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

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.