Authors:
Diana Julia Tedesco, Fadi Khalaf, Marc Jeschke, Maria Fernanda Hutter, Zachary Ricciuti

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Background: Sepsis is the most critical complication in burn patients and the leading cause of death post-burn. Clinical characteristics that differentiate survivors and non-survivors have not been explored yet, highlighting the need for further investigation into factors driving mortality in this population. This study aims to undertake a comparative analysis of survivors and non-survivors among burn patients with sepsis to identify key demographic and clinical distinctions to improve our understanding of prognostic indicators in burn-related sepsis.
Methods: Patients (≥18 years) with thermal burn injuries ≥5% TBSA admitted to a provincial burn centre in Toronto, Canada, between 2006 and 2021, with a subsequent clinical diagnosis of sepsis during hospitalization, were included. Eligible patients were stratified based on outcome (survivors vs. non-survivors). Demographics, injury characteristics, mortality, pathogens, and complications were assessed.
Results: 240 patients, including 197 survivors and 43 non-survivors, were included in the analysis. Compared to survivors, non-survivors were older (62.6 (15.2) vs. 48.6 (16.7) years; p<0.05) and had a decreased proportion of males (58.1% vs. 75.6%; p<0.05). Interestingly, distributions of burn etiologies, TBSA, and inhalation injuries were similar between survivors and non-survivors. Survivors and non-survivors also differed in their comorbid conditions upon admission, with non-survivors presenting with an increased prevalence of respiratory disease (p<0.05), diabetes (p<0.05), and hypertension (p<0.05). During hospitalization, the median onset of sepsis occurred earlier in non-survivors at 8 days post-burn, compared to 10 days post-burn in survivors (p<0.05). Additionally, non-survivors experienced an increased incidence of acute kidney injury (p<0.001), acute respiratory distress syndrome (p<0.01), respiratory failure (p<0.01), and graft loss due to infection (p<0.05). Non-survivors experienced a median (IQR) survival after sepsis diagnosis of 11.5 days (5-29). Surprisingly, we observed a similar presence of pathogens among survivors and non-survivors, with the overall most common species being Enterococcus (20.0%), Enterobacter (15.8%), Staphylococcus (12.5%), Klebsiella (10.0%), and Pseudomonas (10.0%). Conclusion: These findings identify older age, female sex, and earlier sepsis onset as factors associated with mortality in burn patients with sepsis. Interestingly, pathogen identity did not influence sepsis outcomes, indicating that further investigation is needed into underlying immunometabolic responses contributing to mortality. Together, these findings identified prognostic factors for post-burn sepsis mortality, which can help guide the development of strategies to improve outcomes in burn patients with sepsis.

Authors:
Aaron George, Anne Sescleifer, Hugo Bonatti, John Kessler, Junius Rosario

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Background: Pasteurella spp (PS) are Gram negative facultative anaerobic rods causing diseases in humans and animals such as cattle, sheep but also elephants. Dogs and cats carry the organism and do not develop disease but may transmit the pathogen to humans especially in case of bite injuries.
Patients and Methods: Our institutional database was searched for all cases of PS infection during a 4-year period. All animal and human bites in which pathogens were identified were analyzed. Sixteen bites in which PS were isolated were compared to 12 bites in which other organisms (staphylococci 6, streptococci 3, Eikenella corrodes 1, Capnocytophaga canimorsus 1, Anaerococcus prevotii 1) were isolated.
Results: 76 isolates of PS in 64 patients (46.9% male) were identified. Median age was 60.7 (range 2.3 to 94.3) years), there were 5 pediatric cases (8%). Rate of DM was 30%, 25% of patients were active smokers. 22% of isolates were from blood cultures, 5% were from drained abscesses, 32% from drained fluid and 33% were from wounds. PS (83% P. multocida, 16% P. canis, 2% P. species) infections were located at head/neck/mouth 5%, trunk 2%, upper extremity 27%, lower extremity, 2% other and 22% blood stream. Bites were the most common single cause of PS infections. Most bites involved the upper extremities (64%), 11 were caused by cats and 10 by dogs and all infections were monomicrobial, however, in 40% additional “normal flora” was reported. Table 1 compares PS and non-PS bites and shows demographic, clinical and microbiology data of all PS infections. PS were more commonly associated with cat bites (50% vs 25%). Treatment consisted of surgical drainage/debridement and antibiotics including Betalactms, Tetracyclines or Fluoroquinolons.
Conclusion: PS account for >50% of all bite associated infections. The pathogen should be covered in empiric therapy of bite associated infections. Of note, PS are capable of causing a variety of other infections.

Authors:
Jessica Weaver, John Austin, Michelle Lippincott

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Background
Falls are the most common mechanism of traumatic injury in geriatric patients. There are studies suggesting that urinary tract infections (UTIs) may be a cause for fall. Thus, a screening urinalysis (UA) is frequently obtained in geriatric patients. However, this does not discern between UTI and asymptomatic bacteriuria. Geriatric patients may present with either baseline or acquired cognitive impairment that prevent them from describing genitourinary symptoms. According to the Infectious Diseases Society of America (IDSA), patients without systemic signs of infection such as fever or hemodynamic instability should be assessed for other causes and closely monitored, even with bacteriuria. We conducted a study in our trauma system to assess UTI screening and treatment. We hypothesize that geriatric falls are likely to receive unnecessary urinalyses (UAs) and receive antibiotic treatment that is not otherwise indicated.
Methods
Our trauma registry was queried for all patients admitted to the trauma service aged 65 years and older between 2020-23 for a ground-level fall with an initial Glasgow Coma Score less than 15. Demographics such as age, sex, race, ethnicity, and insurance were obtained from the registry. Individual charts were reviewed for vital signs, lab values, UA, urine culture (UCx), antibiotic treatment and indication data. A UA was recorded as positive if it was positive for nitrites, leukocyte esterase, had greater than 10 white blood cells per high power field, or had at least “few” bacteria. Our institution automatically reflexes to UCx based on pre-set criteria for UAs. Estimated charge of a UA with microscopy was obtained from the chargemaster.
Results
489 geriatric trauma patients met inclusion criteria. Of these, 268 (54.8%) had a UA done within 24 hours of admission and were included for further analysis. 115 of these 268 (42.9%) patients had positive UAs, of which 103 automatically reflexed to a UCx. Women were more likely to have a positive UA, with 69.6% of positive UAs belonging to women versus 43.8% of negative UAs (p < 0.005). Of those with positive UAs, 69/115 (60%) patients were initially given antibiotic therapy for UTI treatment, with 50/69 (72.5%) of these patients eventually growing a positive UCx. There was no difference in rates of sepsis on presentation (p = 0.65) or mortality (p = 0.16) between the treated and untreated groups. Of all UAs done, 263/268 (98.1%) were given to patients without a systemic sign of infection or other reason for UA testing, leading to excess medical costs of $38,398. Only 4 of the 69 patients who received antibiotics for a UTI (5.8%) had urosepsis or other IDSA criteria for treatment. Conclusion Cognitively impaired geriatric fall patients in our trauma system were consistently over-tested and over-treated for UTIs. Application of IDSA guidelines to current screening practices for geriatric fall patients can potentially reduce unnecessary antibiotic use in these patients.

Authors:
Adianto Nugroho, Aditomo Widarso, Anti Dharmayanti, Hana Ayu Shafira, Ifael Yerosias Mauleti, Indah Jamtani, Rofi Y Saunat

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Abstract
Background. Determining pathogenic etiology and antimicrobial resistance is vital in managing complicated intra-abdominal infections (cIAI), particularly in guiding the use of appropriate empiric antibiotics. This study aims to describe the most commonly isolated pathogens and their resistance patterns in cIAI cases in a single tertiary center in Indonesia.
Methods. This cross-sectional descriptive study analyzed data from patients with cIAI who underwent emergent or elective surgeries at Fatmawati General Hospital (FGH) in Jakarta, Indonesia, between April 2020 and June 2024. One hundred thirty-three cases were reviewed, and 55 intraoperative samples were tested for microbial culture and sensitivity.
Results. Gram-negative bacteria were the most prevalent isolates (n=30, 54.5%), with E. coli (n=19, 63.3%) and K. pneumonia (n=8, 26.7%) being the most commonly identified pathogens. Gram-positive bacteria accounted for eight cases (14.5%), while Candida tropicalis was found in two cases (3.6%). Gram-negative bacteria exhibited the highest sensitivity to carbapenems and amikacin but low sensitivity to penicillin-based antibiotics. Gram-positive bacteria showed moderate sensitivity to penicillin-based antibiotics and the highest sensitivity to tigecycline and linezolid, followed by vancomycin.
Conclusions. Gram-negative bacteria, mainly E. coli, were the most common pathogens in cIAI cases at FGH. They are susceptible to carbapenem and amikacin, making them highly effective options for empiric therapy in these cases. Monitoring microbial resistance patterns is essential to optimizing treatment strategies and combating antimicrobial resistance.

Authors:
Courtney Meyer, Jason Sciarretta, Jonathan Nguyen, Lucy Hart, Randi Smith, Will Dunne, Zachary Grady

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Background
Ultra massive transfusion (UMT), defined as the transfusion of > 20 units of red blood cell product, is utilized for trauma patients in severe hemorrhagic shock. Patients requiring UMT have high rates of mortality and survivors are at risk for infectious complications. Yet, the exact risk remains unknown. The aim of this study was to quantify the risk of infections after UMT by evaluating the incidence, type, causative organisms, treatment and outcomes in trauma survivors.
Methods
A retrospective review was conducted at a Level 1 trauma center from 05/2018- 11/2021 of all trauma patients who received UMT. Data were collected from prospectively maintained registries & chart review including demographics, comorbidities, infection type (bacteremia, fungemia, surgical site infection (SSI), osteomyelitis, pneumonia (PNA), urinary tract infection, empyema, & Clostridioides difficile infection), culture data, and antibiotic administration & duration. Outcomes of hospital & intensive care unit (ICU) length of stay and mortality were also evaluated.
Results
A total of 193 patients were included in the study period with an overall mortality rate of 54.4%. Infection occurred in 25.4% of patients and at least one antibiotic dose was administered for 93.8% of patients. For those that survived at least 48 hours, 50.9% had an infection. There was no difference in age, sex, comorbidities, injury mechanism, injury severity, initial vital signs & laboratory values, and operative interventions required between those with and without an infection. Patients without an infection had more bowel injuries (49.0% vs. 20.7%, p<0.05). In these patients, the most frequent infections were PNA (33%), bacteremia (19.8%), and deep SSI (9.4%). There were 55 unique organisms with the most frequent being Enterobacter cloacae (8.9%), Pseudomonas aeruginosa (8.1%), Enterobacter aerogenes (7.0%), and Enterococcus faecalis (7.0%). In the entire cohort, there were 1,182 unique antibiotic courses with an average antibiotic duration of 3.5 days. The most frequently administered antibiotics were cefazolin (27.6%), vancomycin (17.0%), and metronidazole (11.3%). Infectious disease consultation occurred for 22.6% of patients who survived at least 48 hours. Patients with infection had more ventilator days (14.5 vs. 4 days, p<0.001) and longer ICU (24.5 vs. 6 days, p<0.001) and hospital (41 vs. 13 days, p<0.001) length of stay. Patients without an infection had higher rates of mortality (32.7% vs. 12.1%, p=0.01). Conclusion Patients who require UMT following traumatic injury have high rates of infection, most frequently pneumonia, bacteremia, & deep surgical site infections caused by a variety of microorganisms. Though this high rate exists, it may be similar to other critically injured patients who do not require UMT such that once a patient is stabilized from a resuscitation standpoint, their infection rates may be similar to their non-UMT counterparts.