Quick and Short: The Impact of Time to Surgery and Operative Duration on Infection Risk in Emergency Surgery

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Authors:
George C Velmahos, Haytham M A Kaafarani, Ikemsinachi C Nzenwa, John O Hwabejire, Michael DeWane, Vahe S Panossian, Yasmin Arda

Body of Abstract:
Background: Emergency surgery (ES) is associated with up to 8 times higher risk of perioperative morbidity and mortality compared to elective surgery. This study aimed to identify the impact of time to surgery and operative duration on infectious complications after ES.

Methods: Using the ACS-NSQIP 2013-2017 database, all ES patients 18 years or older were identified using the variable ‘Emergency Case’. Patients with preoperative sepsis were excluded. The primary outcome was postoperative infectious complications, defined as the presence of any of the following: sepsis, septic shock, surgical site infection (i.e. superficial, deep, and organ space), pneumonia, and urinary tract infection. Multivariable logistic regression analyses that adjusted for age, body mass index, comorbidities, surgical approach, and type of surgery were used to investigate the impact of time to surgery (more than 12 hours) and operative duration (more than 2 hours) on postoperative infection. Sensitivity analyses were performed to examine the same relationship in three subsets of patients: 1) exploratory laparotomy, 2) cholecystectomy, and 3) appendectomy.

Results: Out of a total of 4,299,148 patients, 264,213 ES patients were included, and 24,921 (9.43%) had infectious complications. On univariate analysis, patients with infectious complications were more likely to have preoperative comorbidities (e.g. obesity, diabetes, heart failure), an American Society of Anesthesiologists (ASA) grade of 3 or higher, an open surgical approach, longer time to surgery (50.4% vs. 39.4%, p < 0.001), and a longer operative duration (31.6% vs. 14.3%, p < 0.001). On multivariable analyses, time to surgery longer than 12 hours was associated with a 14% higher risk of postoperative infectious complications (OR 1.14; 95% CI 1.1-1.18), and operative duration greater than 2 hours was associated with twice the risk of infection (OR 1.99; 95% CI 1.91-2.08). Sensitivity analyses showed that prolonged surgery was associated with infectious complications in all cohorts, while delayed surgery was significantly associated with infectious complications only in exploratory laparotomy (Figure 1). Conclusions: Prolonged time to surgery and operative duration are independently associated with increased risk of infectious complications in ES patients. These findings highlight the importance of early and abbreviated surgical interventions in ES.

Utility of Serum (1,3)-β-D-glucan in Diagnosing and Treating Fungal Infections in Patients with Burn Injury

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Authors:
Jeffrey Shupp, Lauren Moffatt, Melissa McLawhorn, Salma Hassan, Shawn Tejiram, Taryn Travis

Body of Abstract:
Introduction
Invasive fungal infections are life-threatening and occur in immunocompromised or critically ill patients. Patients with severe burn injuries are at increased risk for developing invasive fungal infection. Fungal infections are independently associated with increased mortality in burn patients, making early detection in this population paramount. Conventional methods of fungal culture may be unable to detect invasive fungal infection or result in delayed diagnosis. Fungitell® is a diagnostic test that detects (1, 3)-β-D-glucan (BDG) in serum to help diagnose invasive fungal infections. There is a paucity of literature examining the use of BDG assays in burn injured patients to diagnose invasive fungal infection. The aim of this work was to examine the use of BDG assays in a population of severe burn injured patients to determine its utility in guiding antifungal use as well as patient outcomes at a single institution.
Methods
Patients admitted at a single burn center with severe burn injuries estimated to be 15% total body surface area (TBSA) of burn or greater from July 2019 to June 2024 were retrospectively examined. Medical records were reviewed for demographics, injury characteristics, BDG levels, use of antifungals, presence of concomitant bacterial infections, antibiotic therapy, resolution of infection, and mortality. Friedman’s test was used to compare BDG levels across multiple measurements following the initiation of antifungal treatment. A Spearman’s correlation test to analyze the correlation between initial BDG levels and duration of antifungal treatment.
Results
During the study period, 44 patients had BDG levels reported. Of these patients, the most common etiology of burn injury was flame (84.4%). The median (IQR) total body surface area of burn injury was 33.4% (24.8-47.5). Overall mortality rate was 52.3%. Of the patients that had BDG levels measured, 37 were started on antifungal treatment after the initial level was collected (84.1%). Of these patients, only 12 (32.4%) had culture data positive for fungal infection. Discontinuation of treatment was guided by decreasing or negative BDG levels in 73.3% of patients. Among patients with three or more BDG levels obtained, there were increased BDG levels from the first to second measurements [123 (51.75-201.0) vs 159 (113.5-238.8); p=0.007]. However, levels decreased between the second and third measurements [159 (113.5-238.8) vs 126 (85.0-252.0); p=0.004] (Figure 1). There is a weak correlation between initial BDG level and the duration of antifungal treatment (Spearman ρ =0.3194, 95% CI 0.01579-0.5690; p=0.0173).
Conclusion
This data demonstrates that patients were initiated on antifungal treatment after collection of initial BDG level and continued despite negative culture data in many patients, suggesting the utility of BDG assay to guide antifungal use in patients with burn injury. Further study is necessary to elucidate best practices in BDG level use.

Diverticulitis in Pregnancy: A National Readmissions Database Study

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Authors:
Alan Smith, Dayle Colpitts, Jessica Weaver

Body of Abstract:
Background
Current guidelines recommend employing standard procedural indications for the management of appendicitis and biliary disease in pregnant patients. Withholding the standard of care for these conditions based on pregnancy status alone is associated with an increase in maternal and fetal complications. There is a paucity of data however, regarding diverticular disease in obstetric patients, and there remains no formal management guidelines for this population. The incidence of diverticulitis in patients younger than 50 years old increased by 132% from 1980-2007. Furthermore, CDC data continues to demonstrate an upward trend in the mean age of pregnant individuals, with 19% of all pregnancies in the US occurring in women 35 years and older. National trends toward earlier onset diverticulitis combined with more advanced maternal age may converge, making diverticulitis an increasingly important etiology of obstetric abdominal infection. The purpose of this study was to identify the prevalence of diverticulitis is pregnant patients as well as the common complications associated with this disease process.

Methods
The National Readmissions Database (NRD) was queried for all visits in the first 3 quarters of each year 2016 to 2019, that included a patient with an ICD-10 code for diverticulitis and pregnancy. These entries were then further investigated for demographics, gestation, severity of disease, rates of intervention, readmissions, and pregnancy-related complications.

Results
470 patients were identified with a diagnosis of diverticulitis and pregnancy. Age at admission ranged from 17 to 52 years old with most patients presenting in the third decade (n=296, 62.9%). Most patients (n=340, 72.3%) were in the third trimester of pregnancy. 160/470 (34.0%) of admissions led to fetal delivery within 48 hours. 3.8% of patients (n=18) had complicated diverticulitis on index admission, with 8 patients undergoing diagnostic laparoscopy (1.7%), 2 exploratory laparotomy (0.4%), and ultimately 5 had colonic resection (1.1%). The 90-day readmission rate for perforation or abscess was 1.3%. There were no reported maternal deaths. The overall rate of fetal loss was 1.9%, and fetal complications was 2.3%. The most frequent complication events were abnormal fetal heart rate 20.8%, gestational diabetes 19.1%, hypertension 17.6%, fetal distress 5.3%, preterm labor 5.1%, hemorrhage 4.5%, and amniotic space infection 2.8%.

Conclusions
Diverticulitis can affect a broad range of pregnant patients and is not a benign condition. It should not be neglected in the differential workup for obstetric intraabdominal infections, especially given the population-level trends towards earlier onset of diverticular disease and advancing maternal age. Further investigation is warranted to better define the outcomes and guide best practices in this population.

Emergency Cesarean Section Preoperative Antibiotic Prophylaxis – Opportunities for improvement

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Authors:
Alex Kaizer, Dante Yeh, Gabriela Cortese, Heather Young, Robyn Bronshtein, Stefka Fabbri

Body of Abstract:
Background: Surgical Care Improvement Project (SCIP) recommends intravenous prophylactic antibiotics (abx) to be given within 60 minutes before incision to reduce the risk of surgical site infection (SSI). In non-elective cesarean sections, time constraints present challenges to timely abx administration. The aim of this quality improvement study was to assess SCIP compliance in emergent cesareans to identify opportunities for improvement.

Methods: This retrospective study included patients undergoing emergent cesarean at our institution between May 2016 and Dec 2023. Cases of emergent cesarean in the context of major trauma were excluded. Maternal demographic, obstetric, medical, and labor outcomes were abstracted from the medical record. The primary outcome was the incidence of timely (within 60 minutes of incision) administration of abx. Secondary outcomes included maternal ICU admission, hospital length of stay (LOS), loss to follow-up, SSI, and 30-day outcomes such as readmission, reoperation, and Emergency Department (ED) visit. Logistic regression analyses were performed using select variables to identify predictors of SCIP compliance.

Results: A total of 891 patients were included in the study and the majority were non-Caucasian with public insurance (Table). The most common indication for cesarean delivery was non-reassuring fetal status and the most common form of anesthesia was epidural. Antibiotics were administered in 96% of cases, but only 72% were given within 60 minutes before skin incision (SCIP compliance). Chlorhexidine-alcohol was most commonly used for abdominal skin preparation. There were significant differences between the SCIP Not Compliant vs. Compliant group (Table), but multiple logistic regression identified only ASA Class 3 (OR 0.69 95% CI 0.49-0.97, p=.034), ASA Classes 4/5 (OR 0.22 95% CI 0.04-0.96, p=.047), and prolapsed cord as indication for C-section (OR 0.22 95% CI 0.10-0.49, p<.001) as predictors of SCIP Not Compliant. Race and Insurance Status were not significant predictors of SCIP compliance. Maternal morbidity was low, with only 2% ICU admission and median hospital LOS 4 days. A large proportion (32%) were lost to follow-up. The SSI rate was low (1%) and patients infrequently needed interventions. Conclusion: At our safety net hospital, we identified multiple opportunities for improvement, including timeliness of preoperative abx administration, abdominal skin preparation agent, and post-discharge follow-up. SCIP non-compliance was significantly associated with indications for emergent cesarean and higher ASA class. Post-operative SSI rates were low, though a selection bias may be present due to high loss-to-follow-up. Further research is necessary to develop strategies to improve compliance.

Spectrum of pathogens associated with foot infections: review of 178 episodes from a rural hospital

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Authors:
Hugo Bonatti, Krupesh Patel, Manuel Linarte, Rachel Tuer

Body of Abstract:
Background: The spectrum of pathogens associated with foot infections seems to be expanding due to changes in demographics, more invasive medical therapy, spread of multidrug resistant pathogens and improved microbiologic test systems.
Patients and Methods: Our institutional database was searched for all cases of foot infection treated by a single podiatrist during a 4-year period in which a pathogen was identified. Identification of organisms was done using biochemical assays until 2020 and in 2021 matrix assisted laser desorption/ionization – time of flight (MALDI-TOF) mass spectrometry was introduced. All patients underwent incision and drainage of abscesses, wound debridement or minor amputation as indicated during which the specimens for microbiology were retrieved.
Results: A total of 310 isolates in 178 patients (1.7 isolates/patient) were analyzed. Only 1st isolates were considered. There were 124 men and 54 women with a median age of 58.3 (range 10.1 to 91.6) years) including 13 pediatric cases (7%). Median BMI was 30.9 (range 18.6 – 85.7) kg/m2 with an obesity rate of 56%. Rate of DM was 51%, 20% of patients were active smokers. 33% of specimens consisted of tissue biopsies, 25% came from drained abscesses, 22% from drained fluid collections, and 20% from wounds. In 177 cases microscopy was done showing WBC in 67%, Gram positive cocci in 68%, Gram negative rods in 29% and Gram positive rods in 15%. 45% of pathogens were diagnosed using MALDI-TOF, 36% of infections were polymicrobial and in 58% in addition to pathogens, “normal flora” was reported. Staphylococci were isolated in 112 cases (63%) with MSSA accounting for 32% and MRSA for 24%; streptococci were reported in 50 cases (22%) with Streptococcus agalactiae (23 isolates) being the most common; enterococci were found only in 3 patients. In 31% of patients Gram negative rods were reported and Pseudomonas aeruginosa was the most common with 11 isolates followed by Citrobacter spp (8), Proteus spp (7) and E. coli (6). Anaerobes were also found in 31% of patients with Bacteroides spp and Prevotella spp accounting for 12 and 6 isolates, respectively, however, Gram positive anaerobic cocci including Finegoldia magna (10), Parvimonas micra (1), Anaerococcus prevotii (6), Peptostreptococcus anaerobius (4) and Peptoniphilus asaccharolyticus (9) outnumbered Gram negative rods.
Conclusion: Whereas staphylococci remain the most common pathogens causing foot infections requiring treatment by podiatry, many other pathogens must be considered. Empiric treatment should cover MRSA, Gram negative rods including Pseudomonas aeruginosa as well as anaerobes and appropriate specimens for microbiology should be sent during surgery in order to tailor treatment.

Biomarkers for Predicting Burn-Sepsis in Younger Adults and Older Adults: A Single-Centre Cohort Study

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

Body of Abstract:
Background: Sepsis is a leading cause of mortality in burn patients, posing significant challenges due to its complex presentation and diagnosis. Early and accurate diagnosis of sepsis is critical to improving outcomes, yet current diagnostic methods are limited. Although many studies have linked various biomarker alterations to burn sepsis, few have comprehensively established sepsis as a prognostic factor for these alterations, owing to its time-sensitive progression, population heterogeneity, and the confounding effects of burn injuries. This study addresses this critical gap by examining the longitudinal impact of sepsis on biomarker levels over time in a large cohort of septic and non-septic burn patients, while accounting for key confounding variables, providing valuable insights to improve clinical decision-making and patient care.

Methods: Patients admitted to a regional burn center were assessed for eligibility. Inclusion criteria included adults (≥18 years) with thermal burn injuries affecting ≥5% of total body surface area (TBSA). Patients were categorized into younger (18–59 years) and older (≥60 years) adults and further stratified based on the presence or absence of sepsis. Serum levels of 9 organ function markers and 19 inflammatory cytokines were measured at multiple time points during hospitalization and compared between patients with and without prior sepsis in both age groups. A repeated measures longitudinal regression analysis accounting for time was conducted to compare biomarker levels before and after sepsis onset, assessing their prognostic potential. Analyses adjusted for age, sex, TBSA, and days post-injury.

Results: A total of 1,331 patients (997 younger; 334 older) were included. Sepsis significantly increased alkaline phosphatase (ALP), creatine kinase (CK), urea, and pH (p<0.001 for all) in all patients, while glucose and bilirubin levels decreased (p<0.001 and p=0.025, respectively). Among younger adults, sepsis significantly elevated ALP, CK, urea, and pH, while reducing creatinine, glucose, and bilirubin (p<0.001 for all). In older adults, sepsis increased ALP, CK, urea (p<0.001 for all), and pH (p=0.027) but also elevated creatinine (p<0.001), contrasting with the adult results. Inflammatory cytokine analysis revealed that sepsis decreased IL-6 (p<0.001) and MCP-10 (p<0.001) while increasing TNF-α (p<0.01) across all patients. Younger adults showed reductions in IL-6 (p<0.001), IL-15 (p<0.05), and MCP-10 (p<0.001) with an increase in TNF-α (p<0.05), whereas older adults exhibited increases in IL-1α (p<0.05) and IL-8 (p<0.05). Conclusions: This study demonstrates the longitudinal impact of sepsis on various biomarkers overtime, highlighting those with predictive potential for aiding diagnosis. It also examines how biomarker levels change from pre- to post-sepsis, providing insights into its progression. Age-specific differences highlight the need for tailored diagnostic approaches.

Ascariasis during corrective Roux-en-Y hepaticojejunostomy.

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Authors:
Cristina Botero Fonnegra, Kedar Sukharamwala, Prashant Sukharamwala, Samarth Patel, Subhasis Misra

Body of Abstract:
Background

Ascaris spp. is a parasitic nematode whose eggs can remain viable in the environment for extended periods. Ascariasis, the infection caused by Ascaris spp., occurs when individuals ingest these eggs. Over 1 billion people are affected worldwide. In developed nations, however, sporadic cases are often linked to individuals who have traveled to regions where the infection is endemic. The infection can be asymptomatic or present with gastrointestinal symptoms, bowel obstruction, or biliary disorders due to the migration of the parasite through the small bowel. The number of cases in the United States has been increasing, particularly in southeastern regions, due to travel, immigration, and climate conditions that favor the survival of the parasite.

Case presentation

The patient was a 22-year-old woman who initially presented with symptomatic cholelithiasis at an outside institution, where she underwent a laparoscopic cholecystectomy. Her medical history was significant for recent immigration from Polynesia. She was subsequently discharged but re-presented with abdominal pain 7 days later. A CT scan revealed a biliary leak, and an ERCP identified a bile duct injury, with no other significant imaging findings. She was transferred to our tertiary care facility for corrective Roux-en-Y hepaticojejunostomy. During intraoperative inspection of her small bowel, numerous cord-like structures were palpated, suggesting a parasitic infection.
Given the clinical suspicion of an intestinal helminth infection, a decision was made to perform an enterotomy to extract the parasites, which were milked from the ligament of Treitz to the terminal ileum (Figure 1). Gross examination, along with subsequent microbiological and pathological analysis, confirmed the presence of Ascaris lumbricoides. The patient was treated with albendazole during her stay, and a follow-up stool antigen test was negative, confirming the eradication of the infection. The patient recovered well postoperatively.

Conclusion
This case presents an unexpected and significant intraoperative finding that was not evident preoperatively, despite the use of preoperative imaging. The successful identification and management of this patient underscores the importance of heightened clinical vigilance for parasitic infections in patients with a history of travel to high-endemic areas.

The Use Of A Novel Microbicidal Liquid Polymer (Preventogen) To Reduce Tunneled Hemodialysis Catheters Infections In Patients Receiving Hemodialysis

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Authors:
Brett Hazuka, Julie Morris, Samir Awad

Body of Abstract:
Background: Catheter related bloodstream infections (CRBSI) from the use of tunneled hemodialysis catheters (THDC) are reported to be 1.1 to 6.1 episodes per 1000 catheter days and are associated with increased morbidity, hospitalization, and death. Standard of care (SOC) of the catheter exit site (ES) include various dressings such as Coversite, Tegaderm and Biopatch/CHG, which are currently used to reduce ES infections and decrease CRBSI, have had no significant impact on CRBSI rates. Preventogen, a novel microbicidal Liquid Polymer, which on drying forms an occlusive elastomeric barrier around the THDC at the ES 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. Our objective was to evaluate the impact of Preventogen, on catheter site infection rates. We hypothesized that the use of Preventogen will protect patients undergoing dialysis with THDC against bacterial and fungal infections.
Methods: Under an IRB approved protocol, a retrospective review of a prospective data base of patients that had de novo THDC placement for HD at three dialysis centers was performed from 6-1-24 to 12-11-24. For each patient, Preventogen was applied for 1 inch around the tunneled hemodialysis catheter at the insertion site and catheter during placement and reapplied weekly thereafter at HD session for a total period of 180 days or until an ES infection or CRBSI developed. Age, gender, race, comorbidities (HTN, CHF, DM, Tobacco, ETOH use, Cirrhosis, Cancer, Obesity, Anticoagulation), CKD stage, insertion site, type of catheter, catheter days, ES infections and CRBSIs were collected. ES infection and CRBSI rates were calculated as number of infections per 1000 catheter days and compared to historical documented rates using SOC dressings.
Results: To date, 38 out of 60 patients have been enrolled. All patients were >= CKD 3 stage. The median age was 59 yo, 20(53%) were Males, 21(55%) White, 15(40%) Black, 2(5%) Other. Comorbidities included 26(68%) HTN, 18(47%) ETOH use, 14(37%) Smokers, 14(37%) Obese (BMI>30), 14(37%) on Anticoagulation, 12(36%) Diabetic, 10(26%) CHF, 9(24%) Cirrhotic, and 7(18%) Cancer. The IJ site was used in 34(89%). THDCs inserted were all polyurethane. Over the study period with 4090 catheter days there were no CRBSIs, and one (2.6%) catheter exchanged due to a suspected ES site infection with cultures demonstrating no growth. In contrast, historical data collected at the same dialysis centers demonstrated that 5.2% (33 of 637) of THDC were removed secondary to infection.
Conclusion: Given the reported ES infection rate of 4.1 per 1000 catheter days and CRBSI of 4.5 per 1000 catheter days, in this ongoing study, preliminary results demonstrate that the use of Preventogen liquid polymer as a dressing for THDC was safe with no documented ES infections and no cases of CRBSI over 4090 catheter days. Further study is ongoing.

Impact of Donor Microbiota on the Efficacy of Fecal Microbiota Transplantation in a Mouse Model of Lethal Bacterial Infection

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Authors:
Andrew Benjamin, Ellen Cohn, Jessica Cao, John Alverdy, Olga Zaborina, Rebecca Meltzer, Robert Keskey

Body of Abstract:
Background: A western diet (WD) that is high in fat and low in fiber negatively affects the composition and function of the gut microbiota and has been implicated in a number of poor outcomes following both surgical and infectious stress. We have demonstrated that mice consuming WD experience alterations in their gut microbiota with decreased diversity and reduced metabolite production that are associated with increased mortality when compared to a low fat, high fiber, standard chow diet (SD). Furthermore, we demonstrated that a fecal microbiota transplant (FMT) from an SD FMT donor can rescue an SD recipient from lethal bacterial peritonitis. However, it remains unclear the extent to which the quality of the donor and recipient microbiota impact the efficacy of FMT rescue from lethal infection.

Hypothesis: We hypothesized that dietary induced changes to the FMT donor microbiota impact the ability of FMT to rescue mice from lethal infection, independent of the microbiota of the recipient.

Methods: C57BL/6 male mice were maintained on the following diets varying in fat and fiber composition for 6 weeks prior to the experiment: a standard diet (SD, 18% fat and 18% fiber), western diet (WD, 60% fat and no fiber), and high fat/high fiber diet (HFHF, 45% fat and 30% fiber). An FMT was prepared by sacrificing a healthy littermate and resuspending the cecal contents in sterile saline, using donors from each diet (SD-FMT, WD-FMT, and HFHF-FMT). Infection-related survival was assessed using an established murine model of lethal bacterial infection with intraperitoneal (IP) injection of Serratia marcescens (Sm). Approximately 1mL of FMT was delivered to each mouse via enema at the time of IP Sm and mice were monitored for 24 hours to determine survival. Cecal contents and serum were collected for 16S rRNA sequencing and metabolomics at time of sacrifice.

Results: An SD-FMT delivered to an SD recipient significantly increased gut tryptophan, short chain fatty acids, and indole metabolites without impacting microbiota composition. SD-FMT was associated with significantly reduced disease severity, as seen by lower sepsis scores and higher temperatures, and improved survival in both SD (100% survival with FMT vs 20% without) and WD (75% survival with FMT vs 25% without) recipients (n=5 per group, p=0.011). WD-FMT failed to rescue both SD and WD recipients (n=5 per group, p=0.7). The addition of dietary fiber to a high fat diet (HFHF-FMT) alone was not sufficient to improve survival following IP Sm, indicating that both dietary fat and fiber content are important in shaping an FMT donor microbiota capable of rescuing mice from lethal infection.

Conclusions: FMT results in significant functional changes to the gut microbiota and can rescue mice from lethal bacteria peritonitis, in a manner which is dependent on the FMT donor microbiota, but independent of the recipient. High fat diet-induced changes to the FMT donor microbiota negate this rescue effect.

Against Medical Advice but Not Infection: The Readmission Ramifications of Leaving AMA after Trauma Care.

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Authors:
Fabiana C Sanchez, Grace M Niziolek, Grant V Bochicchio, Jason A Snyder, Leonardo J Diaz Gandica, Lindsay M Kranker, Marco J Henriquez, Marguerite W Spruce, Melissa Canas, Michael W Alchaer, Ricardo A Fonseca

Body of Abstract:
Background:
Trauma patients who leave the hospital against medical advice (AMA) are at higher risk of adverse outcomes, including hospital readmission. Infection-related readmissions may be driven by incomplete treatment, missed follow-up care, or limited access to outpatient resources. This study compares infection-related readmission rates in trauma patients that left AMA versus those discharged per standard hospital protocol.
Methods:
We conducted a retrospective cohort study using data from an urban Level 1 trauma registry from 2018 to 2022. The study population included trauma patients with an Injury Severity Score (ISS) greater than or equal to 9 who resided within the four counties surrounding our institution. Patients who died during the index hospitalization or were discharged to hospice were excluded. Patients were categorized into those who left against medical advice (AMA) and those who underwent standard discharge (non-AMA). The primary outcome was infection-related readmission (IRR). Data collected included patient demographics, mechanism of injury (MOI), ISS, culture results, antibiotic usage, and length of stay. Statistical analyses conducted included t-tests, chi-square tests, and binary logistic regression.
Results:
Among the 5,845 trauma patients, 130 (2.2%) left against medical advice (AMA), and 5,715 (97.8%) were discharged under standard care (non-AMA). AMA patients were more likely to be male (84.6% vs 61.7%, p < 0.001), younger (40.9 years vs 53.0 years, p < 0.001), Black non-Hispanic (66.2% vs 47.6%, p < 0.001), and injured by a penetrating mechanism (33.8% vs 21%, p < 0.001). A total of 213 patients (3.6%) were readmitted within 30 days; patients who left AMA had an overall 30-day readmission rate that was fivefold higher than the non-AMA trauma population (16.9% vs. 3.3%, p < 0.001). A total of 90 patients were readmitted due to infection (1.5%, 9 AMA vs 81 non-AMA). The infection-related readmission rate was significantly higher in the AMA group compared to those discharged non-AMA (6.9% [9/130] vs 1.4% [81/5715], p <0.001). Logistic regression showed that leaving AMA was a significant predictor of readmission due to infection (OR = 4.592, 95% CI: 2.202–9.576, p < 0.001). Conclusions: Leaving the hospital AMA is an independent predictor of readmission due to infection after controlling for sex, age, race/ethnicity, and social vulnerability. This underscores the need for targeted interventions and closer follow-up for this high-risk group to reduce infection-related readmissions, especially among those with a penetrating mechanism of injury. Further research is needed to stratify the patient’s reason for leaving AMA to reduce the associated risk of adverse outcomes incurred by patients.