Malnutrition in Emergency General Surgery Patients: Does Its Impact Differ by Procedural Risk Level?

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Authors:
Barbara Okafor, Joaquim Havens, Manuel Castillo-Angeles, Rebecca Wiener, Reza Askari, Stephanie Nitzschke

Body of Abstract:
Background: Malnutrition is a critical factor influencing patient outcomes following emergency general surgery (EGS). It is associated with increased morbidity, prolonged hospital stays, and higher healthcare costs. Understanding the extent and impact of malnutrition can inform strategies to improve surgical outcomes and patient recovery. Therefore, our goal was to determine if the increased burden of morbidity and mortality of malnutrition in EGS patients varies based on the level of procedural risk.

Methods: The Nationwide Inpatient Sample (2015-2018) was queried to identify adult patients that underwent one of 7 previously described EGS procedures. These were stratified as high-risk (excision of large intestine, excision of small intestine, surgical treatment of ulcer of stomach or duodenum, lysis of peritoneal adhesions and laparotomy) and low-risk (appendectomy and cholecystectomy). Malnutrition was defined using ICD-10 Diagnosis codes. Our main outcome was in-hospital mortality. Multivariable logistic regression analysis was used to determine the association between malnutrition and mortality, and subsequently, this was stratified by procedural risk level.

Results: A weighted total of 3,493,853 EGS admissions were identified. Mean age was 53.64 (SD 20.71), 43.76% were male and 66.51% were white. Overall mortality was 2.33%. Malnutrition was found in 278,175 (7.96%) EGS patients and mortality within this group was 8.27%. High-risk procedures represented 55.32% of the total EGS population. After adjusting for demographic and clinical characteristics, malnutrition was an independent predictor of mortality (Odds Ratio [OR] 3.07, 95% Confidence Interval [CI] 2.94 – 3.20). After stratified analysis, this association remained significant for high-risk procedures (OR 2.34, 95% CI 2.24 – 2.44) and it was stronger within low-risk procedures (OR 5.82, 95% CI 4.96 – 6.83).

Conclusion: Malnutrition was significantly associated with mortality in patients undergoing EGS, with an even greater association in low-risk procedures. These findings support that preoperative assessment, and screening should be applied universally because even low-risk procedures may represent a high risk among patients who are malnourished.

Outcomes and Predictors of Fungal Necrotizing Soft Tissue Infections

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Authors:
Anahita Jalilvand, Bradley Butsch, Courtney Collins, George Abboud, Jonathan Wisler, Patrick Quinn, Shachi Srivatsa

Body of Abstract:
Background: The treatment of necrotizing soft tissue infections (NSTIs) relies heavily on early antibiotic initiation and surgical debridement. While rare, fungal NSTIs are often difficult to diagnose. We sought to better understand outcomes, treatment patterns, and predictors in fungal necrotizing soft tissue infections.

Methods: Retrospective analysis of institutional data for patients diagnosed with NSTIs was performed (n = 634; 2011-2023). Patients were stratified by the presence of fungi in the wound culture. Abstracted patient characteristics included demographics, comorbidities, treatments received, and hospitalization outcomes. Primary outcomes included mortality, length of stay, intensive care requirements, acute kidney injury, and 30-day readmission. Logistic regression was used to identify potential predictors of fungal infection.

Results: Of 634 patients, 110 (17.4%) had fungal-positive wound cultures and 524 (82.6%) did not. Patients with fungal NSTIs were more likely to have type two diabetes mellitus (74.5% vs. 61.6%, p=0.014). There was no difference between cohorts in the incidence of sepsis, APACHE II score, or SOFA score. Of those with positive fungal cultures, candida albicans was the most common (47.3%) followed by the grouping of other candida types including galbrata, parapsilosis, and auris (44.5%). The most common antifungal antibiotics used were fluconazole (35.5%) and caspofungin (32.7%). The median time from wound culture to therapy administration was 3 (IQR 2, 5) days and the median time from wound culture to culture result was 2 (IQR 2,5) days. Only 12 patients (10.9%) received empiric antifungal therapy. Regarding hospital course, patients with positive fungal wound cultures were more likely to require two or more operative debridement (p < 0.001), had a higher total length of stay (19 vs. 12 days, p < 0.001), require mechanical ventilation (p < 0.001), and had higher 30-day (9.9% vs 18.2%, p = 0.01) and 90-day mortality (12% vs 20%, p = 0.038). Patients with polymicrobial cultures positive for fungi and clostridial species had the highest 90-day mortality rate (38%). Diabetes mellitus was an independent predictor of developing a fungal NSTI (odds ratio 2.11, 95% CI 1.27 – 3.49, p = 0.004). Conclusion: Fungal NSTI infections were associated with higher rates of 30-day and 90-day mortality with more complex hospital courses than those without fungi. Diabetes mellitus was an independent predictor for fungal NSTI. Very few patients received empiric anti-fungal therapy and on average anti-fungal therapy was not initiated until three days after fungal infection was present. Our data suggests that empiric anti-fungal therapy should be considered in patients who are critically ill with an NSTI, especially those with known diabetes. The high incidence of azole-resistant candida species (galbrata, parapsilosis/auris) in our patients suggests that caspofungin is a more appropriate empiric therapy than fluconazole.

Intensive time travel: Clinical characteristics of early and late bronchoscopic cultures in intubated medical and surgical ICU patients

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Authors:
Alyssa Douville, Brett Fair, Christopher Merrick, Emily Johnson, Kailee Severt, L. Paige Clement, Nathan Schmoekel, Savannah Gross, Srishti Singal, Thomas Schroeppel

Body of Abstract:
Introduction
Pneumonia is a leading cause of morbidity and mortality in ICU patients. Organisms associated with pneumonia and outcomes vary according to duration of mechanical ventilation (MV), length of stay (LOS), antimicrobial exposure, and local ecology. Objectives of this study are to define organisms and outcomes of early and late bronchoscopy with cultures (bronch) in intubated patients in a mixed ICU setting. Surgical/trauma (SICU) and medical ICU (MICU) teams treat unique patient populations. We hypothesize patient demographics are more predictive of causative organism and outcomes in early and late bronch rather than physical care environment.
Methods
A retrospective comparison of SICU and MICU patients who received bronch with either bronchial alveolar lavage (BAL) or bronchial washings between 1/1/2022 and 12/31/2023 was performed at a level-1 trauma center in a mixed ICU. Exclusion criteria were withdrawal of life-sustaining therapy or another service performing bronch. Variables collected include demographics, hospital and ICU LOS, mortality, MV duration prior to bronch, isolated pathogens, and duration of therapy. Early bronch was defined as ≤ 7 days with late as > 7 days. Categorical variables were analyzed with Chi square or Fisher’s exact test and continuous variables were analyzed with Student’s t-test or Wilcoxon rank sum based on data distribution.
Results
161 patients were identified during the study period, 102 patients with early bronch and 59 with late. Normal flora was most commonly identified in both patient populations in both early and late groups (46.8 MICU vs 71.4% SICU for all bronch, p=0.001). Compared with MICU, the SICU population was younger, but there were no other differences in sex or duration of MV prior to bronch (Table). There were no differences in multidrug resistant organisms (MDRO), extended-spectrum beta-lactamases (ESBL), the presence of gram-negative (GN), or gram-positive (GP) organisms in early or late bronch. MICU patients were more likely to have fungal organisms present in both early and late groups which was most commonly Candida sp. SICU patients were more likely to grow H. influenzae in early bronch (2.3 vs 17.2%, p=0.022) and Methicillin-sensitive S. aureus in late (0 vs 15.4%, p=0.033). MICU patients received a longer duration of antimicrobial therapy (7 vs 5 days, p=0.0006), but had a shorter hospital LOS (25 vs 32 days, p=0.031) and higher in-hospital mortality (15.6 vs 3.6%, p=0.013).
Conclusion
The organisms identified in early and late bronch as well as duration of therapy differed by primary team in a mixed ICU setting. MICU and SICU patients are inherently different due to the nature of their presentations and etiology of their illness and/or injury. Antibiograms should be based on patient population and not unit location in a mixed ICU setting.

Antibiotic Prophylaxis in Gastrointestinal Surgery: Balancing Efficacy and Resistance

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Authors:
Amira Elfergani, Main Maitah, Yehya Maitah

Body of Abstract:
Background:
Postoperative infections remain a major concern in GI surgery, contributing to significant morbidity and mortality. Antibiotic prophylaxis is a widely used strategy to reduce the risk of infection. However, the increasing prevalence of antimicrobial resistance calls for rigorous evaluation of current practices and non-antibiotic alternatives, such as probiotics, preoperative optimization, and advanced surgical techniques.

Methods:
A comprehensive review of the literature was conducted using PubMed, focusing on studies published between 2013 and 2023. The search strategy included “antibiotic prophylaxis,” “postoperative infections,” “probiotics,” and “surgical site infections.” Clinical trials, cohort studies, and meta-analyses involving adult patients undergoing GI surgery were included. Data were extracted to evaluate the effectiveness of antibiotic prophylaxis and non-antibiotic strategies in reducing infection rates.

Results:
Antibiotic prophylaxis continues to demonstrate efficacy in reducing surgical site infections (SSIs), particularly when administered within one hour prior to incision. However, extended use or misuse of antibiotics has contributed to rising antimicrobial resistance. Non-antibiotic approaches, including the use of probiotics and synbiotics to modulate the gut microbiome and enhanced recovery protocols, show potential in reducing postoperative infections without contributing to resistance. Surgical Techniques including minimally invasive surgeries, normothermia maintenance, intraoperative antiseptic irrigation, negative pressure would therapy, and antimicrobial-coated sutures and meshes also demonstrated significant reduction in SSIs.

Conclusions:
While antibiotic prophylaxis remains a critical component of infection prevention in GI surgery, it is essential to incorporate non-antibiotic strategies to mitigate resistance risks. Emerging alternatives such as probiotics and surgical optimization provide promising adjuncts to standard care.

Surgical Site Infections in Pediatric Patients with Diabetes Mellitus

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Authors:
Amira Elfergani, Gehan Bensreiti, Yehya Maitah

Body of Abstract:
Background
Surgical site infections (SSIs) are a significant concern, particularly in those with diabetes mellitus (DM), due to hyperglycemia, compromised immune function, and delayed wound healing. Pediatric patients with DM face unique challenges, such as the role of insulin pumps and autoimmune dysfunction, which complicate direct application of adult findings. However, much of the evidence surrounding SSIs in this population is extrapolated from adult studies. This review explored the risk factors and preventive strategies for SSIs in pediatric DM patients, highlighting areas of agreement, disagreement, and significant gaps in the current knowledge.

Methods
This review analyzed findings from work published between 2009 and 2024 that addressed the relationship between DM and SSIs. Articles were selected based on their relevance to hyperglycemia, immune dysfunction, perioperative management. Primary sources included systematic reviews, meta-analyses, and clinical guidelines.

Results
There is agreement that DM significantly increases the risk of SSIs in surgical patients. Most studies, including large meta-analyses, highlight hyperglycemia as a key modifiable risk factor. However, discrepancies exist regarding the exact threshold of glycemic control required to mitigate this risk. While most studies advocate maintaining glucose levels below 180 mg/dL, others suggest stricter thresholds for pediatric populations. Pediatric-specific data are sparse, with researchers often relying on extrapolation from adult studies. Another area of agreement is the role of immune dysfunction in predisposing diabetic patients to infections. Studies emphasize compromised neutrophil function, chemotaxis, and cytokine production as consistent contributors to SSI risk. Additional mechanisms, such as gut microbiota dysbiosis, may play an under explored role in infection susceptibility, particularly in pediatric populations. Perioperative measures such as maintaining normothermia and minimizing operative times are consistently supported. Postoperative insulin protocols are widely endorsed for adults, but evidence of their effectiveness in pediatric populations remains limited. Timely antibiotic prophylaxis is another area of agreement, with research emphasizing its importance in reducing SSI incidence. The choice of antibiotics and timing of administration needs to be tailored for children with DM, especially considering rising antimicrobial resistance.

Conclusions
This review highlights the increased SSI risk in diabetic surgical patients and the importance of glycemic control, immune function, and perioperative management in mitigating this risk. However, significant gaps remain, particularly concerning pediatric-specific data. Discrepancies in the literature regarding the predictive value of glycemic markers and the optimal thresholds for control underscore the need for further research.

Rare but devastating infection: Graft Infections of Thoracic Aortic Repair Grafts

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Authors:
Alexander Harper, Henry Kwon, Loay Kabbani, Milosh Djuric, Sana Soman

Body of Abstract:
Open and endovascular stent graft treatment for thoracic aortopathy has increased in the past decade. Thoracic endovascular aortic repair (TEVAR) has become a treatment modality for patients who may not have tolerated an open procedure and has increased in the past decade. A rare but devastating complication from grafts is infection of graft material.  Principals in treating this disease has been gleamed from infections of abdominal aortic aneurysm repairs or aortoiliac occlusive disease.

At a single institution tertiary referral center from January 2015 to November 2024, all patients treated for their initial event of an infection or inflammatory reaction due to vascular graft or implants were evaluated. Devices or grafts that were not endovascular stent grafts or grafts used for open repair of thoracic or abdominal aorta were excluded. The sample size and incidence of disease precluded any meaningful statistical comparisons.

In total, 41 patients were treated for an infection of an aortic graft: 2 for grafts in the ascending aorta and arch, one for a TEVAR graft, 1 for thoracoabdominal grafts, 16 patients for abdominal aortic grafts, and 15 with aortoiliac grafts.  The incidence of graft infection is low but those who did  have a graft infection, the mortality rate for grafts placed in the arch, TEVAR, and thoracoabdominal grafts were 100%. Grafts placed distal to the diaphragm mortality rates were 25% for abdominal aortic grafts and 6.7% for aortoiliac graft infections.

Infections of thoracic grafts were from gram positive species including staphylococcus aureus, methicillin resistant staphylococcus aureus (MRSA), and streptococcus pneumoniae. Inciting incidents included dental procedures, septic arthritis, and a fistula between the bronchus and aorta. Two patients underwent replacement of the grafts while two had no viable surgical options for replacing the infected graft. Mortalities associated with abdominal aortic graft infections had cultures that were positive for staphylococcus aureus, candida, enteric micro-organisms, and one expired prior to cultures were obtained. Those who survived underwent surgery for replacement of their graft with cultures often consistent with enteric organisms.  Aortoiliac grafts infections had a wide variety of organisms. Those who survived were often sent home on a 6-week course of antibiotics and required transfer to a subacute skilled nursing facility.

Although rare, infections of graft material of the thoracic aorta carry significant mortality with little opportunity for operative intervention in comparison to those with abdominal aortic graft infections and distal graft infections. Medical and surgical management is limited, and significant care should be taken in prevention of infections of these grafts.

The Impact of Chronic Steroids on Post-Operative Infectious Complications in Emergency versus Elective General Surgery; a Nationwide Analysis

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Authors:
Casey M Luckhurst, Charudutt N Paranjape, George C Velmahos, Haytham M A Kaafarani, Ikemsinachi C Nzenwa, John O Hwabejire, Josip Plascevic, Vahe S Panossian, Yasmin Arda

Body of Abstract:
Background: Perioperative use of chronic steroids is associated with delayed wound healing, a higher incidence of wound dehiscence, and an increased risk of postoperative infections. We aimed to evaluate the clinical impact of chronic steroid use on infectious complications in patients undergoing emergency general surgery (EGS) and elective general surgery.

Methods: Patients ≥18 years undergoing emergency or elective general surgery from the 2013-2019 ACS-NSQIP database were included. Patients were stratified by surgical urgency (emergency vs. elective) and corticosteroid use (chronic steroid users vs. non-users). Propensity score matching (PSM) was performed in a 1:1 ratio to balance demographic characteristics, comorbidities, operative characteristics between groups. Post-PSM, univariate logistic regression analyses were conducted to evaluate infectious complications, wound disruption, and mortality between the groups.

Results: After PSM, a total of 12,560 EGS patients and 42,268 elective patients were included, with equal number of patients in both chronic steroid (EGS, n=6,280; elective, n=21,134) and non-steroid (EGS, n=6,280; elective, n=21,134) group. Post-PSM, all covariates (demographics, comorbidities, operative characteristics) had a standardized mean difference of ±0.1. Overall, in both EGS (45.4% vs. 42.4%) and elective (12.8% vs. 11.0%) settings, chronic steroid users had significantly worse composite infectious complications (p<0.001). In the EGS cohort, chronic steroid users experienced higher rates of surgical site infections (SSI), specifically deep site infections (1.8% vs. 1.3%, p=0.008) and organ space infections (10.0% vs. 8.6%, p=0.006) compared to non-steroid users. Similarly, in the elective settings, organ space SSI were higher for steroids users (4.5% vs. 3.6%, p<0.001). However, in the elective settings, patients on chronic steroids also had increased rates of pneumonia (1.8% vs. 1.4%, p<0.001), as well as sepsis (3.4% vs. 2.7%, p<0.001) and septic shock (1.1% vs. 0.9%, p=0.014). Beyond infectious complications, chronic steroid users undergoing EGS had higher rates of wound dehiscence (3.2% vs. 2.0%, p<0.001). Mortality rates were significantly higher in chronic steroid users undergoing EGS (15.6% vs. 13.1%, p<0.001), but no significant difference was observed in the elective cohort (0.8% vs. 0.6%, p=0.16) (Figure 1). Conclusion: Chronic steroid use is a risk factor for postoperative infectious complications in both emergency and elective general surgery. In both settings, patients on chronic steroids experienced higher rates of SSIs, and systemic infections like pneumonia and sepsis. Furthermore, chronic steroid use was associated with increased wound dehiscence and mortality in EGS. These findings highlight the importance of thorough preoperative assessment and patient counseling to facilitate informed decision-making about the potential risks and benefits of surgery.

Predictors of Methicillin-Resistant Staphylococcus Aureus in Necrotizing Soft Tissue Infections

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Authors:
Anahita Jalilvand, Bradley Butsch, Courtney Collins, George Abboud, Jonathan Wisler, Patrick Quinn, Shachi Srivatsa

Body of Abstract:
Background: Management of necrotizing soft tissue infections (NSTI) consists of emergent surgical debridement and broad-spectrum antibiotic treatment. Methicillin-resistant staphylococcus aureus (MRSA) is one of the few resistant organisms frequently covered empirically. In this study, we aim to better assess the prevalence, outcomes, and predictors associated with MRSA-positive NSTIs.

Methods: A retrospective analysis of institutional data for patients diagnosed with NSTIs was identified (n = 634; 2011-2023). Outcomes of interest included mortality, length of stay, intensive care requirements, acute kidney injury (AKI), discharge destination, and 30-day readmission. Outcomes were examined based on whether the patient’s wound culture grew MRSA or not. Characteristics collected for each patient included demographics, comorbidities, micro-organisms, and index hospitalization data. Significant predictors of MRSA infection were identified using logistic regression.

Results: Of 634 patients, 77 (12.3%) grew MRSA-positive wound cultures, and 557 (89.2%) did not. The MRSA-positive cohort had higher incidences of liver disease (19.5% vs. 7.5%, p=0.001) and intravenous drug use (24.7% vs. 8.6%, p<0.001). Bacteremia was more prevalent in the MRSA-positive cohort (29.9% vs 15.6%, p = 0.003). MRSA-positive infections were more likely in upper limbs (19.7%), lower limbs (16.3%), and head/neck NSTIs (15.8%) and least likely in groin NSTIs (5.2%, p < 0.001). Groin infection was an independent negative predictor of having MRSA-positive cultures (odds ratio 0.35, 95% CI 0.17-0.71, p = 0.004). There was no difference between cohorts in in-hospital mortality, 90-day mortality, length of stay, amputation, debridement number, acute kidney injury, or discharge disposition. There was a higher rate of 30-day hospital readmission (32.5% vs 21.4%, p = 0.042) in the MRSA-positive cohort. Conclusion: Patients with MRSA-positive wound cultures were more likely to have bacteremia and had higher rates of 30-day readmission. Groin NSTIs were significantly less likely to grow MRSA than other NSTI locations.