Authors:
Alejandro Navarro, Geovani Faddoul, Jason Perlmutter, Jorge Ortiz, Meng-Hao Li, Naoru Koizumi

Body of Abstract:
Background: Cytomegalovirus (CMV) infection affecting kidney transplant recipients can lead to graft failure, increased morbidity, and mortality 1. Although efforts have focused on identifying risk factors for CMV infections, large data analyses are centered on the adult population2. This assessment examines induction regimens and risk factors associated with primary and secondary CMV infections, including seroconversion, in pediatric kidney transplants.

Methods: The UNOS database was analyzed from year 2000 to 2024. Cox regression evaluated the occurrence of CMV IgM+ from IgG- or IgG+ (N=10,591). Logistic regression examined seroconversion analysis (IgM-/IgG- to IgM+/IgG+) (N = 7,207)

Results: Prednisone maintenance correlated with higher infection and seroconversion (HR 1.32 95%CI[1.03-1.69]; p=0.028 and OR 1.53 95%CI[1.25 – 1.89]; p=<0.001 respectively). Seroconversion was less likely with dual induction anti-thymocyte globulin (ATG) + IL2 receptor antagonist (IL2Ra) (OR 0.41 95%[0.22-0.77]; p=0.006). Seroconversion was less likely for recipients transplanted between 2012-2024 compared to the previous era (OR 0.69 95%[0.57 - 0.82]; p=<0.001). CMV negative to positive transplant had the highest odds of infection and seroconversion (HR 2.7 95%[2.10 - 3.71]; p=<0.001 and OR 2.7 95%[2.27 - 3.44]; p=<0.001 respectively). Conclusion: Alemtuzumab and IL2Ra did not correlate with better CMV infection of seroconversion compared to ATG in pediatric kidney transplants. Improvement in seroconversion rates over the last decade may be attributed to improved prophylactic and induction protocols. 1. Balani SS, Sadiq S, Jensen CJ, Kizilbash SJ. Prevention and management of CMV infection in pediatric solid organ transplant recipients. Front Pediatr. 2023 Feb 20;11:1098434. doi: 10.3389/fped.2023.1098434. PMID: 36891229; PMCID: PMC9986459 2. Al Atbee MYN, Tuama HS. Cytomegalovirus infection after renal transplantation. J Med Life. 2022 Jan;15(1):71-77. doi: 10.25122/jml-2021-0209. PMID: 35186139; PMCID: PMC8852648.

Authors:
Alexandria Brackett MA, MLIS, Arpana Jain, MD, Fabrizio Darby, Jacob D. Edwards, MD, L. Andrew O. Benedict, MD, Margarita Elloso, MD, Sabrina Sanchez, MD, Shaan Bhandarkar, BS, Surgical Infection Society Diversity, Equity and Inclusion Committee N/A, Vanita Ahuja, MD, MPH, MBA

Body of Abstract:
Background: Several studies have highlighted higher rates of adverse outcomes, including superficial surgical site infections (SSI) in Indigenous populations. However, there is a paucity of review literature regarding SSI in these populations compared to other ethnic and racial groups. The aim of this project was to complete a thorough scoping review of the incidence of SSI in Indigenous populations in the USA and Canada compared to non-Indigenous patients.

Methods: Based upon systematic assessment of relevant articles found in Scopus, PubMed, and PubMed Central, a comprehensive scoping review was conducted. The search terms surgical wound infection, surgical site infection, Native American, Indigenous, and First Nation were utilized. Studies in English that were either cohort, cross-section, case-control, or randomized control studies on humans of all ages and genders were included. Studies that were reviews, case series, case reports, editorials, letters to editors, animal studies, or studies that did not examine surgical site infection as a direct outcome of surgery were excluded.

Results: We retrieved 1718 articles, 9 of which were included for review. The most reported adverse surgical infection was superficial SSI. Five studies reported a statistically significant increased risk of superficial SSI in Indigenous populations compared to white patients. Two of these studies reported outcomes from elective procedures (tympanoplasty and cervical discectomy and fusion). The tympanoplasty study showed an odds ratio of 5.503 (2.572 – 11.776; p-value<0.0001) of SSI in Indigenous patients compared to white patients; the cervical discectomy and fusion study showed an odds ratio of 2.59 (1.05 - 6.36; p-value=0.037). Increased rates of deep incisional SSI for Indigenous populations compared to white patients were statistically significant in one of three studies looking at this outcome. The study reported an odds ratio of 1.26 (1.12 - 1.41; p-value=0.0002). With regards to organ space SSI, two studies out of the three reporting this variable found statistically significant increases for Indigenous patients compared to white patients. Additionally, one study reported increases in rates of pneumonia (odds ratio=2.24; 1.58 - 3.19; p-value <0.0001) and another an increase in sepsis with prevalence of 4.3% in Indigenous populations compared to 2.3% in white patients (p-value <0.001.) Conclusions: There are statistically significant differences in the incidence of SSI and other surgical infections for Indigenous patients when compared to their white counterparts, the most glaring being increased odds of superficial SSI, though deep incisional SSI and organ space SSI rates are also elevated in these populations. Further studies are warranted to investigate causes of these increased infection rates and formulate strategies for reducing these adverse outcomes. Figure 1. PRISMA Flow Diagram of Screening Process

Authors:
Abby Gross, Ajita Prabhu, Benjamin T. Miller, Jeffrey Claridge, Sayf Said, Sofya Asfaw

Body of Abstract:
Background: Optimizing antibiotic stewardship in acute appendicitis is essential to improving care quality and combating antimicrobial resistance. We aimed to reduce the overutilization of broad-spectrum antibiotics for acute appendicitis within our hospital system through the implementation of an Emergency General Surgery (EGS) care pathway.

Methods: A task force comprised of residents and general surgery staff developed an evidence-based EGS care pathway for managing acute appendicitis in an iterative process. This pathway was implemented across six teaching hospitals within our health system through educational sessions, with periodic updates every three months based on outcomes review. This pathway was not implemented at an additional ten hospitals within our health system. Cases of acute appendicitis were identified via ICD-10 codes, covering 6 months before and after implementation (9/13/2023–9/13/2024).

The primary outcome was the use of guideline-compliant narrow-spectrum antibiotic regimens (Ceftriaxone, Ciprofloxacin, Levofloxacin, or Ertapenem with Flagyl) compared to broad-spectrum regimens (Piperacillin-tazobactam, Meropenem, Aztreonam/Flagyl, Cefepime/Flagyl). Secondary outcomes included postoperative antibiotic usage and duration, length of stay, and 30-day all-cause readmission.

Results: There were 972 cases evaluated during the study period, of which 460 were pre-implementation (44.2%) and 581 were post-implementation (55.8%). There was no significant difference in age, sex, Charlson Comorbidity Index, or complicated appendicitis rate before versus after implementing the care pathway (Table 1).

After care pathway implementation, the rate of narrow-spectrum antibiotics increased by 42.10% (p=0.035), while broad-spectrum antibiotic use decreased by 8.34% (p=0.012). The increase occurred at all six hospitals (Hospital A: 39.4% to 43.8%, Hospital B: 11.7% vs 31.6%, Hospital C: 18.7% to 19.5%, Hospital D: 15.1% to 18.2%, Hospital E: 16.7% to 20.0%, Hospital F: 12.2% to 13.7%). The appendectomy rate increased by 17.42% with the implementation of the care pathway (p<0.001). There was no statistically significant difference in the use of post-operative antibiotics (p=0.648) or duration of post-operative antibiotics (p=0.823). There was also no significant difference in length of stay (p=0.224), 30-day readmission rate (p=0.236), or percutaneous drain rate (p=1.000). A total of 1,876 cases of acute appendicitis occurred at the hospitals where the care pathway was not implemented during the same period. Among those hospitals, the rate of broad-spectrum antibiotic use increased from 55.29% to 61.50% (434 of 785 vs. 671 of 1,091; p=0.002), and post-operative antibiotics increased from 71.26% to 75.38% (434 of 611 vs. 686 of 911; p=0.075). Conclusion: Standardized care pathways across health systems promote antibiotic stewardship in acute appendicitis, reducing reliance on broad-spectrum antibiotics while maintaining clinical outcomes.

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.

Authors:
Allison Berndtson, Jarrett Santorelli, John Austin, Katherine Chen, Laura Haines, Louis Perkins, Parisa Oviedo, Sadie Munter, Sarah Gierok

Body of Abstract:
Background
Skin and soft tissue infections (SSTIs) contribute to over 6 million emergency department (ED) visits annually, often requiring complex medical and surgical care. Methamphetamines are the second-most commonly used illicit substance in the U.S., with rising prevalence nationally and locally. This study aimed to identify clinical patterns and outcomes among SSTI patients with methamphetamine use to inform future care strategies. We hypothesized that methamphetamine users with SSTIs would require more surgical interventions and extended courses of broad-spectrum antibiotics when compared to non-users.
Methods
We performed a retrospective cohort study of patients presenting with SSTIs over three years who received a surgical consultation at our institution. Demographics (e.g., age, sex, race, housing status, Area Deprivation Index [ADI]), surgical interventions, antibiotic regimens, and culture data were analyzed. Methamphetamine use was determined by patient disclosure or urine toxicology. Broad-spectrum antibiotic use was defined as treatment with agents such as third-generation cephalosporins, carbapenems, or MRSA- and Pseudomonas-targeted therapies. Statistical analyses included t-tests for continuous variables and Fisher’s exact test for categorical variables.
Results
Among 321 clinical encounters, 299 were admitted and included in our analysis. Methamphetamine users were significantly younger, more often unhoused, and had higher ADI scores (all p < 0.005). They were also more likely to leave against medical advice (AMA) (p = 0.002). Broad-spectrum antibiotics were more commonly used across all patients (p < 0.005), and methicillin-resistant Staphylococcus aureus (MRSA) was the predominant pathogen in wound cultures. Methamphetamine users were more likely to grow aerobic species, while non-users had more anaerobic or facultative anaerobic pathogens (p < 0.005). No significant differences were observed in mortality, rates of surgical intervention, bacteremia, or polymicrobial infections. Conclusion Methamphetamine users with SSTIs present with unique clinical and microbiological challenges, including distinct wound flora and higher likelihood of AMA discharges. While they require similar rates of surgical intervention and broad-spectrum antibiotic therapy, managing these patients requires a tailored approach that accounts for their social determinants of health. These findings underscore the importance of integrating flexible, patient-centered strategies into SSTI care to address both medical and social complexities effectively.