI rates with no observed 30-day SSIs in a patient cohort expected to have a 4% SSI rate. Preventogen liquid Polymer can be safely used as elastomeric see-through dressing in clean and clean contaminated surgical cases to significantly reduce SSI rates.

The amazing world of obligate anaerobic Gram positive cocci: a critical analysis of 598 infectious episodes in the era of MALDI-TOF MS

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Authors:
Aaron George, Hugo Bonatti, Joel Grunhut, Pooja Ajith

Body of Abstract:
Background: Peptostrepotococci have been known as 2nd most common anaerobic bacteria causing diseases in humans. Better microbiology testing systems have allowed for better distinguishing the different species and genus of Gram positive obligate anaerobic cocci (GPAC). The currently accepted classification distinguishes between Peptostreptococcus anaerobius (PA), Finegoldia magna (FM), Parvimonas micra (PM), Peptionphilus asaccharolyticus (PAs) and Anaerococcus prevotii (AP), however, this list is expanding.
Patients and Methods: Our institutional database was searched for all infections caused by GPAC during a 4-year period. Identification was done using biochemical assays during the first 2 years and thereafter, using MALDI-TOF.
Results: In total, 714 isolates of GPAC in 597 patients (52.3% male) were identified. Table 1 shows demographic, clinical and microbiology data for the different GPAC: PA (90), FM (212), PM (74), PAs (125) and AP (146); in 50 cases (8%) two different GPAC were isolated. Median age was 56.5 (range 1 day to 98.8) years including 16 pediatric and 53 octogenarian patients. Median BMI was 30.8 (range 11.5 – 77.5) kg/m2 with a 56% obesity rate; 37% were diabetic and 35% active smokers. Drained abscesses/fluid collections and tissue samples accounted for 84%% of specimens, wound cultures for 5% and blood cultures for 11% of specimens; 57% of GPAC isolates were identified since MALDI-TOF introduction. Infection locations were head/neck 4%, trunk 35%, upper extremity 3%, lower extremity 36%, intraabdominal 11%, chest 1% and blood stream 11%. Microscopy of 530 specimens revealed WBC in 78%, Gram positive cocci in 78%, Gram negative rods in 38% and Gram positive rods in 29%. Normal flora, in addition to GPAC was reported in 54% of specimens. In 25% EC was a single isolate; spectrum of pathogens isolated in addition to GPAC in 446 mixed infections included staphylococci (127), streptococci (103), enterococci (18), Gram negative rods (161), other anaerobes (264), and yeast (10). Treatment consisted of surgical drainage/debridement during which samples for microbiology were taken and antibiotics with anaerobic activity.
Conclusion: GPAC are a diverse group of pathogen and have remained an important cause of serious surgical infections. PM was more commonly found in intraabdominal infections and together with AP had the highest propensity to invade the blood stream. FM on the other hand is most commonly found in soft tissue infections.

Necrotizing Enterocolitis is Associated with Elevated Iron Levels and Toxic Lipid Radicals in Neonatal Intestinal Tissue

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Authors:
Alex Frickenstein, Aslan Massahi, Catherine Hunter, Chase Calkins, Cody Dalton, Grant Gershner, Heather Grubbs

Body of Abstract:
Purpose: Necrotizing enterocolitis (NEC) is a devastating disease that continues to plague neonates in neonatal intensive care units, despite over sixty years of research. Ferroptosis, a recently discovered version of programmed cell death similar to Apoptosis, is characterized by the accumulation of lipid radicals and iron. While Ferroptosis has been illustrated in NEC, but its role has yet to be defined. We hypothesize that patients with active NEC will have higher levels of iron compared to other groups. We also hypothesize that patients with active NEC will have higher levels of the toxic lipid radicals 4-hydroxyl-2-hexenal (4-HHE) and 4-hydroxynonenal (4-HNE), which are seen in oxidative stress.

Methods: For iron analysis, intestinal tissue was collected from control patients, patients with a history of NEC, and patients with active NEC. The tissue underwent acid digestion, and a subsequent colorimetric assay was performed using a bathophenanthroline-based colorimetric assay. Using the same patients, new tissue samples were prepared and analyzed using inductively coupled plasma mass spectrometry (ICP-MS). For lipid radical analysis, enteroids were grown from similar cohorts and underwent NEC induction. These were then harvested, processed, and analyzed using western blotting for 4HHE and 4HNE. Statistical analysis was then performed using One- or Two-way ANOVA and Student’s t-test as appropriate.

Results: Patients with active NEC had significantly elevated levels of iron compared to control (p=0.0029) and those with a history of NEC (p=0.0008). There was no significant difference between control patients and those with a history of NEC (p=0.6699). This pattern was consistent for ICP-MS. Patients with NEC had significantly higher levels of iron compared to control patients (p=0.015). Enteroids who underwent NEC induction had significantly elevated levels of 4-HHE (p=0.0114). While these enteroids had decreased levels of 4-HNE compared to the control, this difference did not reach statistical significance.

Conclusion: Patients with active NEC had significantly higher levels of iron compared to controls and those who had recovered from NEC. This was found true using two different modes of iron level quantification. Additionally, NEC enteroids had significantly elevated levels of 4-HHE. In line with our lab’s previous research, this strongly implies that Ferroptosis plays a role in the pathology of NEC. In line with our lab’s previous research, this strongly implies that Ferroptosis plays a role in the pathology of NEC.

Investigating microbial mitigation for surgical incision sites using UV-C

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Authors:
Benjamin Robertson, Christopher Jones, David Brenner, Deborah Mosca, Eric Prast, Ernest Blatchley III, Karl Linden, Katja Auer, Nancy Havill, Richard Rasansky

Body of Abstract:
Background
Surgical site infections (SSIs) are a serious complication following surgery, requiring additional antibiotics, prolonged hospitalizations, or hospital readmission. The emergence of multidrug-resistant pathogens has diminished the effectiveness of traditional antimicrobials thus requiring a new approach to prevention and treatment. We are developing an innovative device (xIP) that uses UV-C to inactivate pathogens in surgical incision sites, mitigating the risk of developing an SSI.
Irradiation in the UV-C range (200-280 nm) is well known to inactivate pathogens by damaging DNA and RNA. Despite its known effectiveness in surface and aerosol pathogen inactivation, there is a limited body of work for the application of UV-C on surgical sites.

Methods

To assess disinfection in the UV-C range we explored three sources. A Krypton-Chloride Excimer (KrCl*) lamp ( peak = 222 nm), a pulsed Xenon (PX) emitter (broad spectrum), and a UVC LED ( peak = 282 nm). Inactivation of Escherichia coli (E. coli, ATCC 29425) and methicillin-resistant Staphylococcus aureus (MRSA, USA300) was determined by in vitro exposure to UV-C at doses of 0 (control), 2, 5, 10, 15, and 20mJ/cm2.

Microbial suspensions of log-phase cultures were pelletized and resuspended in phosphate buffered saline three times. The adjusted suspension concentration of ~109 CFU/mL was then diluted to 107 CFU/mL. After UV exposure, suspensions were plated on an agar substrate using a grid-based method. After incubating for 48 hours at 37°C, remaining viability was determined.

Results

For all emitters, we observed a 4.5-5+ log reduction in MRSA and 4-5+ log reduction in E. coli at the highest UV dose (20mJ/cm2). PX and KrCl* emitters both showed peak inactivation of 5+ in both test microorganisms, while LED showed 4 and 4.5 log reduction in E. coli and MRSA, respectively. PX demonstrated the highest inactivation efficiency (log-reduction per unit dose), followed by KrCl* and LED.

Conclusions

In-vitro data suggest that surgical sites could be effectively treated in less than a minute with a small hand-held device and less than 10 seconds with a larger device. Inactivation of MRSA using a superficial wound model in hairless SHKI1-elite mice (Charles River strain code 477) is in progress.

In-silico modelling using optical raytracing is in progress to understand the impact of wound and skin micro-environment on the performance of the device. These data will help inform ex-vivo testing using porcine or surrogate human skin (EpiDerm FT) models to evaluate the performance of our device in different wound types such as incisions, abrasions, and punctures as well as the impact of fluids such as saline and blood.

Development of the xIP device is underway in collaboration with healthcare professionals to produce a product that is effective, fits into current practice, and is broadly automated. Upon successful completion of a prototype device, clinical efficacy will be explored.

DUPLICATE SUBMISSION – DO NOT SCORE** Rare in the Air: Disseminated Coccidiomycosis in an Immunocompetent Patient

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Authors:
Nicole Siparsky

Body of Abstract:
Background: Coccidioidomycosis is a fungal infection endemic to the southwestern United States, often manifesting as a mild respiratory illness in immunocompetent individuals. Disseminated coccidioidomycosis occurs rarely (1%), typically in immunocompromised patients, involving extrapulmonary sites such as skin/soft tissue, bones, and the central nervous system (CNS). We present an unusual case of disseminated coccidioidomycosis with extensive multi-system involvement in an otherwise healthy young male, complicated by significant psychiatric and treatment adherence challenges.
Methods: We performed a retrospective case review after obtaining expedited Institutional Review Board approval by exemption, including notes, labs, imaging, culture data, and procedural reports.
Results: A 23-year-old male with asthma presented with an 8-month history of generalized pain, weight loss, intermittent chills, and limited ambulation due to right hip pain. Residential history included Arizona and the Great Lakes region with notable prior incarceration in Arizona. Examination revealed tachycardia (HR 120 beats per minute), lethargy, and tender swellings of the right thigh and left buttock. Labs demonstrated anemia (Hgb 7.9 g/dL), leukocytosis (13 × 10³/μL), elevated C reactive protein (165 mg/L), and hypoalbuminemia (2.5 g/dL). Imaging revealed a miliary pattern of pulmonary micronodules, cystic structures in multiple anatomical regions, and destructive bony lesions. Fine needle aspiration of a thigh lesion confirmed Coccidioides immitis. Cerebrospinal fluid sampling revealed WBC 0/uL, glucose 55 mg/dL, protein 28.9 mg/dL, and negative bacterial and fungal cultures. He was initially treated with fluconazole 400 mg daily. Subsequent admissions highlighted complications from poor medication adherence and worsening fungal burden despite increasing the fluconazole dose to 400 mg twice daily. Repeat imaging demonstrated extensive fluid collections and abscesses involving the pelvis, lumbar spine, and femoral regions. Psychiatry also noted psychotic features and cognitive decline, further complicating care. The antifungal regimen escalated to liposomal amphotericin B and voriconazole due to new neurologic involvement and significant disease progression. His course also included surgical drainage of a 22 cm buttock muscle abscess by skip-incision technique with insertion of four long-term surgical loop drains to prevent recurrence, as well as percutaneous drainage of deep space abscesses of the right thigh not amenable to simple drainage.
Conclusion: This case highlights the atypical presentation and challenges in managing disseminated coccidioidomycosis in an immunocompetent patient. Delayed diagnosis, medication nonadherence, and psychiatric comorbidities necessitated a multidisciplinary approach. Effective management required antifungal therapy escalation and surgical interventions. This case emphasizes the importance of early diagnosis and comprehensive care.

Infection: A Major Contributor to Anemia of Critical illness

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Authors:
Conor Dillon, Elizabeth Wang, Harshank Patel, Hassan Nadeem, Monica Patten, Robert Sawyer, Sara Hennessy, Tjasa Hranjec

Body of Abstract:
Background: Critically ill patients often receive transfusions beyond the initial resuscitation (>48 hours), not always associated with hemorrhage or perioperative blood loss. We hypothesized that injured, infected patients would receive fewer products due to their hypercoagulable state.

Methods: A single center, chart review identified all adult, trauma patients, admitted to our trauma Intensive Care Unit (ICU) with hospital length of stay (LOS) ≥7 days over a 12-month period. Infections were divided into early (≤72 hours post-trauma) and late (>72 hours post trauma). Univariate analysis was used to evaluate an association between anemia (hemoglobin ≤ 7.9) outside of the initial resuscitation window (>48 hours), infection, and transfusion. Multivariate analysis identified risk factors for transfusion.

Results: A total of 145 patients were included: mean age 50±1.7 years, mostly male (71%) with mean LOS 14.7±0.9 days. Among 79 (54.5%) injured patients requiring no transfusion during hospitalization, 9 (11.4%) were treated for an infection (Figure 1). Comparatively, 66 patients were transfused beyond 48 hours, with 52 patients (78.8%) infected, p<0.0001. Pneumonia was most frequently diagnosed (70%), followed by intra-abdominal infection (17.3%). Infected patients received a total of 271 RBC transfusions, compared to 28 in non-infected patients, p<0.0001. Patients with early infections received less red blood cells (RBC) compared to late infections (1.3±0.6 vs 5.1±1.0, p=0.0024). Early diagnosis and treatment of infections was associated with less RBC (3.1±0.9 vs 6.0±1.5, p=0.0824). Most episodes of anemia had no identifiable bleeding source, however, 77.5% of infections were diagnosed within 72 hours of the lowest, documented hemoglobin. Nearly one-third of the patients experienced severe bleeding (GI hemorrhage, retroperitoneal hematoma, hemoptysis) and required life-saving interventions. Most (93%) patients with severe bleeding were found to have late or persistent infections that despite treatment and clinical improvement, were not abolished. When adjusted for age and gender, perioperative bleeding (OR 13.8, CI 4.1-46) and infection (OR 37.7, CI 12.5-113.4) were found to be the most significant predictors of transfusion beyond the resuscitation period (c-statistic 0.908). Of note, only patients with late infections developed documented venous thrombosis (n=6). Conclusions: A strong association exists between infection and significant hemorrhage in the ICU. An acute decrease in hemoglobin (anemia of critical illness) without obvious cause may be considered as a trigger for infectious work-up in patients whose clinical signs, symptoms and laboratory/radiologic findings are unclear. Prompt diagnosis and treatment of infection may decrease the risk of severe hemorrhage and volume of transfusions. Figure 1. Venn diagram of patients based on their infection, transfusion or perioperative status

Infections caused by the emerging anaerobic surgical pathogen Finegoldia magna: review of 212 cases

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Authors:
Aaron George, Hugo Bonatti, Joel Grunhut, Jonathan Adams, Junius Rosario, Pooja Ajith

Body of Abstract:
Background: Finegoldia magna (FM), previously referred to as Peptostreptococcus magnus, is a Gram-positive obligate anaerobic coccus (GPAC) that typically reside as part of the normal human skin and mucosal flora. They can act as an opportunistic pathogens being one of the most pathogenic GPAC. Severe infections such as endocarditis, pericarditis, necrotizing pneumonia and less common intraabdominal infections have been reported. FM has a higher propensity to cause soft tissue infections including necrotizing fasciitis.
Patients and Methods: Our institutional database was searched for all cases of FM infections during a 4-year period. Pathogens reported out as Peptostreptococcus magnus prior to introduction of MALDI-TOF in 2021 were reclassified as FM.
Results: A total of 261 isolates of FM in 212 patients (43% male) were identified. Median age was 54.1 (range 2.5 to 97.6) years). FM accounted for 37% of all 714 isolates of GPAC outnumbering Peptostreptococcus anaerobius (15%), Parvimonas micra (12%), Peptoniphilus asaccharolyticus (21%) and Anaerococcus prevotii (25%). For FM patients, rate of obesity was 60%, DM 39% and 34% of patients were active smokers. 93% of isolates were from drained abscesses or fluid collections and tissue biopsies, 4% were from wounds and 3% were recovered from blood cultures. 67% of specimens were sent by surgical services, 6% by medical teams, 11% by primary care and 16% cam from the emergency department. Infections were located at head&neck 3%, trunk 34%, upper extremity 3%, lower extremity 53% intraabdominal 4% with 3% bacteremia cases. Microscopy of 205 specimens revealed WBC in 76%, Gram positive cocci in 77%, Gram negative rods in 26% and Gram positive rods in 20%. In 24% FM was a single isolate, spectrum of pathogens isolated in addition to FM included staphylococci (29%), streptococci (17%), enterococci (3%), Gram negative rods (24%), anaerobes including other GPAC (50%), and yeast (1%). Staphylococcus aureus was the most common single co-infecting pathogens (27%) with 50% being MRSA. Treatment consisted of surgical drainage/debridement and antibiotics including Betalactms or clindamycin; outcome was in general favorable.
Conclusion: FM is an emerging pathogen mainly causing skin and soft tissue infections of the trunk and lower extremity. The exact role of FM in mixed infections is still unclear and warrants additional research.