Authors:

Body of Abstract:
Background: CMV is one of the most consequential infections affecting kidney transplant recipients, leading to higher risk of graft loss, morbidity and mortality1. There are multiple risk factors for CMV seroconversion including donor/recipient serological status, anti-thymocyte globulin (ATG) induction and mycophenolate maintenance immunosuppression2,3. This study evaluates induction regimens, among other risk factors, over the past two and the half decades.

Methods: UNOS database was analyzed from year 2000 to 2024. Cox regression was used for the occurrence of CMV IgM+ from IgG- or IgG+ (N=206,113). Logistic regression was done for seroconversion analysis (IgM-/IgG- to IgM+/IgG+) (N = 45,783).

Results: Recipient who were older, men, of African American or Hispanic ethnicity/group, with higher cPRA and longer wait listing had higher odds of (primary and secondary) infection and seroconversion due to CMV infection. Alemtuzumab correlated with higher odds of infection but lower seroconversion (HR 1.18 95%CI[1.09-1.26]; p<0.001 and OR 0.89 95%[0.80-0.98]; p=0.027 respectively) than thymoglobulin. Seroconversion was less likely with IL2Ra induction (OR 0.86 95%[0.78-0.95]; p=0.003) and infection less likely with dual induction ATG+IL2 Receptor antagonist (HR 0.72 95%[0.60-0.86]; p<0.001). Seroconversion was less likely for recipients transplant between 2012 and 2024 compared to 2000 until 2011 (OR 0.91 95%[0.84-0.99]; p=0.035). Conclusions: While primary and secondary CMV infections seem to be similar over time, the risk of seroconversion appears to have improved in the past decade, possibly due to the adoption of better prophylaxis regimens. 1- Selvey, L.A., Lim, W.H., Boan, P. et al. Cytomegalovirus viraemia and mortality in renal transplant recipients in the era of antiviral prophylaxis. Lessons from the western Australian experience. BMC Infect Dis 17, 501 (2017). https://doi.org/10.1186/s12879-017-2599-y 2- Luan FL, Samaniego M, Kommareddi M, Park JM, Ojo AO. Choice of induction regimens on the risk of cytomegalovirus infection in donor-positive and recipient-negative kidney transplant recipients. Transpl Infect Dis. 2010 Dec;12(6):473-9. doi: 10.1111/j.1399-3062.2010.00532.x. PMID: 20576019; PMCID: PMC3831513. 3- Sarmiento JM, Dockrell DH, Schwab TR, Munn SR, Paya CV. Mycophenolate mofetil increases cytomegalovirus invasive organ disease in renal transplant patients. Clin Transplant. 2000 Apr;14(2):136-8. doi: 10.1034/j.1399-0012.2000.140206.x. PMID: 10770418.

Authors:
Chris Guidry, Clint Humphrey, Duncan Nickerson, Jennifer Doan, John Flynn, Lauren Kerivan, Matt Shoemaker, Rahel Eshete, Robert Winfield, Robinson Okolo, Stepheny Berry, Terra Hill, Tien Pham

Body of Abstract:
Introduction
Despite evidence and guidelines recommending against prophylactic antibiotics for patients with facial fractures, their use remains widespread. To combat this issue, we created a multidisciplinary practice management guideline (PMG) recommending against the use of prophylactic antibiotics for these patients. This study evaluates the impact of the PMG on the rate of antibiotic recommendation and administration.

Methods
We conducted a retrospective review of electronic medical records of adult patients admitted to our Level 1 trauma center with a facial fracture secondary to traumatic mechanism between May 2022 to May 2024. The PMG was initiated on May 1, 2023. Patients were divided into pre- and post-implementation groups. Chi-square and Wilcoxon two-sample analyses were conducted to compare rates of antibiotic administration pre- and post-implementation.

Results
A total of 501 patients with a traumatic facial fracture were identified, of which 49.3% were during the pre-implementation and 50.7% within the post-implementation timeframes. Patients were primarily non-Hispanic (92%), White (70.7%), male (71.3%), and had a median age of 47 years. Maxillofacial infections were present in 0.4% of patients for both timeframes (p=0.98). There were no differences in either antibiotic recommendation or administration rates from pre- to post-PMG implementation of 29% to 34.5% (p=0.18) and 33.7% to 41% (p=0.09), respectively.

Conclusion
The creation of a multidisciplinary PMG failed to reduce prophylactic antibiotic administration for traumatic facial fractures. Antibiotic administration did not impact rates of maxillofacial infections between the two groups. Further investigations into the perceptions of antibiotic use in traumatic facial fractures is necessary to assess barriers to implementation of this PMG as well as to improve antibiotic stewardship.

Authors:
Chandler Hinson, Peter Nthumba, Wambui Wamburu

Body of Abstract:
Introduction
Clinical guidelines provide directives on diagnosing, treating, and managing medical conditions, drawing from evidence to optimize patient care. Surgical guidelines are essential tools to enhance safety, reduce errors, and improve outcomes. Kenya’s national clinical guidelines, developed in 2009, aim to standardize surgical practices across healthcare facilities. However, evidence on their dissemination, adaptation, and utilization, particularly in county hospitals, remains limited. This study investigates the use of surgical guidelines in Kenya’s Level 4 and 5 hospitals, identifies barriers to their implementation, and evaluates their impact on surgical outcomes.

Methods
A cross-sectional study was conducted across four counties in Kenya. Inclusion criteria required the facility being able to provide emergency and specialized surgical services. Data was collected through structured, in-person interviews targeting heads of surgical departments, surgical staff, and medical superintendents. Qualitative methods through trend analysis of interviews were employed to examine access to guidelines, training, enforcement, barriers to implementation, and impacts on surgical practices and outcomes.

Results
The study included 43 participants from five Level 4 and 5 hospitals, with 91% reporting access to surgical guidelines. WHO (72%) and Ministry of Health adapted (40%) guidelines were the most commonly used, primarily addressing pre-operative (58%), intra-operative (44%), and post-operative (56%) care. Training on the guidelines were predominantly conducted in person (65%). Participants reported significant benefits of guideline use, including improved services (43%), reduced errors (38%), and enhanced infection control (28%). The guidelines were also credited with improving the quality of care (72%) and reducing infection rates (65%). However, barriers to implementation persisted with resource constraints (50%), negative staff attitudes (24%), and human capital shortages (15%). While 76% of facilities employed enforcement mechanisms like supervision, audits, and checklists, inconsistent application and limited resources hindered their effectiveness. Dissemination issues were highlighted by 87% of respondents, with many citing insufficient availability and distribution of guidelines. Despite these challenges, 93% of participants affirmed the importance of surgical guidelines in standardizing care and improving outcomes.

Conclusion
Surgical guidelines significantly are perceived to improve care in Kenya’s Level 4 and 5 hospitals. However, resource limitations, inadequate dissemination, and inconsistent enforcement undermine their effectiveness. Addressing these barriers through targeted interventions, better training, and resource allocation is critical. Strengthened enforcement and leadership support are needed to optimize guideline use, enhance compliance, and improve surgical outcomes.

Authors:
Lewis Kaplan

Body of Abstract:
Background:
SBO is a common emergency general surgical (EGS) condition that is often related to adhesions. The Bologna Guideline outlines three management pathways, but it is not clear how pathway selection influences post-operative surgical site infection (SSI) in those who require operation for adhesive SBO resolution.

Methods:
A multi-national, prospective, observational, time-bound snapshot audit of SBO management was conducted across a 6-month window (SnapSBO; November 1, 2023 – May 31, 2024). Demographics, laboratory, radiology, and operative data were prospectively collected along with hospital length-of-stay (H-LOS), complications (including infections) and outcome. Patients were groups by management pathway (successful non-operative management (NOM), NOM followed by surgery (NOMOR), or immediate OR). Groups were compared using chi-square tests or Fisher’s exact tests for categorical data; significance was assumed for p < 0.05. Results: A total of 1,737 patients with adhesive SBO were assessed across 21 countries. 850 underwent successful NOM, 379 pursued NOMOR, and 508 were managed with OR. There was no difference between operative cohorts in terms of age (NOMOR 65.2±17.3 vs OR 65.5±18.4 years; p = 0.834), or sex (NOMOR 53.6% vs OR 52% Female; p = 0.688). A greater comorbidity burden was present in NOMOR (77.8%) versus OR patients (69.7%; p < 0.001). OR patients demonstrated a higher incidence of intestinal ischemia (NOMOR 22.8% vs OR 33%; p = 0.002). Time to OR was expectedly longer in NOMOR (43.8±30.6 hours vs OR 12.4±15.2 hours; p < 0.001). Similarly, total H-LOS (NOMOR 7.7±8.0 vs OR 12.4±15.2 days; p < 0.001) and post-operative H-LOS (NOMOR 6.6±9.1 vs OR 10.1±10.4 days; p < 0.001) were also significantly longer following a NOM trial. Superficial wound dehiscence (3.9%) and fascial dehiscence (2.6%) were uncommon in the two operative groups. Overall SSI incidence was similar across groups (NOMOR 8.7% vs OR 7.7%; p = 0.578). While overall deep SSI overall frequency was low (3.9%), deep SSI was more frequent in NOMOR (5.5%) compared to OR patients (2.8%, p = 0.035). Conclusions: SBO patients who undergo a trial of NOM before operation seem to incur an elevated risk of post-operative deep SSI, a finding that may reflect time to OR as well as hospital and surgeon factors. The granular elements that underpin this risk merits specific evaluation.

Authors:
Adam Gutierrez, Andrea Gochi, April Mendoza, Genna Beattie, Gregory Victorino

Body of Abstract:
Introduction
Open pelvic fractures (OPFs), defined as a fracture in the setting of a punctured skin or internal hollow viscus organ, can present in a wide variety of complex trauma settings. Guidance for antibiotic coverage in open pelvic fractures, though, remains poorly defined. We hypothesized that antibiotic coverage and duration would be highly variable in the setting of concomitant gastrointestinal (GI) and urogenital (GU) injuries when compared to those without, and despite these differences surgical site infections would remain higher in the setting of OPF with GI/GU involvement.

Methods
We retrospectively reviewed patients diagnosed with OPF between October 2014 and June 2024. Demographics and clinical data were obtained from the trauma registry of a Level 1 Trauma center. Further data on fracture patterns and antibiotics were ascertained from medical records. The primary outcome was antibiotic treatment duration, and the secondary outcome was the occurrence of infectious complications. Univariate and multivariate logistic regression analyses were performed.

Results
Among 160 patients (19 blunt, 141 penetrating injuries; median age: 30 ± 11.6 years; 85% male), 89 (55%) had concomitant GI/GU injuries. This group had higher injury severity scores (ISS, 19 vs. 11, p < 0.001), greater rates of hypotension (19% vs. 4.2%, p = 0.007), massive transfusion protocol activation (35% vs. 9.8%, p < 0.001), and exploratory laparotomy (85% vs. 17%, p < 0.001) compared to patients without GI/GU injuries. There was no significant difference in antibiotic administration timing (<1 hour) or duration (<24 hours vs. >24 hours) (Table 1). GI/GU injuries were associated with higher rates of organ space infections and deep surgical site infections (Table 1). Multivariate analysis identified rectal injuries (OR: 5.4, 95% CI: 1.6–18.0) and washout/irrigation and debridement (OR: 42.6, 95% CI: 3.9–460.6) as predictors of prolonged antibiotic courses (>24 hours). Hypotension (OR: 12.9, 95% CI: 2.5–67.5) and ICU admission (OR: 12.3, 95% CI: 3.6–42.8) were strongly associated with development of organ space infections, ISS was associated with development of deep surgical site infection (OR: 1.1, 95% CI 1.0 – 1.2), and colon injuries were associated with development of osteomyelitis (OR: 60.3, 95% CI: 1.03–3523). Only 23% of OPF with GI/GU received broad spectrum antibiotics and antibiotic variability was significantly higher after GI/GU OPF (p<0.001) (Table 1). Conclusion Antibiotic management in OPFs remains highly variable and OPF with GI/GU injuries are frequently not initiated on broad coverage despite evidence of contamination. Larger studies are required to determine the current antibiotic practice patterns and the risks of infectious complications especially osteomyelitis in this patient population.