Perioperative Medicine

SAN FRANCISCO – Training residents to notify attending surgeons of any significant change in a patient’s condition greatly reduced the proportion of critical events that were not communicated to attending surgeons, from 33% to 2%, in a prospective study of four hospitals.

The current study was undertaken in response to a previous study by the same research group showing that ambiguity about who is responsible for communications contributed to communication breakdowns between attending surgeons and other members of the team at any point in patient care, Dr. Caprice C. Greenberg said at the annual clinical congress of the American College of Surgeons.

In the previous study, 444 malpractice claims were reviewed, and this process identified 60 cases in which communication breakdown resulted in harm to a patient. Dr. Greenberg and colleagues found that communication breakdowns related to surgery are equally likely to happen during preoperative, intraoperative, and postoperative care, and most commonly involve communications attempted between an attending surgeon and another attending surgeon, a resident, or the patient or family.

Ambiguity about who is responsible for communicating played a role in 58% of communication breakdowns, said Dr. Greenberg, director of the Wisconsin Surgical Outcomes Research Program and associate professor of surgery at the University of Wisconsin, Madison.

Hand-offs of patient care from one provider to another contributed to 43% of communication breakdowns, and transferring a patient to a different location contributed to 39% of communication breakdowns. The data also showed that an asymmetry in status between the two communicating parties contributed to 74% of message breakdowns (J. Am. Coll. Surg. 2007;204:533-40).

Dr. Greenberg and her associates identified "triggers" that should prompt residents or nurses to contact attending surgeons, including a patient’s admission to a hospital, discharge, or a visit to an emergency department, transfer into or out of the ICU, unplanned intubation, or the development of cardiac arrest, new arrhythmia, or hemodynamic instability.

"Developing skills in communication are as important as the development and maintenance of technical skills."

Significant neurologic changes, major wound complications, unplanned blood transfusion, an invasive procedure or operation, or errors in medication or treatment necessitating an intervention also should trigger communication with the attending surgeon. Even simply concern by a surgical trainee or a request from a nurse or another physician to contact the attending surgeon were considered triggers for communication.

The triggers were included in guidelines created by representatives of the four hospitals in Harvard University’s system in a collaboration organized by the system’s malpractice insurers. Under the new guidelines, residents were to notify attending surgeons of any significant changes in a patient’s condition regardless of the day or time. The residents would be trained to understand what qualifies as "significant changes" based in part on specialty-specific definitions, she said.

"What a urologist cares about is probably a little bit different from what a neurosurgeon or cardiac surgeon cares about," she explained.

A study of practices before instituting these policies found that residents thought that 61 of 80 critical patient events (76%) did not need to be communicated to attending surgeons for safe patient care, and 26 events were not communicated (33%). Of the 54 events that were communicated, discussions with the attending surgeons changed management in 18 cases (33%). Attending surgeons responded to calls 100% of the time (Ann. Surg. 2009;250:861-5).

"It wasn’t that the attendings didn’t want to be called. It was that residents either felt unempowered to call or they felt that it wasn’t necessary," she said.

After adoption of the new guidelines, only 1 of 47 critical events (2%) was not communicated to an attending surgeon, the current study found (Ann. Surg. 2011;253:849-54).

"Developing skills in communication are as important as the development and maintenance of technical skills" to reduce the risk of errors, Dr. Greenberg said.

Breakdowns in communication are common and play a significant role in adverse events, prior data suggest. One study of 48 surgeries found that 31% of 421 attempted communications between surgical team members failed, and approximately a third of these communication failures potentially jeopardized patient safety (Qual. Saf. Health Care 2004;13:330-4).

Other strategies to reduce the risk of errors during surgery include "workload leveling," Dr. Greenberg added. This means the attending surgeon should communicate frequently to members of the interdisciplinary surgical team about the status of the case and expected progression of the case, so that team members can manage their time and plan to do auxiliary tasks at the appropriate times.

It’s probably impossible to avoid all errors, so surgeons need to find the right balance of error prevention and error mitigation through "resilience" – the ability to anticipate, cope with, recover from, and learn from unforeseen developments, she added. "To start to increase resilience, we really need to teach people adaptability and flexibility," she said.

Dr. Greenberg said she has no relevant conflicts of interest.

SAN FRANCISCO – Training residents to notify attending surgeons of any significant change in a patient’s condition greatly reduced the proportion of critical events that were not communicated to attending surgeons, from 33% to 2%, in a prospective study of four hospitals.

The current study was undertaken in response to a previous study by the same research group showing that ambiguity about who is responsible for communications contributed to communication breakdowns between attending surgeons and other members of the team at any point in patient care, Dr. Caprice C. Greenberg said at the annual clinical congress of the American College of Surgeons.

In the previous study, 444 malpractice claims were reviewed, and this process identified 60 cases in which communication breakdown resulted in harm to a patient. Dr. Greenberg and colleagues found that communication breakdowns related to surgery are equally likely to happen during preoperative, intraoperative, and postoperative care, and most commonly involve communications attempted between an attending surgeon and another attending surgeon, a resident, or the patient or family.

Ambiguity about who is responsible for communicating played a role in 58% of communication breakdowns, said Dr. Greenberg, director of the Wisconsin Surgical Outcomes Research Program and associate professor of surgery at the University of Wisconsin, Madison.

Hand-offs of patient care from one provider to another contributed to 43% of communication breakdowns, and transferring a patient to a different location contributed to 39% of communication breakdowns. The data also showed that an asymmetry in status between the two communicating parties contributed to 74% of message breakdowns (J. Am. Coll. Surg. 2007;204:533-40).

Dr. Greenberg and her associates identified "triggers" that should prompt residents or nurses to contact attending surgeons, including a patient’s admission to a hospital, discharge, or a visit to an emergency department, transfer into or out of the ICU, unplanned intubation, or the development of cardiac arrest, new arrhythmia, or hemodynamic instability.

"Developing skills in communication are as important as the development and maintenance of technical skills."

Significant neurologic changes, major wound complications, unplanned blood transfusion, an invasive procedure or operation, or errors in medication or treatment necessitating an intervention also should trigger communication with the attending surgeon. Even simply concern by a surgical trainee or a request from a nurse or another physician to contact the attending surgeon were considered triggers for communication.

The triggers were included in guidelines created by representatives of the four hospitals in Harvard University’s system in a collaboration organized by the system’s malpractice insurers. Under the new guidelines, residents were to notify attending surgeons of any significant changes in a patient’s condition regardless of the day or time. The residents would be trained to understand what qualifies as "significant changes" based in part on specialty-specific definitions, she said.

"What a urologist cares about is probably a little bit different from what a neurosurgeon or cardiac surgeon cares about," she explained.

A study of practices before instituting these policies found that residents thought that 61 of 80 critical patient events (76%) did not need to be communicated to attending surgeons for safe patient care, and 26 events were not communicated (33%). Of the 54 events that were communicated, discussions with the attending surgeons changed management in 18 cases (33%). Attending surgeons responded to calls 100% of the time (Ann. Surg. 2009;250:861-5).

"It wasn’t that the attendings didn’t want to be called. It was that residents either felt unempowered to call or they felt that it wasn’t necessary," she said.

After adoption of the new guidelines, only 1 of 47 critical events (2%) was not communicated to an attending surgeon, the current study found (Ann. Surg. 2011;253:849-54).

"Developing skills in communication are as important as the development and maintenance of technical skills" to reduce the risk of errors, Dr. Greenberg said.

Breakdowns in communication are common and play a significant role in adverse events, prior data suggest. One study of 48 surgeries found that 31% of 421 attempted communications between surgical team members failed, and approximately a third of these communication failures potentially jeopardized patient safety (Qual. Saf. Health Care 2004;13:330-4).

Other strategies to reduce the risk of errors during surgery include "workload leveling," Dr. Greenberg added. This means the attending surgeon should communicate frequently to members of the interdisciplinary surgical team about the status of the case and expected progression of the case, so that team members can manage their time and plan to do auxiliary tasks at the appropriate times.

It’s probably impossible to avoid all errors, so surgeons need to find the right balance of error prevention and error mitigation through "resilience" – the ability to anticipate, cope with, recover from, and learn from unforeseen developments, she added. "To start to increase resilience, we really need to teach people adaptability and flexibility," she said.

Dr. Greenberg said she has no relevant conflicts of interest.

SAN FRANCISCO – Training residents to notify attending surgeons of any significant change in a patient’s condition greatly reduced the proportion of critical events that were not communicated to attending surgeons, from 33% to 2%, in a prospective study of four hospitals.

The current study was undertaken in response to a previous study by the same research group showing that ambiguity about who is responsible for communications contributed to communication breakdowns between attending surgeons and other members of the team at any point in patient care, Dr. Caprice C. Greenberg said at the annual clinical congress of the American College of Surgeons.

In the previous study, 444 malpractice claims were reviewed, and this process identified 60 cases in which communication breakdown resulted in harm to a patient. Dr. Greenberg and colleagues found that communication breakdowns related to surgery are equally likely to happen during preoperative, intraoperative, and postoperative care, and most commonly involve communications attempted between an attending surgeon and another attending surgeon, a resident, or the patient or family.

Ambiguity about who is responsible for communicating played a role in 58% of communication breakdowns, said Dr. Greenberg, director of the Wisconsin Surgical Outcomes Research Program and associate professor of surgery at the University of Wisconsin, Madison.

Hand-offs of patient care from one provider to another contributed to 43% of communication breakdowns, and transferring a patient to a different location contributed to 39% of communication breakdowns. The data also showed that an asymmetry in status between the two communicating parties contributed to 74% of message breakdowns (J. Am. Coll. Surg. 2007;204:533-40).

Dr. Greenberg and her associates identified "triggers" that should prompt residents or nurses to contact attending surgeons, including a patient’s admission to a hospital, discharge, or a visit to an emergency department, transfer into or out of the ICU, unplanned intubation, or the development of cardiac arrest, new arrhythmia, or hemodynamic instability.

"Developing skills in communication are as important as the development and maintenance of technical skills."

Significant neurologic changes, major wound complications, unplanned blood transfusion, an invasive procedure or operation, or errors in medication or treatment necessitating an intervention also should trigger communication with the attending surgeon. Even simply concern by a surgical trainee or a request from a nurse or another physician to contact the attending surgeon were considered triggers for communication.

The triggers were included in guidelines created by representatives of the four hospitals in Harvard University’s system in a collaboration organized by the system’s malpractice insurers. Under the new guidelines, residents were to notify attending surgeons of any significant changes in a patient’s condition regardless of the day or time. The residents would be trained to understand what qualifies as "significant changes" based in part on specialty-specific definitions, she said.

"What a urologist cares about is probably a little bit different from what a neurosurgeon or cardiac surgeon cares about," she explained.

A study of practices before instituting these policies found that residents thought that 61 of 80 critical patient events (76%) did not need to be communicated to attending surgeons for safe patient care, and 26 events were not communicated (33%). Of the 54 events that were communicated, discussions with the attending surgeons changed management in 18 cases (33%). Attending surgeons responded to calls 100% of the time (Ann. Surg. 2009;250:861-5).

"It wasn’t that the attendings didn’t want to be called. It was that residents either felt unempowered to call or they felt that it wasn’t necessary," she said.

After adoption of the new guidelines, only 1 of 47 critical events (2%) was not communicated to an attending surgeon, the current study found (Ann. Surg. 2011;253:849-54).

"Developing skills in communication are as important as the development and maintenance of technical skills" to reduce the risk of errors, Dr. Greenberg said.

Breakdowns in communication are common and play a significant role in adverse events, prior data suggest. One study of 48 surgeries found that 31% of 421 attempted communications between surgical team members failed, and approximately a third of these communication failures potentially jeopardized patient safety (Qual. Saf. Health Care 2004;13:330-4).

Other strategies to reduce the risk of errors during surgery include "workload leveling," Dr. Greenberg added. This means the attending surgeon should communicate frequently to members of the interdisciplinary surgical team about the status of the case and expected progression of the case, so that team members can manage their time and plan to do auxiliary tasks at the appropriate times.

It’s probably impossible to avoid all errors, so surgeons need to find the right balance of error prevention and error mitigation through "resilience" – the ability to anticipate, cope with, recover from, and learn from unforeseen developments, she added. "To start to increase resilience, we really need to teach people adaptability and flexibility," she said.

Dr. Greenberg said she has no relevant conflicts of interest.

BOSTON – The line between proper prescribing of opioids and pill pushing is thin and easily crossed, forensic psychiatrists said at the annual meeting of the American Academy of Psychiatry and the Law.

The U.S. Supreme Court in 1975 ruled that physicians who are licensed by the Drug Enforcement Administration (DEA) to prescribe narcotics such as extended-release oxycodone (OxyContin) under the Controlled Substances Act are liable to prosecution "when their activities fall outside the usual course of professional practice."

But the decision about what constitutes deviation from normal professional practice might fall to the judicial system, and several high-profile cases of doctors being convicted as drug pushers have made many practitioners who would otherwise consider prescribing opioids leery of the drugs, said Dr. Gregory G. Sokolov, of the division of psychiatry and the law in the department of psychiatry at the University of California, Davis.

"There is a role for opiate medications, and there is a role for OxyContin for severe pain," Dr. Sokolov said. "Some of these cases have really scared people away from treating pain patients and prescribing opiates, and although there are going to be people who are troubled and problematic, there are patients who truly benefit from these medications."

Chronic opioid therapy is more commonly used for control of severe cancer-related pain, but appropriate non-cancer uses exist for such agents; the trick is knowing which patients will benefit, and which are malingering, said Dr. Ajay D. Wasan from the departments of psychiatry, anesthesiology, and perioperative and pain medicine at Brigham and Women’s Hospital in Boston.

"Some of these cases have really scared people away from treating pain patients and prescribing opiates."

Dr. Sokolov discussed the case of United States vs. Ronald A. McIver, D.O. Dr. McIver, who ran a pain therapy center in Greenwood, S.C., was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution, after the death of a patient with high post-mortem doses of opiates in his bloodstream.

Dr. McIver is currently serving sentences of 20 years in federal prison for distribution, and 30 years for dispensing drugs that resulted in the patient’s death. His appeals, including one made to the U.S. Supreme Court, have been rejected.

Forensic psychiatrists might be called upon to provide expert opinion in criminal cases asking whether a prescribing physician is guilty of illegally prescribing opioids for distribution or abuse, in civil actions such as malpractice cases, and in medical board investigations, including allegations of physician impairment from opioid abuse, Dr. Sokolov noted.

Prescribing and Monitoring Opioids

Clinical guidelines for the use of chronic opioids in non-cancer pain are consistent in their recommendations, Dr. Wasan said (J. Pain. 2009;10:131-46).

Key issues pain psychiatrists should consider are the patient’s comorbid psychiatric diagnoses and the ongoing psychological processes that sustain or worsen pain (for example, catastrophizing, poor coping skills, or low self-efficacy). The clinician also should consider the affective component of the patient’s pain, and whether he/she has comorbid substance use disorders or is capable of using an opioid prescription responsibly.

"So many times, psychiatrists say, ‘If the pain [were] better treated, then the psychiatric problems would go away.’ Pain physicians say that, too. But what both sides don’t quite realize is that once you develop a significant psychiatric comorbidity – even if it started because of pain, it takes on a life of its own," Dr. Wasan said.

He cautioned that, in general, opioids only should be prescribed for painful medical conditions, with the exception of methadone and buprenorphine/naloxone (Suboxone) for substance use disorders.

Prescribing opioids requires a medical evaluation and regular follow-up. The prescribing clinician should take or have on hand a full medical history of pain and underlying pathology, full physical exam, and collateral information about the patient from other providers. The patient should be reassessed on an ongoing basis, at least every 6 months.

"There is no issue with psychiatrists prescribing opioids as long as they follow these guidelines," he stated.

Opioid therapy agreements can be helpful, but must be based on mutual trust and honesty established between the patient and the physician in the first visit. Such agreements facilitate informed consent, patient education and compliance, and establish boundaries and consequences for opioid misuse or diversion. The agreement should be flexible, and not written like a contract, Dr. Wasan said.

Neither Dr. Sokolov nor Dr. Wasan reported funding sources for their studies. Both reported that they have no financial relationships pertaining to the content of their presentations.

BOSTON – The line between proper prescribing of opioids and pill pushing is thin and easily crossed, forensic psychiatrists said at the annual meeting of the American Academy of Psychiatry and the Law.

The U.S. Supreme Court in 1975 ruled that physicians who are licensed by the Drug Enforcement Administration (DEA) to prescribe narcotics such as extended-release oxycodone (OxyContin) under the Controlled Substances Act are liable to prosecution "when their activities fall outside the usual course of professional practice."

But the decision about what constitutes deviation from normal professional practice might fall to the judicial system, and several high-profile cases of doctors being convicted as drug pushers have made many practitioners who would otherwise consider prescribing opioids leery of the drugs, said Dr. Gregory G. Sokolov, of the division of psychiatry and the law in the department of psychiatry at the University of California, Davis.

"There is a role for opiate medications, and there is a role for OxyContin for severe pain," Dr. Sokolov said. "Some of these cases have really scared people away from treating pain patients and prescribing opiates, and although there are going to be people who are troubled and problematic, there are patients who truly benefit from these medications."

Chronic opioid therapy is more commonly used for control of severe cancer-related pain, but appropriate non-cancer uses exist for such agents; the trick is knowing which patients will benefit, and which are malingering, said Dr. Ajay D. Wasan from the departments of psychiatry, anesthesiology, and perioperative and pain medicine at Brigham and Women’s Hospital in Boston.

"Some of these cases have really scared people away from treating pain patients and prescribing opiates."

Dr. Sokolov discussed the case of United States vs. Ronald A. McIver, D.O. Dr. McIver, who ran a pain therapy center in Greenwood, S.C., was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution, after the death of a patient with high post-mortem doses of opiates in his bloodstream.

Dr. McIver is currently serving sentences of 20 years in federal prison for distribution, and 30 years for dispensing drugs that resulted in the patient’s death. His appeals, including one made to the U.S. Supreme Court, have been rejected.

Forensic psychiatrists might be called upon to provide expert opinion in criminal cases asking whether a prescribing physician is guilty of illegally prescribing opioids for distribution or abuse, in civil actions such as malpractice cases, and in medical board investigations, including allegations of physician impairment from opioid abuse, Dr. Sokolov noted.

Prescribing and Monitoring Opioids

Clinical guidelines for the use of chronic opioids in non-cancer pain are consistent in their recommendations, Dr. Wasan said (J. Pain. 2009;10:131-46).

Key issues pain psychiatrists should consider are the patient’s comorbid psychiatric diagnoses and the ongoing psychological processes that sustain or worsen pain (for example, catastrophizing, poor coping skills, or low self-efficacy). The clinician also should consider the affective component of the patient’s pain, and whether he/she has comorbid substance use disorders or is capable of using an opioid prescription responsibly.

"So many times, psychiatrists say, ‘If the pain [were] better treated, then the psychiatric problems would go away.’ Pain physicians say that, too. But what both sides don’t quite realize is that once you develop a significant psychiatric comorbidity – even if it started because of pain, it takes on a life of its own," Dr. Wasan said.

He cautioned that, in general, opioids only should be prescribed for painful medical conditions, with the exception of methadone and buprenorphine/naloxone (Suboxone) for substance use disorders.

Prescribing opioids requires a medical evaluation and regular follow-up. The prescribing clinician should take or have on hand a full medical history of pain and underlying pathology, full physical exam, and collateral information about the patient from other providers. The patient should be reassessed on an ongoing basis, at least every 6 months.

"There is no issue with psychiatrists prescribing opioids as long as they follow these guidelines," he stated.

Opioid therapy agreements can be helpful, but must be based on mutual trust and honesty established between the patient and the physician in the first visit. Such agreements facilitate informed consent, patient education and compliance, and establish boundaries and consequences for opioid misuse or diversion. The agreement should be flexible, and not written like a contract, Dr. Wasan said.

Neither Dr. Sokolov nor Dr. Wasan reported funding sources for their studies. Both reported that they have no financial relationships pertaining to the content of their presentations.

BOSTON – The line between proper prescribing of opioids and pill pushing is thin and easily crossed, forensic psychiatrists said at the annual meeting of the American Academy of Psychiatry and the Law.

The U.S. Supreme Court in 1975 ruled that physicians who are licensed by the Drug Enforcement Administration (DEA) to prescribe narcotics such as extended-release oxycodone (OxyContin) under the Controlled Substances Act are liable to prosecution "when their activities fall outside the usual course of professional practice."

But the decision about what constitutes deviation from normal professional practice might fall to the judicial system, and several high-profile cases of doctors being convicted as drug pushers have made many practitioners who would otherwise consider prescribing opioids leery of the drugs, said Dr. Gregory G. Sokolov, of the division of psychiatry and the law in the department of psychiatry at the University of California, Davis.

"There is a role for opiate medications, and there is a role for OxyContin for severe pain," Dr. Sokolov said. "Some of these cases have really scared people away from treating pain patients and prescribing opiates, and although there are going to be people who are troubled and problematic, there are patients who truly benefit from these medications."

Chronic opioid therapy is more commonly used for control of severe cancer-related pain, but appropriate non-cancer uses exist for such agents; the trick is knowing which patients will benefit, and which are malingering, said Dr. Ajay D. Wasan from the departments of psychiatry, anesthesiology, and perioperative and pain medicine at Brigham and Women’s Hospital in Boston.

"Some of these cases have really scared people away from treating pain patients and prescribing opiates."

Dr. Sokolov discussed the case of United States vs. Ronald A. McIver, D.O. Dr. McIver, who ran a pain therapy center in Greenwood, S.C., was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution, after the death of a patient with high post-mortem doses of opiates in his bloodstream.

Dr. McIver is currently serving sentences of 20 years in federal prison for distribution, and 30 years for dispensing drugs that resulted in the patient’s death. His appeals, including one made to the U.S. Supreme Court, have been rejected.

Forensic psychiatrists might be called upon to provide expert opinion in criminal cases asking whether a prescribing physician is guilty of illegally prescribing opioids for distribution or abuse, in civil actions such as malpractice cases, and in medical board investigations, including allegations of physician impairment from opioid abuse, Dr. Sokolov noted.

Prescribing and Monitoring Opioids

Clinical guidelines for the use of chronic opioids in non-cancer pain are consistent in their recommendations, Dr. Wasan said (J. Pain. 2009;10:131-46).

Key issues pain psychiatrists should consider are the patient’s comorbid psychiatric diagnoses and the ongoing psychological processes that sustain or worsen pain (for example, catastrophizing, poor coping skills, or low self-efficacy). The clinician also should consider the affective component of the patient’s pain, and whether he/she has comorbid substance use disorders or is capable of using an opioid prescription responsibly.

"So many times, psychiatrists say, ‘If the pain [were] better treated, then the psychiatric problems would go away.’ Pain physicians say that, too. But what both sides don’t quite realize is that once you develop a significant psychiatric comorbidity – even if it started because of pain, it takes on a life of its own," Dr. Wasan said.

He cautioned that, in general, opioids only should be prescribed for painful medical conditions, with the exception of methadone and buprenorphine/naloxone (Suboxone) for substance use disorders.

Prescribing opioids requires a medical evaluation and regular follow-up. The prescribing clinician should take or have on hand a full medical history of pain and underlying pathology, full physical exam, and collateral information about the patient from other providers. The patient should be reassessed on an ongoing basis, at least every 6 months.

"There is no issue with psychiatrists prescribing opioids as long as they follow these guidelines," he stated.

Opioid therapy agreements can be helpful, but must be based on mutual trust and honesty established between the patient and the physician in the first visit. Such agreements facilitate informed consent, patient education and compliance, and establish boundaries and consequences for opioid misuse or diversion. The agreement should be flexible, and not written like a contract, Dr. Wasan said.

Neither Dr. Sokolov nor Dr. Wasan reported funding sources for their studies. Both reported that they have no financial relationships pertaining to the content of their presentations.

Low body mass index is a significant predictor of mortality within 30 days of surgery, according to a report published online in the Nov. 21 issue of Archives of Surgery.

Low BMI raises postoperative mortality risk even after allowances are made for the type of surgery and for the individual patient’s preoperative expected risk of death, said Florence E. Turrentine, Ph.D., R.N., of the department of surgery, University of Virginia, Charlottesville, and her associates.

In particular, the one-fifth of patients with the lowest BMI (less than 23.1 kg/m²) "demonstrated a significant increased risk of death, with 40% higher odds than the risk of death among patients in the middle range for BMI," they noted.

Most studies have reported no increase in postoperative mortality with increased BMI, but because these have had small numbers of patients and limited follow-up periods, the investigators undertook a larger analysis using the American College of Surgeons’ National Surgical Quality Improvement Program data set. "The analysis of such a large number of patients allowed us to [examine] individual procedures done by general surgeons to a level of specificity not previously available," Dr. Turrentine and her colleagues noted.

The study subjects were 189,533 patients who underwent a major general or vascular surgical procedure in 2005 and 2006 at 183 participating medical centers. All patients were examined preoperatively and were given a 30-day mortality probable risk score based on more than 30 demographic characteristics, comorbidities, and laboratory values (Arch. Surg. 2011 Nov. 21 [doi:10.1001/archsurg.2011.310]).

A total of 3,245 patients (1.7%) died within 30 days of their surgery.

Interestingly, compared with normal weight, obesity was associated with lower rather than higher postoperative surgical risk, but not to a statistically significant degree. Somewhat unexpectedly, it was low BMI that raised mortality risk.

Patients were divided into quintiles based on their BMI. After the data were adjusted to account for predicted mortality risk and type of surgery, the percentage of deaths among patients in the lowest BMI quintile (2.8%) was more than double that among patients in the highest BMI quintile (1.0%), which included patients with a BMI of 35.3 or greater.

Thirty-day mortality also was significantly higher among patients in the lowest quintile of BMI than among patients in the middle quintiles (1.8%, 1.5%, and 1.4%).

In this analysis, overweight and obese patients in the upper two quintiles had lower 30-day mortality than did normal-weight patients in the middle quintiles, but those differences did not attain statistical significance.

The investigators further analyzed the data by type of surgery, discriminating among 45 different procedures. Laparoscopy, which was selected as the reference procedure, had an overall mortality of 2.0%. In comparison with laparoscopy, exploratory laparotomy carried the highest 30-day mortality (13.9%).

The effect of BMI on 30-day mortality was found to be quite different for certain operations. High BMI raised 30-day mortality risk for colostomy formation, wound debridement, colorectal resection, hernia repair, and mastectomy.

No financial conflicts of interest were reported.

Low body mass index is a significant predictor of mortality within 30 days of surgery, according to a report published online in the Nov. 21 issue of Archives of Surgery.

Low BMI raises postoperative mortality risk even after allowances are made for the type of surgery and for the individual patient’s preoperative expected risk of death, said Florence E. Turrentine, Ph.D., R.N., of the department of surgery, University of Virginia, Charlottesville, and her associates.

In particular, the one-fifth of patients with the lowest BMI (less than 23.1 kg/m²) "demonstrated a significant increased risk of death, with 40% higher odds than the risk of death among patients in the middle range for BMI," they noted.

Most studies have reported no increase in postoperative mortality with increased BMI, but because these have had small numbers of patients and limited follow-up periods, the investigators undertook a larger analysis using the American College of Surgeons’ National Surgical Quality Improvement Program data set. "The analysis of such a large number of patients allowed us to [examine] individual procedures done by general surgeons to a level of specificity not previously available," Dr. Turrentine and her colleagues noted.

The study subjects were 189,533 patients who underwent a major general or vascular surgical procedure in 2005 and 2006 at 183 participating medical centers. All patients were examined preoperatively and were given a 30-day mortality probable risk score based on more than 30 demographic characteristics, comorbidities, and laboratory values (Arch. Surg. 2011 Nov. 21 [doi:10.1001/archsurg.2011.310]).

A total of 3,245 patients (1.7%) died within 30 days of their surgery.

Interestingly, compared with normal weight, obesity was associated with lower rather than higher postoperative surgical risk, but not to a statistically significant degree. Somewhat unexpectedly, it was low BMI that raised mortality risk.

Patients were divided into quintiles based on their BMI. After the data were adjusted to account for predicted mortality risk and type of surgery, the percentage of deaths among patients in the lowest BMI quintile (2.8%) was more than double that among patients in the highest BMI quintile (1.0%), which included patients with a BMI of 35.3 or greater.

Thirty-day mortality also was significantly higher among patients in the lowest quintile of BMI than among patients in the middle quintiles (1.8%, 1.5%, and 1.4%).

In this analysis, overweight and obese patients in the upper two quintiles had lower 30-day mortality than did normal-weight patients in the middle quintiles, but those differences did not attain statistical significance.

The investigators further analyzed the data by type of surgery, discriminating among 45 different procedures. Laparoscopy, which was selected as the reference procedure, had an overall mortality of 2.0%. In comparison with laparoscopy, exploratory laparotomy carried the highest 30-day mortality (13.9%).

The effect of BMI on 30-day mortality was found to be quite different for certain operations. High BMI raised 30-day mortality risk for colostomy formation, wound debridement, colorectal resection, hernia repair, and mastectomy.

No financial conflicts of interest were reported.

Low body mass index is a significant predictor of mortality within 30 days of surgery, according to a report published online in the Nov. 21 issue of Archives of Surgery.

Low BMI raises postoperative mortality risk even after allowances are made for the type of surgery and for the individual patient’s preoperative expected risk of death, said Florence E. Turrentine, Ph.D., R.N., of the department of surgery, University of Virginia, Charlottesville, and her associates.

In particular, the one-fifth of patients with the lowest BMI (less than 23.1 kg/m²) "demonstrated a significant increased risk of death, with 40% higher odds than the risk of death among patients in the middle range for BMI," they noted.

Most studies have reported no increase in postoperative mortality with increased BMI, but because these have had small numbers of patients and limited follow-up periods, the investigators undertook a larger analysis using the American College of Surgeons’ National Surgical Quality Improvement Program data set. "The analysis of such a large number of patients allowed us to [examine] individual procedures done by general surgeons to a level of specificity not previously available," Dr. Turrentine and her colleagues noted.

The study subjects were 189,533 patients who underwent a major general or vascular surgical procedure in 2005 and 2006 at 183 participating medical centers. All patients were examined preoperatively and were given a 30-day mortality probable risk score based on more than 30 demographic characteristics, comorbidities, and laboratory values (Arch. Surg. 2011 Nov. 21 [doi:10.1001/archsurg.2011.310]).

A total of 3,245 patients (1.7%) died within 30 days of their surgery.

Interestingly, compared with normal weight, obesity was associated with lower rather than higher postoperative surgical risk, but not to a statistically significant degree. Somewhat unexpectedly, it was low BMI that raised mortality risk.

Patients were divided into quintiles based on their BMI. After the data were adjusted to account for predicted mortality risk and type of surgery, the percentage of deaths among patients in the lowest BMI quintile (2.8%) was more than double that among patients in the highest BMI quintile (1.0%), which included patients with a BMI of 35.3 or greater.

Thirty-day mortality also was significantly higher among patients in the lowest quintile of BMI than among patients in the middle quintiles (1.8%, 1.5%, and 1.4%).

In this analysis, overweight and obese patients in the upper two quintiles had lower 30-day mortality than did normal-weight patients in the middle quintiles, but those differences did not attain statistical significance.

The investigators further analyzed the data by type of surgery, discriminating among 45 different procedures. Laparoscopy, which was selected as the reference procedure, had an overall mortality of 2.0%. In comparison with laparoscopy, exploratory laparotomy carried the highest 30-day mortality (13.9%).

The effect of BMI on 30-day mortality was found to be quite different for certain operations. High BMI raised 30-day mortality risk for colostomy formation, wound debridement, colorectal resection, hernia repair, and mastectomy.

No financial conflicts of interest were reported.

Impaired cognition among older adults who undergo elective surgery is significantly associated with adverse postoperative outcomes, including increased complications, length of stay, and long-term mortality, results from a single-center study showed.

In addition, delirium was found to be an effect modifier in the relationship between impaired cognition and adverse postoperative outcomes.

"The most striking finding is that delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality," lead investigator Dr. Thomas N. Robinson said in an interview before the annual meeting of the Western Surgical Association, where the work was presented.

In what he said is the first study of its kind, Dr. Robinson, of the department of surgery at the University of Colorado, Denver, and his associates prospectively evaluated 186 adults aged 65 and older who underwent an elective operation requiring postoperative ICU admission.

To assess preoperative baseline cognitive function, they used the validated Mini-Cog test, which combines an uncued three-item recall test with a clock drawing task. Impaired cognition was defined as a Mini-Cog score of 3 or less.

To assess delirium, the researchers used the Confusion Assessment Method for the ICU, a validated tool that evaluates delirium based on fluctuation in mental status, inattention, disorganized thinking, and altered level of consciousness.

"Delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality."

To determine adverse outcomes, they used definitions from the Veterans Affairs Surgical Quality Improvement Program.

Dr. Robinson, who also holds an appointment in the department of surgery at the Denver Veterans Affairs Medical Center, reported that the mean age of the 186 patients was 73 years and 96% were male. Nearly half (44%) had impaired cognition.

Compared with their counterparts who had normal cognition at baseline, those with impaired cognition had a higher rate of one or more complications (41% vs. 24%, respectively), a higher incidence of delirium (78% vs. 37%), longer hospital stays (a mean of 15 vs. 9 days), a higher rate of discharge to an institutional care facility (42% vs. 18%), a higher 30-day readmission rate (21% vs. 10%), and a higher 6-month mortality (11% vs. 5%). All differences were statistically significant.

Dr. Robinson also reported that the hazard ratio for death was 2.77 higher among patients with impaired cognition and delirium at baseline compared with patients with normal cognition and delirium. On the other hand, the hazard ratio for death was 1.86 times higher among patients who had impaired cognitive function but no delirium at baseline.

In their abstract, the researchers noted certain limitations of the study, including the fact that nearly all patients were male and that a wide variety of operations were included, which "leads to large variability in measurements such as blood loss, operating room time, and length of stay."

They went on to conclude that "recognition of the brain’s function as a relevant marker of postoperative events has implications on the clinician’s ability to counsel their older patients about the anticipated postoperative course. In the future, preoperative risk stratification will likely not be based on physiologic compromise of a single organ system alone. Instead, the sum of compromise across multiple health-related domains (e.g., cognition, function, nutrition, disease burden) will likely be used to forecast postoperative outcomes."

The study received financial support from the National Institute on Aging and the American Geriatrics Society. Dr. Robinson said that he had no relevant financial disclosures.

Impaired cognition among older adults who undergo elective surgery is significantly associated with adverse postoperative outcomes, including increased complications, length of stay, and long-term mortality, results from a single-center study showed.

In addition, delirium was found to be an effect modifier in the relationship between impaired cognition and adverse postoperative outcomes.

"The most striking finding is that delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality," lead investigator Dr. Thomas N. Robinson said in an interview before the annual meeting of the Western Surgical Association, where the work was presented.

In what he said is the first study of its kind, Dr. Robinson, of the department of surgery at the University of Colorado, Denver, and his associates prospectively evaluated 186 adults aged 65 and older who underwent an elective operation requiring postoperative ICU admission.

To assess preoperative baseline cognitive function, they used the validated Mini-Cog test, which combines an uncued three-item recall test with a clock drawing task. Impaired cognition was defined as a Mini-Cog score of 3 or less.

To assess delirium, the researchers used the Confusion Assessment Method for the ICU, a validated tool that evaluates delirium based on fluctuation in mental status, inattention, disorganized thinking, and altered level of consciousness.

"Delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality."

To determine adverse outcomes, they used definitions from the Veterans Affairs Surgical Quality Improvement Program.

Dr. Robinson, who also holds an appointment in the department of surgery at the Denver Veterans Affairs Medical Center, reported that the mean age of the 186 patients was 73 years and 96% were male. Nearly half (44%) had impaired cognition.

Compared with their counterparts who had normal cognition at baseline, those with impaired cognition had a higher rate of one or more complications (41% vs. 24%, respectively), a higher incidence of delirium (78% vs. 37%), longer hospital stays (a mean of 15 vs. 9 days), a higher rate of discharge to an institutional care facility (42% vs. 18%), a higher 30-day readmission rate (21% vs. 10%), and a higher 6-month mortality (11% vs. 5%). All differences were statistically significant.

Dr. Robinson also reported that the hazard ratio for death was 2.77 higher among patients with impaired cognition and delirium at baseline compared with patients with normal cognition and delirium. On the other hand, the hazard ratio for death was 1.86 times higher among patients who had impaired cognitive function but no delirium at baseline.

In their abstract, the researchers noted certain limitations of the study, including the fact that nearly all patients were male and that a wide variety of operations were included, which "leads to large variability in measurements such as blood loss, operating room time, and length of stay."

They went on to conclude that "recognition of the brain’s function as a relevant marker of postoperative events has implications on the clinician’s ability to counsel their older patients about the anticipated postoperative course. In the future, preoperative risk stratification will likely not be based on physiologic compromise of a single organ system alone. Instead, the sum of compromise across multiple health-related domains (e.g., cognition, function, nutrition, disease burden) will likely be used to forecast postoperative outcomes."

The study received financial support from the National Institute on Aging and the American Geriatrics Society. Dr. Robinson said that he had no relevant financial disclosures.

Impaired cognition among older adults who undergo elective surgery is significantly associated with adverse postoperative outcomes, including increased complications, length of stay, and long-term mortality, results from a single-center study showed.

In addition, delirium was found to be an effect modifier in the relationship between impaired cognition and adverse postoperative outcomes.

"The most striking finding is that delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality," lead investigator Dr. Thomas N. Robinson said in an interview before the annual meeting of the Western Surgical Association, where the work was presented.

In what he said is the first study of its kind, Dr. Robinson, of the department of surgery at the University of Colorado, Denver, and his associates prospectively evaluated 186 adults aged 65 and older who underwent an elective operation requiring postoperative ICU admission.

To assess preoperative baseline cognitive function, they used the validated Mini-Cog test, which combines an uncued three-item recall test with a clock drawing task. Impaired cognition was defined as a Mini-Cog score of 3 or less.

To assess delirium, the researchers used the Confusion Assessment Method for the ICU, a validated tool that evaluates delirium based on fluctuation in mental status, inattention, disorganized thinking, and altered level of consciousness.

"Delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality."

To determine adverse outcomes, they used definitions from the Veterans Affairs Surgical Quality Improvement Program.

Dr. Robinson, who also holds an appointment in the department of surgery at the Denver Veterans Affairs Medical Center, reported that the mean age of the 186 patients was 73 years and 96% were male. Nearly half (44%) had impaired cognition.

Compared with their counterparts who had normal cognition at baseline, those with impaired cognition had a higher rate of one or more complications (41% vs. 24%, respectively), a higher incidence of delirium (78% vs. 37%), longer hospital stays (a mean of 15 vs. 9 days), a higher rate of discharge to an institutional care facility (42% vs. 18%), a higher 30-day readmission rate (21% vs. 10%), and a higher 6-month mortality (11% vs. 5%). All differences were statistically significant.

Dr. Robinson also reported that the hazard ratio for death was 2.77 higher among patients with impaired cognition and delirium at baseline compared with patients with normal cognition and delirium. On the other hand, the hazard ratio for death was 1.86 times higher among patients who had impaired cognitive function but no delirium at baseline.

In their abstract, the researchers noted certain limitations of the study, including the fact that nearly all patients were male and that a wide variety of operations were included, which "leads to large variability in measurements such as blood loss, operating room time, and length of stay."

They went on to conclude that "recognition of the brain’s function as a relevant marker of postoperative events has implications on the clinician’s ability to counsel their older patients about the anticipated postoperative course. In the future, preoperative risk stratification will likely not be based on physiologic compromise of a single organ system alone. Instead, the sum of compromise across multiple health-related domains (e.g., cognition, function, nutrition, disease burden) will likely be used to forecast postoperative outcomes."

The study received financial support from the National Institute on Aging and the American Geriatrics Society. Dr. Robinson said that he had no relevant financial disclosures.

SAN FRANCISCO – A majority of patients who are rehospitalized after surgery have a postoperative complication, most commonly after colectomy, lower extremity bypass, or carotid endarterectomy.

Reducing postoperative complications could reduce costs associated with readmissions by millions of dollars per year, a retrospective study of data on 90,932 patients from 214 hospitals suggests.

Investigators linked records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Medicare Provider Analysis and Review files for patients aged 65 years or older who underwent surgery in 2005-2008.

Within 30 days of surgery, 13% of patients were readmitted. A postoperative complication listed in the ACS-NSQIP registry was seen in 53% of readmitted patients compared with 16% of patients who did not need readmission, Dr. Elise H. Lawson and her associates reported at the annual clinical congress of the American College of Surgeons.

The study looked at 20 postoperative complications, including surgical site infections, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, coma, cardiac arrest requiring CPR, myocardial infarction, bleeding requiring transfusion, deep venous thrombosis, sepsis or septic shock, being on a ventilator for more than 48 hours, and an unplanned return to the OR, among others.

Colectomy was associated with the greatest number of readmissions, followed by lower extremity bypass and carotid endarterectomy. After colectomy, 27% of patients developed a complication, and 13.4% of all colectomy patients were readmitted within 30 days.

Readmission rates after colectomy were 28% for patients who developed postoperative complications and 8% for patients without complications, said Dr. Lawson of the University of California, Los Angeles. She won the College’s 2011 Excellence in Research Award for her study.

Hypothetically, if postoperative complications could be prevented after colectomy, the risk-adjusted probability of readmission within 30 days would be 8%, she said. The study adjusted for the effects of many other factors that influenced the risk of having a postoperative complication, including age, sex, body mass index, functional status, emergency procedures, smoking, renal failure, and diabetes.

Not only did patients with complications have more readmissions, but those readmissions were more expensive. The cost for readmission after colectomy was $13,400 for patients with a complication and $7,500 for those without complications.

It’s unrealistic to think that a hospital could prevent all postoperative complications, Dr. Lawson said. Reducing complications after colectomy by even 10% (to 24%) would lower the overall postcolectomy readmission rate from 13.4% to 12.8%, the investigators estimated. For the 108,820 colectomies performed each year in Medicare beneficiaries aged 65 years or older, a 10% reduction in postoperative complications would reduce costs from readmissions alone by $9.3 million per year, she said.

Reducing complications after colectomy by 30% (to 19%) would lower the postcolectomy readmission rate to 11.7% and save an estimated $28 million per year in readmission costs. Halving the postcolectomy complication rate (to 13.5%) would reduce the readmission rate to 10.6% and save an estimated $46 million per year in readmission costs.

Previous data suggest that 13% of surgical patients and 16% of medical patients are readmitted after discharge from hospitalization, accounting for an estimated $17 billion in Medicare costs. Medicare plans to reduce payments for readmissions starting in 2013.

The reasons that patients are readmitted are not well understood, which was one motivation for the study, Dr. Lawson said. Unplanned readmissions that are related to the initial surgery may be due to postoperative complications or exacerbations of a preoperative comorbidity. Unplanned readmissions also may be for reasons unrelated to the initial surgery, such as for trauma or falls. In other cases, readmission may be planned for chemotherapy or elective procedures. The study excluded patients who died before discharge or who were not discharged from the primary hospitalization.

Dr. Lawson said she has no relevant conflicts of interest.

SAN FRANCISCO – A majority of patients who are rehospitalized after surgery have a postoperative complication, most commonly after colectomy, lower extremity bypass, or carotid endarterectomy.

Reducing postoperative complications could reduce costs associated with readmissions by millions of dollars per year, a retrospective study of data on 90,932 patients from 214 hospitals suggests.

Investigators linked records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Medicare Provider Analysis and Review files for patients aged 65 years or older who underwent surgery in 2005-2008.

Within 30 days of surgery, 13% of patients were readmitted. A postoperative complication listed in the ACS-NSQIP registry was seen in 53% of readmitted patients compared with 16% of patients who did not need readmission, Dr. Elise H. Lawson and her associates reported at the annual clinical congress of the American College of Surgeons.

The study looked at 20 postoperative complications, including surgical site infections, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, coma, cardiac arrest requiring CPR, myocardial infarction, bleeding requiring transfusion, deep venous thrombosis, sepsis or septic shock, being on a ventilator for more than 48 hours, and an unplanned return to the OR, among others.

Colectomy was associated with the greatest number of readmissions, followed by lower extremity bypass and carotid endarterectomy. After colectomy, 27% of patients developed a complication, and 13.4% of all colectomy patients were readmitted within 30 days.

Readmission rates after colectomy were 28% for patients who developed postoperative complications and 8% for patients without complications, said Dr. Lawson of the University of California, Los Angeles. She won the College’s 2011 Excellence in Research Award for her study.

Hypothetically, if postoperative complications could be prevented after colectomy, the risk-adjusted probability of readmission within 30 days would be 8%, she said. The study adjusted for the effects of many other factors that influenced the risk of having a postoperative complication, including age, sex, body mass index, functional status, emergency procedures, smoking, renal failure, and diabetes.

Not only did patients with complications have more readmissions, but those readmissions were more expensive. The cost for readmission after colectomy was $13,400 for patients with a complication and $7,500 for those without complications.

It’s unrealistic to think that a hospital could prevent all postoperative complications, Dr. Lawson said. Reducing complications after colectomy by even 10% (to 24%) would lower the overall postcolectomy readmission rate from 13.4% to 12.8%, the investigators estimated. For the 108,820 colectomies performed each year in Medicare beneficiaries aged 65 years or older, a 10% reduction in postoperative complications would reduce costs from readmissions alone by $9.3 million per year, she said.

Reducing complications after colectomy by 30% (to 19%) would lower the postcolectomy readmission rate to 11.7% and save an estimated $28 million per year in readmission costs. Halving the postcolectomy complication rate (to 13.5%) would reduce the readmission rate to 10.6% and save an estimated $46 million per year in readmission costs.

Previous data suggest that 13% of surgical patients and 16% of medical patients are readmitted after discharge from hospitalization, accounting for an estimated $17 billion in Medicare costs. Medicare plans to reduce payments for readmissions starting in 2013.

The reasons that patients are readmitted are not well understood, which was one motivation for the study, Dr. Lawson said. Unplanned readmissions that are related to the initial surgery may be due to postoperative complications or exacerbations of a preoperative comorbidity. Unplanned readmissions also may be for reasons unrelated to the initial surgery, such as for trauma or falls. In other cases, readmission may be planned for chemotherapy or elective procedures. The study excluded patients who died before discharge or who were not discharged from the primary hospitalization.

Dr. Lawson said she has no relevant conflicts of interest.

SAN FRANCISCO – A majority of patients who are rehospitalized after surgery have a postoperative complication, most commonly after colectomy, lower extremity bypass, or carotid endarterectomy.

Reducing postoperative complications could reduce costs associated with readmissions by millions of dollars per year, a retrospective study of data on 90,932 patients from 214 hospitals suggests.

Investigators linked records from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Medicare Provider Analysis and Review files for patients aged 65 years or older who underwent surgery in 2005-2008.

Within 30 days of surgery, 13% of patients were readmitted. A postoperative complication listed in the ACS-NSQIP registry was seen in 53% of readmitted patients compared with 16% of patients who did not need readmission, Dr. Elise H. Lawson and her associates reported at the annual clinical congress of the American College of Surgeons.

The study looked at 20 postoperative complications, including surgical site infections, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, coma, cardiac arrest requiring CPR, myocardial infarction, bleeding requiring transfusion, deep venous thrombosis, sepsis or septic shock, being on a ventilator for more than 48 hours, and an unplanned return to the OR, among others.

Colectomy was associated with the greatest number of readmissions, followed by lower extremity bypass and carotid endarterectomy. After colectomy, 27% of patients developed a complication, and 13.4% of all colectomy patients were readmitted within 30 days.

Readmission rates after colectomy were 28% for patients who developed postoperative complications and 8% for patients without complications, said Dr. Lawson of the University of California, Los Angeles. She won the College’s 2011 Excellence in Research Award for her study.

Hypothetically, if postoperative complications could be prevented after colectomy, the risk-adjusted probability of readmission within 30 days would be 8%, she said. The study adjusted for the effects of many other factors that influenced the risk of having a postoperative complication, including age, sex, body mass index, functional status, emergency procedures, smoking, renal failure, and diabetes.

Not only did patients with complications have more readmissions, but those readmissions were more expensive. The cost for readmission after colectomy was $13,400 for patients with a complication and $7,500 for those without complications.

It’s unrealistic to think that a hospital could prevent all postoperative complications, Dr. Lawson said. Reducing complications after colectomy by even 10% (to 24%) would lower the overall postcolectomy readmission rate from 13.4% to 12.8%, the investigators estimated. For the 108,820 colectomies performed each year in Medicare beneficiaries aged 65 years or older, a 10% reduction in postoperative complications would reduce costs from readmissions alone by $9.3 million per year, she said.

Reducing complications after colectomy by 30% (to 19%) would lower the postcolectomy readmission rate to 11.7% and save an estimated $28 million per year in readmission costs. Halving the postcolectomy complication rate (to 13.5%) would reduce the readmission rate to 10.6% and save an estimated $46 million per year in readmission costs.

Previous data suggest that 13% of surgical patients and 16% of medical patients are readmitted after discharge from hospitalization, accounting for an estimated $17 billion in Medicare costs. Medicare plans to reduce payments for readmissions starting in 2013.

The reasons that patients are readmitted are not well understood, which was one motivation for the study, Dr. Lawson said. Unplanned readmissions that are related to the initial surgery may be due to postoperative complications or exacerbations of a preoperative comorbidity. Unplanned readmissions also may be for reasons unrelated to the initial surgery, such as for trauma or falls. In other cases, readmission may be planned for chemotherapy or elective procedures. The study excluded patients who died before discharge or who were not discharged from the primary hospitalization.

Dr. Lawson said she has no relevant conflicts of interest.

The use of prophylactic ciprofloxacin-containing regimens for prostate biopsies resulted in significantly fewer infective complications than did regimens containing co-amoxiclav and gentamicin, according to an audit of hospital records of 709 patients at one institution.

Researchers in the United Kingdom found that regimens containing ciprofloxacin resulted in an infective complications rate of 2.4%, compared with 12.9% for co-amoxiclav/gentamicin regimens.

The results of this 20-month audit supports the use of ciprofloxacin as part of a prophylactic regimen for transrectal ultrasound-guided prostate biopsy (TRUSP Bx), wrote Mr. Thomas Madden and his coinvestigators in the British Journal of Urology International (BJU International 2011;108:1597-602 [doi:10.1111/j.1464-410X.2011.10160.x]).

Prior to April 2008, patients undergoing TRUSP biopsy were treated with ciprofloxacin 500 mg orally prior to the procedure; followed by 500 mg ciprofloxacin twice daily for 5 days (regimen 1). After April 2008, patients were treated with ciprofloxacin 500 mg orally prior to procedure; followed by 500 mg ciprofloxacin twice daily for 3 days (regimen 2).

Subsequently various recommendations were made to help the hospital to reduce its incidence of Clostridium difficile infection and remain within national guidelines. This included restricting the use of fluoroquinolones and cephalosporins with substitution of co-amoxiclav. The standard antibiotic prophylaxis regimen for all surgeries, including urologic procedures, was changed in July 2008 to 120 mg intravenous gentamicin given 10 minutes preprocedure; followed by 375 mg co-amoxiclav given orally three times daily for 3 days (regimen 3).

In November 2008, the regimen was changed to 120 mg intravenous gentamicin given 10 minutes preprocedure; followed by 625 mg co-amoxiclav given orally three times daily for 3 days (regimen 4). In March 2009, the regimen was changed back to ciprofloxacin 500 mg given orally preprocedure; followed by ciprofloxacin 500 mg given twice daily for 3 days (regimen 5).

"Ciprofloxacin is well documented to achieve excellent prostatic tissue concentration."

"In view of the limited data supporting the change, it was agreed that postoperative infection rates should be monitored to confirm efficacy. This audit looks at the rates of infective complications before and after the change of antibiotic regimen," they wrote.

The investigators identified all patients undergoing TRUSP biopsy from January 2008 through March 2009 from clinic records. Because the electronic patient records at the Cambridge University Hospitals Trust stores all letters from clinics and any admissions, a search starting with the TRUSP Bx clinic letter was able to confirm the antibiotics chosen for prophylaxis. The audit continued for a further 6 months to assess the effect of returning to the use of quinolones as prophylaxis. Patients were divided into five groups based on the antibiotic regimen used.

The two (ciprofloxacin-based) regimens used before the intensive-support team visit were associated with infective complication rates of 0.8% and 2% with 5-day and 3-day courses of ciprofloxacin, respectively. After regimen 3 with gentamicin and co-amoxiclav 375 mg three times daily was introduced, the complication rate rose to 14.4%, and substituting a higher dosage of co-amoxiclav brought only a marginal drop to 11.4%. The incidence of infective complications fell to 3.8%, only after the protocol was changed back to ciprofloxacin.

Overall only 4 patients out of 454 (0.9%) who received ciprofloxacin were admitted for infective complications. In the combined groups given gentamicin/co-amoxiclav, 12 patients out of 255 (4.7%) were admitted with sepsis – which was a highly significant difference.

"Further analysis between the groups shows no significant difference between the 5-day and 3-day regimens of ciprofloxacin in terms of infective complications and no difference between the low-dose and high-dose regimens of co-amoxiclav and gentamicin," wrote Mr. Madden, a clinical fellow in the urology department of Addenbrooke’s Hospital in Cambridge, and his coinvestigators.

Analysis of patients with infective complications showed that only 47% of mid-stream urine specimens and 36% of blood culture samples grew any organisms. Notably, of those that did, 89% grew organisms that were sensitive to co-amoxiclav. "Ciprofloxacin is well documented to achieve excellent prostatic tissue concentrations and it is likely that this is the reason for its effectiveness as a prophylactic agent," the authors wrote.

"However, there should be some caution exercised when using ciprofloxacin as there is evidence that resistant microorganisms exist in the community. The four ciprofloxacin-resistant isolates in this study were evenly distributed between the groups of patients. This would seem to indicate a small but significant prevalence of resistance rather than increasing rates, although the numbers involved are too small in this study to draw firm conclusions."

Mr. Madden had no significant financial relationships to disclose.

The use of prophylactic ciprofloxacin-containing regimens for prostate biopsies resulted in significantly fewer infective complications than did regimens containing co-amoxiclav and gentamicin, according to an audit of hospital records of 709 patients at one institution.

Researchers in the United Kingdom found that regimens containing ciprofloxacin resulted in an infective complications rate of 2.4%, compared with 12.9% for co-amoxiclav/gentamicin regimens.

The results of this 20-month audit supports the use of ciprofloxacin as part of a prophylactic regimen for transrectal ultrasound-guided prostate biopsy (TRUSP Bx), wrote Mr. Thomas Madden and his coinvestigators in the British Journal of Urology International (BJU International 2011;108:1597-602 [doi:10.1111/j.1464-410X.2011.10160.x]).

Prior to April 2008, patients undergoing TRUSP biopsy were treated with ciprofloxacin 500 mg orally prior to the procedure; followed by 500 mg ciprofloxacin twice daily for 5 days (regimen 1). After April 2008, patients were treated with ciprofloxacin 500 mg orally prior to procedure; followed by 500 mg ciprofloxacin twice daily for 3 days (regimen 2).

Subsequently various recommendations were made to help the hospital to reduce its incidence of Clostridium difficile infection and remain within national guidelines. This included restricting the use of fluoroquinolones and cephalosporins with substitution of co-amoxiclav. The standard antibiotic prophylaxis regimen for all surgeries, including urologic procedures, was changed in July 2008 to 120 mg intravenous gentamicin given 10 minutes preprocedure; followed by 375 mg co-amoxiclav given orally three times daily for 3 days (regimen 3).

In November 2008, the regimen was changed to 120 mg intravenous gentamicin given 10 minutes preprocedure; followed by 625 mg co-amoxiclav given orally three times daily for 3 days (regimen 4). In March 2009, the regimen was changed back to ciprofloxacin 500 mg given orally preprocedure; followed by ciprofloxacin 500 mg given twice daily for 3 days (regimen 5).

"Ciprofloxacin is well documented to achieve excellent prostatic tissue concentration."

"In view of the limited data supporting the change, it was agreed that postoperative infection rates should be monitored to confirm efficacy. This audit looks at the rates of infective complications before and after the change of antibiotic regimen," they wrote.

The investigators identified all patients undergoing TRUSP biopsy from January 2008 through March 2009 from clinic records. Because the electronic patient records at the Cambridge University Hospitals Trust stores all letters from clinics and any admissions, a search starting with the TRUSP Bx clinic letter was able to confirm the antibiotics chosen for prophylaxis. The audit continued for a further 6 months to assess the effect of returning to the use of quinolones as prophylaxis. Patients were divided into five groups based on the antibiotic regimen used.

The two (ciprofloxacin-based) regimens used before the intensive-support team visit were associated with infective complication rates of 0.8% and 2% with 5-day and 3-day courses of ciprofloxacin, respectively. After regimen 3 with gentamicin and co-amoxiclav 375 mg three times daily was introduced, the complication rate rose to 14.4%, and substituting a higher dosage of co-amoxiclav brought only a marginal drop to 11.4%. The incidence of infective complications fell to 3.8%, only after the protocol was changed back to ciprofloxacin.

Overall only 4 patients out of 454 (0.9%) who received ciprofloxacin were admitted for infective complications. In the combined groups given gentamicin/co-amoxiclav, 12 patients out of 255 (4.7%) were admitted with sepsis – which was a highly significant difference.

"Further analysis between the groups shows no significant difference between the 5-day and 3-day regimens of ciprofloxacin in terms of infective complications and no difference between the low-dose and high-dose regimens of co-amoxiclav and gentamicin," wrote Mr. Madden, a clinical fellow in the urology department of Addenbrooke’s Hospital in Cambridge, and his coinvestigators.

Analysis of patients with infective complications showed that only 47% of mid-stream urine specimens and 36% of blood culture samples grew any organisms. Notably, of those that did, 89% grew organisms that were sensitive to co-amoxiclav. "Ciprofloxacin is well documented to achieve excellent prostatic tissue concentrations and it is likely that this is the reason for its effectiveness as a prophylactic agent," the authors wrote.

"However, there should be some caution exercised when using ciprofloxacin as there is evidence that resistant microorganisms exist in the community. The four ciprofloxacin-resistant isolates in this study were evenly distributed between the groups of patients. This would seem to indicate a small but significant prevalence of resistance rather than increasing rates, although the numbers involved are too small in this study to draw firm conclusions."

Mr. Madden had no significant financial relationships to disclose.

The use of prophylactic ciprofloxacin-containing regimens for prostate biopsies resulted in significantly fewer infective complications than did regimens containing co-amoxiclav and gentamicin, according to an audit of hospital records of 709 patients at one institution.

Researchers in the United Kingdom found that regimens containing ciprofloxacin resulted in an infective complications rate of 2.4%, compared with 12.9% for co-amoxiclav/gentamicin regimens.

The results of this 20-month audit supports the use of ciprofloxacin as part of a prophylactic regimen for transrectal ultrasound-guided prostate biopsy (TRUSP Bx), wrote Mr. Thomas Madden and his coinvestigators in the British Journal of Urology International (BJU International 2011;108:1597-602 [doi:10.1111/j.1464-410X.2011.10160.x]).

Prior to April 2008, patients undergoing TRUSP biopsy were treated with ciprofloxacin 500 mg orally prior to the procedure; followed by 500 mg ciprofloxacin twice daily for 5 days (regimen 1). After April 2008, patients were treated with ciprofloxacin 500 mg orally prior to procedure; followed by 500 mg ciprofloxacin twice daily for 3 days (regimen 2).

Subsequently various recommendations were made to help the hospital to reduce its incidence of Clostridium difficile infection and remain within national guidelines. This included restricting the use of fluoroquinolones and cephalosporins with substitution of co-amoxiclav. The standard antibiotic prophylaxis regimen for all surgeries, including urologic procedures, was changed in July 2008 to 120 mg intravenous gentamicin given 10 minutes preprocedure; followed by 375 mg co-amoxiclav given orally three times daily for 3 days (regimen 3).

In November 2008, the regimen was changed to 120 mg intravenous gentamicin given 10 minutes preprocedure; followed by 625 mg co-amoxiclav given orally three times daily for 3 days (regimen 4). In March 2009, the regimen was changed back to ciprofloxacin 500 mg given orally preprocedure; followed by ciprofloxacin 500 mg given twice daily for 3 days (regimen 5).

"Ciprofloxacin is well documented to achieve excellent prostatic tissue concentration."

"In view of the limited data supporting the change, it was agreed that postoperative infection rates should be monitored to confirm efficacy. This audit looks at the rates of infective complications before and after the change of antibiotic regimen," they wrote.

The investigators identified all patients undergoing TRUSP biopsy from January 2008 through March 2009 from clinic records. Because the electronic patient records at the Cambridge University Hospitals Trust stores all letters from clinics and any admissions, a search starting with the TRUSP Bx clinic letter was able to confirm the antibiotics chosen for prophylaxis. The audit continued for a further 6 months to assess the effect of returning to the use of quinolones as prophylaxis. Patients were divided into five groups based on the antibiotic regimen used.

The two (ciprofloxacin-based) regimens used before the intensive-support team visit were associated with infective complication rates of 0.8% and 2% with 5-day and 3-day courses of ciprofloxacin, respectively. After regimen 3 with gentamicin and co-amoxiclav 375 mg three times daily was introduced, the complication rate rose to 14.4%, and substituting a higher dosage of co-amoxiclav brought only a marginal drop to 11.4%. The incidence of infective complications fell to 3.8%, only after the protocol was changed back to ciprofloxacin.

Overall only 4 patients out of 454 (0.9%) who received ciprofloxacin were admitted for infective complications. In the combined groups given gentamicin/co-amoxiclav, 12 patients out of 255 (4.7%) were admitted with sepsis – which was a highly significant difference.

"Further analysis between the groups shows no significant difference between the 5-day and 3-day regimens of ciprofloxacin in terms of infective complications and no difference between the low-dose and high-dose regimens of co-amoxiclav and gentamicin," wrote Mr. Madden, a clinical fellow in the urology department of Addenbrooke’s Hospital in Cambridge, and his coinvestigators.

Analysis of patients with infective complications showed that only 47% of mid-stream urine specimens and 36% of blood culture samples grew any organisms. Notably, of those that did, 89% grew organisms that were sensitive to co-amoxiclav. "Ciprofloxacin is well documented to achieve excellent prostatic tissue concentrations and it is likely that this is the reason for its effectiveness as a prophylactic agent," the authors wrote.

"However, there should be some caution exercised when using ciprofloxacin as there is evidence that resistant microorganisms exist in the community. The four ciprofloxacin-resistant isolates in this study were evenly distributed between the groups of patients. This would seem to indicate a small but significant prevalence of resistance rather than increasing rates, although the numbers involved are too small in this study to draw firm conclusions."

Mr. Madden had no significant financial relationships to disclose.

BOSTON – Just 1% of all surgical procedures are associated with complex surgical site infections, but many develop in association with ill-suited prophylactic antibiotic regimens, according to an analysis of more than 2.4 million American who underwent cardiac or orthopedic surgery during 2006-2009.

Nevertheless, "the vast majority [of surgery patients] don’t get SSIs. Do we want to modify treatment for all patients to address the small proportion who get complex SSIs?" asked Dr. Dale W. Bratzler.

The low overall rate of complex SSIs suggests that any changes to standard SSI prophylaxis regimens should proceed cautiously. "What we need most are strategies for identifying patients at high risk for SSI due to drug-resistant organisms for targeting modified antimicrobial prophylaxis regimens," said Dr. Bratzler, a professor in the department of health administration and policy of the University of Oklahoma, Oklahoma City.

The analysis he reported at the annual meeting of the Infectious Diseases Society of America used data from two large U.S. databases collected from January 2006 to December 2009. Information on the pathogen distribution of SSIs came from the National Healthcare Safety Network database of the Centers for Disease Control and Prevention, which included data from 1,389 U.S. hospitals during this period on the number and type of SSIs that occurred in patients who underwent coronary artery bypass grafting (CABG), and those who had primary total hip or total knee replacement surgery. The second database, from the Hospital Inpatient Quality Reporting Program of the Centers for Medicare and Medicaid Services, collected data on the type of antimicrobial prophylaxis received by patients who underwent these surgical procedures at 3,330 U.S. hospitals.

"Do we want to modify treatment for all patients to address the small proportion who get complex SSIs?"

The National Healthcare Safety Network data showed that a total of 3,024 patients developed a complex SSI among the 207,053 who underwent CABG (1.5%), and 3,532 patients had a complex SSI among the 495,529 patients who had primary hip or knee replacement surgery (0.7%), Dr. Bratzler reported. Complex SSIs were defined as either deep incisional infections, or infections of an organ or surgical space. Among the CABG-associated complex SSIs, 34% were caused by gram-negative bacteria, with the balance caused by gram-positive pathogens, and 17% of all SSIs involved methicillin-resistant Staphylococcus aureus (MRSA). In the arthroplasty patients, 18% of the complex SSIs involved a gram-negative pathogen, and 21% of all infections had MRSA involvement.

The data on type of antibiotic prophylaxis used showed that among 428,541 patients who underwent CABG in this dataset, 67% received "standard" prophylaxis with either cefazolin or cefuroxime; 12% received a regimen designed for patients with beta-lactam allergy with either vancomycin or clindamycin, plus an aminoglycoside added at the provider’s discretion; and 15% had prophylaxis with an extended-spectrum regimen consisting of either vancomycin plus cefazolin or cefuroxime, or an aminoglycoside plus cefazolin or cefuroxime. The remaining 6% of patients received another prophylaxis regimen.

The prophylaxis data for 2,007,162 arthroplasty patients showed that the standard regimen was used in 77%, the beta-lactam allergy regimen in 13%, and the extended-spectrum regimen in 7%, with the remaining 3% of patients receiving something else.

Dr. Bratzler then compared the expected efficacy of the three most commonly used regimens against the pattern of SSIs that actually occurred in these patients. Patients who received the standard regimen could expect protection against about 40% of the types of bacteria that actually wound up producing SSIs. Patients who received the beta-lactam allergy regimens could expect protection against 56%-96% of the pathogens that actually caused the SSIs, and patients who received the extended-spectrum regimens could expect protection against 69%-96%, he said.

The researchers could not do a more detailed analysis of the relationship between the type of prophylaxis used and the pattern of SSIs that subsequently developed because both databases were anonymous, which precluded cross-referencing the information.

Dr. Bratzler said that he had no disclosures.

BOSTON – Just 1% of all surgical procedures are associated with complex surgical site infections, but many develop in association with ill-suited prophylactic antibiotic regimens, according to an analysis of more than 2.4 million American who underwent cardiac or orthopedic surgery during 2006-2009.

Nevertheless, "the vast majority [of surgery patients] don’t get SSIs. Do we want to modify treatment for all patients to address the small proportion who get complex SSIs?" asked Dr. Dale W. Bratzler.

The low overall rate of complex SSIs suggests that any changes to standard SSI prophylaxis regimens should proceed cautiously. "What we need most are strategies for identifying patients at high risk for SSI due to drug-resistant organisms for targeting modified antimicrobial prophylaxis regimens," said Dr. Bratzler, a professor in the department of health administration and policy of the University of Oklahoma, Oklahoma City.

The analysis he reported at the annual meeting of the Infectious Diseases Society of America used data from two large U.S. databases collected from January 2006 to December 2009. Information on the pathogen distribution of SSIs came from the National Healthcare Safety Network database of the Centers for Disease Control and Prevention, which included data from 1,389 U.S. hospitals during this period on the number and type of SSIs that occurred in patients who underwent coronary artery bypass grafting (CABG), and those who had primary total hip or total knee replacement surgery. The second database, from the Hospital Inpatient Quality Reporting Program of the Centers for Medicare and Medicaid Services, collected data on the type of antimicrobial prophylaxis received by patients who underwent these surgical procedures at 3,330 U.S. hospitals.

"Do we want to modify treatment for all patients to address the small proportion who get complex SSIs?"

The National Healthcare Safety Network data showed that a total of 3,024 patients developed a complex SSI among the 207,053 who underwent CABG (1.5%), and 3,532 patients had a complex SSI among the 495,529 patients who had primary hip or knee replacement surgery (0.7%), Dr. Bratzler reported. Complex SSIs were defined as either deep incisional infections, or infections of an organ or surgical space. Among the CABG-associated complex SSIs, 34% were caused by gram-negative bacteria, with the balance caused by gram-positive pathogens, and 17% of all SSIs involved methicillin-resistant Staphylococcus aureus (MRSA). In the arthroplasty patients, 18% of the complex SSIs involved a gram-negative pathogen, and 21% of all infections had MRSA involvement.

The data on type of antibiotic prophylaxis used showed that among 428,541 patients who underwent CABG in this dataset, 67% received "standard" prophylaxis with either cefazolin or cefuroxime; 12% received a regimen designed for patients with beta-lactam allergy with either vancomycin or clindamycin, plus an aminoglycoside added at the provider’s discretion; and 15% had prophylaxis with an extended-spectrum regimen consisting of either vancomycin plus cefazolin or cefuroxime, or an aminoglycoside plus cefazolin or cefuroxime. The remaining 6% of patients received another prophylaxis regimen.

The prophylaxis data for 2,007,162 arthroplasty patients showed that the standard regimen was used in 77%, the beta-lactam allergy regimen in 13%, and the extended-spectrum regimen in 7%, with the remaining 3% of patients receiving something else.

Dr. Bratzler then compared the expected efficacy of the three most commonly used regimens against the pattern of SSIs that actually occurred in these patients. Patients who received the standard regimen could expect protection against about 40% of the types of bacteria that actually wound up producing SSIs. Patients who received the beta-lactam allergy regimens could expect protection against 56%-96% of the pathogens that actually caused the SSIs, and patients who received the extended-spectrum regimens could expect protection against 69%-96%, he said.

The researchers could not do a more detailed analysis of the relationship between the type of prophylaxis used and the pattern of SSIs that subsequently developed because both databases were anonymous, which precluded cross-referencing the information.

Dr. Bratzler said that he had no disclosures.

BOSTON – Just 1% of all surgical procedures are associated with complex surgical site infections, but many develop in association with ill-suited prophylactic antibiotic regimens, according to an analysis of more than 2.4 million American who underwent cardiac or orthopedic surgery during 2006-2009.

Nevertheless, "the vast majority [of surgery patients] don’t get SSIs. Do we want to modify treatment for all patients to address the small proportion who get complex SSIs?" asked Dr. Dale W. Bratzler.

The low overall rate of complex SSIs suggests that any changes to standard SSI prophylaxis regimens should proceed cautiously. "What we need most are strategies for identifying patients at high risk for SSI due to drug-resistant organisms for targeting modified antimicrobial prophylaxis regimens," said Dr. Bratzler, a professor in the department of health administration and policy of the University of Oklahoma, Oklahoma City.

The analysis he reported at the annual meeting of the Infectious Diseases Society of America used data from two large U.S. databases collected from January 2006 to December 2009. Information on the pathogen distribution of SSIs came from the National Healthcare Safety Network database of the Centers for Disease Control and Prevention, which included data from 1,389 U.S. hospitals during this period on the number and type of SSIs that occurred in patients who underwent coronary artery bypass grafting (CABG), and those who had primary total hip or total knee replacement surgery. The second database, from the Hospital Inpatient Quality Reporting Program of the Centers for Medicare and Medicaid Services, collected data on the type of antimicrobial prophylaxis received by patients who underwent these surgical procedures at 3,330 U.S. hospitals.

"Do we want to modify treatment for all patients to address the small proportion who get complex SSIs?"

The National Healthcare Safety Network data showed that a total of 3,024 patients developed a complex SSI among the 207,053 who underwent CABG (1.5%), and 3,532 patients had a complex SSI among the 495,529 patients who had primary hip or knee replacement surgery (0.7%), Dr. Bratzler reported. Complex SSIs were defined as either deep incisional infections, or infections of an organ or surgical space. Among the CABG-associated complex SSIs, 34% were caused by gram-negative bacteria, with the balance caused by gram-positive pathogens, and 17% of all SSIs involved methicillin-resistant Staphylococcus aureus (MRSA). In the arthroplasty patients, 18% of the complex SSIs involved a gram-negative pathogen, and 21% of all infections had MRSA involvement.

The data on type of antibiotic prophylaxis used showed that among 428,541 patients who underwent CABG in this dataset, 67% received "standard" prophylaxis with either cefazolin or cefuroxime; 12% received a regimen designed for patients with beta-lactam allergy with either vancomycin or clindamycin, plus an aminoglycoside added at the provider’s discretion; and 15% had prophylaxis with an extended-spectrum regimen consisting of either vancomycin plus cefazolin or cefuroxime, or an aminoglycoside plus cefazolin or cefuroxime. The remaining 6% of patients received another prophylaxis regimen.

The prophylaxis data for 2,007,162 arthroplasty patients showed that the standard regimen was used in 77%, the beta-lactam allergy regimen in 13%, and the extended-spectrum regimen in 7%, with the remaining 3% of patients receiving something else.

Dr. Bratzler then compared the expected efficacy of the three most commonly used regimens against the pattern of SSIs that actually occurred in these patients. Patients who received the standard regimen could expect protection against about 40% of the types of bacteria that actually wound up producing SSIs. Patients who received the beta-lactam allergy regimens could expect protection against 56%-96% of the pathogens that actually caused the SSIs, and patients who received the extended-spectrum regimens could expect protection against 69%-96%, he said.

The researchers could not do a more detailed analysis of the relationship between the type of prophylaxis used and the pattern of SSIs that subsequently developed because both databases were anonymous, which precluded cross-referencing the information.

Dr. Bratzler said that he had no disclosures.

NATIONAL HARBOR, MD – Local delivery of an antibiotic using impregnated bone-cement beads enabled sterile cultures to be achieved in the majority of infected surgical sites before final repair or graft replacement, according to a small, retrospective study reported by Dr. Dennis F. Bandyk.

This type of nonbiodegradable antibiotic implant is especially useful in cases of infection related to a groin incision, he said at the annual meeting of the Eastern Vascular Society.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes.

"After EVAR [endovascular aneurysm repair], we have about a 5% incidence of surgical site infection. Arterial revascularization in the literature has a 10% to 30% infection rate, [and] it’s 18% in lengthy lower limb revascularization at our institution in Tampa. Major amputations generally range from a 15% to 25% infection rate, with 22% for the last 3 years at Tampa. The problem likely exists because of colonization with staph, particularly MRSA [methicillin-resistant Staphylococcus aureus], of injured and ischemic tissue, especially with involvement of the groin," Dr. Bandyk said.

"We have no decent methods of preventing these sorts of surgical site infections," he noted. The approach that his group takes to treat these infections is to use sequential in situ antibiotic treatment.

"I believe that many of the SSIs [surgical site infections] we have follow this theme of a biofilm-mediated infection," he said. Specific pathogenic strains colonize the area; they produce an extracellular matrix that then creates selective antibiotic resistance, since many of the antibiotics don’t penetrate biofilms.

The reported study comprised a 7-year case audit of 78 patients (55% male) who had complex SSI following peripheral arterial repair, treatment of an infected hip, or above- or below-knee lower limb amputation (12 infected stumps).

Antibiotic delivery directly to the wounds was mediated via the use of polymethyl methacrylate (PMMA) bone-cement beads. For gram-positive infection, which occurred in 70% of patients, the beads were impregnated with vancomycin (2 g/40 g PMMA) in the early part of the case series. Daptomycin (1.5 g/40 g PMMA) was found superior to vancomycin during in vitro testing, and became the antibiotic of choice for patients seen later in the case series. Tobramycin (2 g/40 g PMMA) was used for gram-negative infection, seen in 30% of patients. This was coupled to culture-specific parenteral antibiotics for 3-6 weeks. MRSA accounted for at least half of all early and late infections, and thus MRSA must be taken into account when comparing therapy options.

Infected surgical sites were explored and cultured, and based on a Gram stain of pus or a prior culture result, PMMA antibiotic-impregnated beads were implanted into the wound after soft tissue debridement, including the adjunct use of wound irrigants such as the "brown volcano" – a mixture of salt, peroxide, and Betadine – which disrupts biofilms.

Arterial infections underwent an average of 2.3 debridements. Surgical wounds were primarily closed with a planned bead exchange 3-5 days later (often repeated one to three times) to confirm sterilization prior to graft preservation or in situ graft replacement. The main outcomes were rates of wound sterilization (negative culture) based on wound type, procedures for persistent infection, and freedom from arterial repair infection.

In terms of outcomes, there were no cases of limb loss, higher-level amputation, or death at 30 days. The rate of recurrent infection was 7% over a mean follow-up period of 3 years. Sterile wound cultures were achieved in 91% of cases after 1-3 bead exchanges. Daptomycin beads appeared to work the most rapidly, Dr. Bandyk added.

"So you can sterilize the wound with the prosthetic in place," he noted.

Because of this strategy’s success, his group has transitioned to treating almost 58% of their SSIs in this way, said Dr. Bandyk, professor of surgery at the University of South Florida, Tampa.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes. Vancomycin is bacteriostatic and does not penetrate biofilms; daptomycin is a bacteriocidal antibiotic that does penetrate biofilms," he explained.

In addition, because the use of antibiotic beads in general "isn’t anything new, you get paid for putting it in and paid for pulling it out."

Discussion after the presentation focused on the expense of daptomycin versus vancomycin and the difficulty of obtaining it in many institutions due to cost and issues of antibiotic stewardship. Dr. Bandyk responded, "I thought we were surgeons. Most surgeons believe that we should use a bactericidal agent that can get to the tissue with a chance of killing the bacteria that are there. I didn’t realize that we were in this sort of price war with the hospital. If you look at what a biofilm infection is, you will understand why vancomycin doesn’t work."

In response to a question as to whether the type of incision was an issue regarding SSI, Dr. Bandyk said: "It’s the patient that’s producing the infection, and certain patient characteristics, so it isn’t necessarily how we’re closing, which way we are putting the incision ... So don’t blame yourself for every surgical site infection. It’s the patient factors that are operative in many of these cases. Of almost all of our infections that occurred, two-thirds came from the MRSA-colonized patient," he said.

Dr. Bandyk reported being on the speakers bureau and having received funding from Cubist Pharmaceuticals, the manufacturer of daptomycin (Cubicin).

NATIONAL HARBOR, MD – Local delivery of an antibiotic using impregnated bone-cement beads enabled sterile cultures to be achieved in the majority of infected surgical sites before final repair or graft replacement, according to a small, retrospective study reported by Dr. Dennis F. Bandyk.

This type of nonbiodegradable antibiotic implant is especially useful in cases of infection related to a groin incision, he said at the annual meeting of the Eastern Vascular Society.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes.

"After EVAR [endovascular aneurysm repair], we have about a 5% incidence of surgical site infection. Arterial revascularization in the literature has a 10% to 30% infection rate, [and] it’s 18% in lengthy lower limb revascularization at our institution in Tampa. Major amputations generally range from a 15% to 25% infection rate, with 22% for the last 3 years at Tampa. The problem likely exists because of colonization with staph, particularly MRSA [methicillin-resistant Staphylococcus aureus], of injured and ischemic tissue, especially with involvement of the groin," Dr. Bandyk said.

"We have no decent methods of preventing these sorts of surgical site infections," he noted. The approach that his group takes to treat these infections is to use sequential in situ antibiotic treatment.

"I believe that many of the SSIs [surgical site infections] we have follow this theme of a biofilm-mediated infection," he said. Specific pathogenic strains colonize the area; they produce an extracellular matrix that then creates selective antibiotic resistance, since many of the antibiotics don’t penetrate biofilms.

The reported study comprised a 7-year case audit of 78 patients (55% male) who had complex SSI following peripheral arterial repair, treatment of an infected hip, or above- or below-knee lower limb amputation (12 infected stumps).

Antibiotic delivery directly to the wounds was mediated via the use of polymethyl methacrylate (PMMA) bone-cement beads. For gram-positive infection, which occurred in 70% of patients, the beads were impregnated with vancomycin (2 g/40 g PMMA) in the early part of the case series. Daptomycin (1.5 g/40 g PMMA) was found superior to vancomycin during in vitro testing, and became the antibiotic of choice for patients seen later in the case series. Tobramycin (2 g/40 g PMMA) was used for gram-negative infection, seen in 30% of patients. This was coupled to culture-specific parenteral antibiotics for 3-6 weeks. MRSA accounted for at least half of all early and late infections, and thus MRSA must be taken into account when comparing therapy options.

Infected surgical sites were explored and cultured, and based on a Gram stain of pus or a prior culture result, PMMA antibiotic-impregnated beads were implanted into the wound after soft tissue debridement, including the adjunct use of wound irrigants such as the "brown volcano" – a mixture of salt, peroxide, and Betadine – which disrupts biofilms.

Arterial infections underwent an average of 2.3 debridements. Surgical wounds were primarily closed with a planned bead exchange 3-5 days later (often repeated one to three times) to confirm sterilization prior to graft preservation or in situ graft replacement. The main outcomes were rates of wound sterilization (negative culture) based on wound type, procedures for persistent infection, and freedom from arterial repair infection.

In terms of outcomes, there were no cases of limb loss, higher-level amputation, or death at 30 days. The rate of recurrent infection was 7% over a mean follow-up period of 3 years. Sterile wound cultures were achieved in 91% of cases after 1-3 bead exchanges. Daptomycin beads appeared to work the most rapidly, Dr. Bandyk added.

"So you can sterilize the wound with the prosthetic in place," he noted.

Because of this strategy’s success, his group has transitioned to treating almost 58% of their SSIs in this way, said Dr. Bandyk, professor of surgery at the University of South Florida, Tampa.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes. Vancomycin is bacteriostatic and does not penetrate biofilms; daptomycin is a bacteriocidal antibiotic that does penetrate biofilms," he explained.

In addition, because the use of antibiotic beads in general "isn’t anything new, you get paid for putting it in and paid for pulling it out."

Discussion after the presentation focused on the expense of daptomycin versus vancomycin and the difficulty of obtaining it in many institutions due to cost and issues of antibiotic stewardship. Dr. Bandyk responded, "I thought we were surgeons. Most surgeons believe that we should use a bactericidal agent that can get to the tissue with a chance of killing the bacteria that are there. I didn’t realize that we were in this sort of price war with the hospital. If you look at what a biofilm infection is, you will understand why vancomycin doesn’t work."

In response to a question as to whether the type of incision was an issue regarding SSI, Dr. Bandyk said: "It’s the patient that’s producing the infection, and certain patient characteristics, so it isn’t necessarily how we’re closing, which way we are putting the incision ... So don’t blame yourself for every surgical site infection. It’s the patient factors that are operative in many of these cases. Of almost all of our infections that occurred, two-thirds came from the MRSA-colonized patient," he said.

Dr. Bandyk reported being on the speakers bureau and having received funding from Cubist Pharmaceuticals, the manufacturer of daptomycin (Cubicin).

NATIONAL HARBOR, MD – Local delivery of an antibiotic using impregnated bone-cement beads enabled sterile cultures to be achieved in the majority of infected surgical sites before final repair or graft replacement, according to a small, retrospective study reported by Dr. Dennis F. Bandyk.

This type of nonbiodegradable antibiotic implant is especially useful in cases of infection related to a groin incision, he said at the annual meeting of the Eastern Vascular Society.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes.

"After EVAR [endovascular aneurysm repair], we have about a 5% incidence of surgical site infection. Arterial revascularization in the literature has a 10% to 30% infection rate, [and] it’s 18% in lengthy lower limb revascularization at our institution in Tampa. Major amputations generally range from a 15% to 25% infection rate, with 22% for the last 3 years at Tampa. The problem likely exists because of colonization with staph, particularly MRSA [methicillin-resistant Staphylococcus aureus], of injured and ischemic tissue, especially with involvement of the groin," Dr. Bandyk said.

"We have no decent methods of preventing these sorts of surgical site infections," he noted. The approach that his group takes to treat these infections is to use sequential in situ antibiotic treatment.

"I believe that many of the SSIs [surgical site infections] we have follow this theme of a biofilm-mediated infection," he said. Specific pathogenic strains colonize the area; they produce an extracellular matrix that then creates selective antibiotic resistance, since many of the antibiotics don’t penetrate biofilms.

The reported study comprised a 7-year case audit of 78 patients (55% male) who had complex SSI following peripheral arterial repair, treatment of an infected hip, or above- or below-knee lower limb amputation (12 infected stumps).

Antibiotic delivery directly to the wounds was mediated via the use of polymethyl methacrylate (PMMA) bone-cement beads. For gram-positive infection, which occurred in 70% of patients, the beads were impregnated with vancomycin (2 g/40 g PMMA) in the early part of the case series. Daptomycin (1.5 g/40 g PMMA) was found superior to vancomycin during in vitro testing, and became the antibiotic of choice for patients seen later in the case series. Tobramycin (2 g/40 g PMMA) was used for gram-negative infection, seen in 30% of patients. This was coupled to culture-specific parenteral antibiotics for 3-6 weeks. MRSA accounted for at least half of all early and late infections, and thus MRSA must be taken into account when comparing therapy options.

Infected surgical sites were explored and cultured, and based on a Gram stain of pus or a prior culture result, PMMA antibiotic-impregnated beads were implanted into the wound after soft tissue debridement, including the adjunct use of wound irrigants such as the "brown volcano" – a mixture of salt, peroxide, and Betadine – which disrupts biofilms.

Arterial infections underwent an average of 2.3 debridements. Surgical wounds were primarily closed with a planned bead exchange 3-5 days later (often repeated one to three times) to confirm sterilization prior to graft preservation or in situ graft replacement. The main outcomes were rates of wound sterilization (negative culture) based on wound type, procedures for persistent infection, and freedom from arterial repair infection.

In terms of outcomes, there were no cases of limb loss, higher-level amputation, or death at 30 days. The rate of recurrent infection was 7% over a mean follow-up period of 3 years. Sterile wound cultures were achieved in 91% of cases after 1-3 bead exchanges. Daptomycin beads appeared to work the most rapidly, Dr. Bandyk added.

"So you can sterilize the wound with the prosthetic in place," he noted.

Because of this strategy’s success, his group has transitioned to treating almost 58% of their SSIs in this way, said Dr. Bandyk, professor of surgery at the University of South Florida, Tampa.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes. Vancomycin is bacteriostatic and does not penetrate biofilms; daptomycin is a bacteriocidal antibiotic that does penetrate biofilms," he explained.

In addition, because the use of antibiotic beads in general "isn’t anything new, you get paid for putting it in and paid for pulling it out."

Discussion after the presentation focused on the expense of daptomycin versus vancomycin and the difficulty of obtaining it in many institutions due to cost and issues of antibiotic stewardship. Dr. Bandyk responded, "I thought we were surgeons. Most surgeons believe that we should use a bactericidal agent that can get to the tissue with a chance of killing the bacteria that are there. I didn’t realize that we were in this sort of price war with the hospital. If you look at what a biofilm infection is, you will understand why vancomycin doesn’t work."

In response to a question as to whether the type of incision was an issue regarding SSI, Dr. Bandyk said: "It’s the patient that’s producing the infection, and certain patient characteristics, so it isn’t necessarily how we’re closing, which way we are putting the incision ... So don’t blame yourself for every surgical site infection. It’s the patient factors that are operative in many of these cases. Of almost all of our infections that occurred, two-thirds came from the MRSA-colonized patient," he said.

Dr. Bandyk reported being on the speakers bureau and having received funding from Cubist Pharmaceuticals, the manufacturer of daptomycin (Cubicin).

Patients with inflammatory bowel disease who undergo surgery have a twofold increase in the risk of deep vein thrombosis or pulmonary embolism, compared with those without IBD, and the risk is even greater among those with IBD who undergo nonintestinal surgery, according to findings from the American College of Surgeons National Surgical Quality Improvement Program.

In a retrospective cohort study of nearly 269,000 patients from the National Surgical Quality Improvement Program (NSQIP) 2008, 2,249 (0.8%) had IBD. Deep vein thrombosis (DVT) or pulmonary embolism (PE) occurred in 1% of those without IBD, in 2.5% of those with IBD, and in 5% of those with IBD who underwent nonintestinal surgery.

Dr. Andrea Merrill of Massachusetts General Hospital and Dr. Frederick Millham of Newton Wellesley Hospital, both in Boston, reported the research online in the Oct. 17 issue of Archives of Surgery. The findings suggest that the standard DVT and PE prophylaxis for patients undergoing surgery should be reconsidered for those with IBD, they concluded.

After adjustment for more than 30 possible confounders available in the NSQIP that add to the power to predict DVT or PE, a significant association remained between IBD and DVT or PE overall (odds ratio, 2.03) and among those undergoing nonintestinal surgery (OR, 4.45), the investigators found (Arch. Surg. 2011 Oct. 17 [doi:10.1001/archsurg.2011.297]).

No difference was seen between the patients with and without IBD in regard to the occurrence of cerebrovascular accident or myocardial infarction, with 0.4% of patients in both groups experiencing such events.

Although IBD has long been known to be associated with an increased risk of thromboembolic events, data on those undergoing surgery has been scarce, and standard DVT and PE prophylaxis guidelines in the IBD population have not been adjusted to include enhanced prophylaxis.

In light of one recent study suggesting a very high risk of postoperative DVT in those undergoing surgery, the investigators sought to evaluate the risk among IBD patients in the NSQIP, which collected data from 170 hospitals in 2008, resulting in a Participant Use Data File (PUF). The de-identified research database is made available to the participating hospitals.

"As such, the NSQIP PUF data set presents an opportunity to examine the relationship of DVT and PE with IBD in a large group of patients for whom data on comorbid conditions and other potential confounding variables are available and well defined. Furthermore, hospitals participating in the NSQIP, having invested in quality improvement, might be expected to treat patients with best practices, at least with respect to DVT prophylaxis," the investigators said, explaining that this would reduce the opportunity for treatment bias between centers.

The finding of an increased risk of DVT or PE in IBD patients was consistent with others in both surgical and nonsurgical IBD patients, they found.

An exception is with the lethality of DVT or PE in the setting of IBD. One prior study demonstrated an increased risk of death among IBD patients with DVT or PE, but the investigators of the current study found no support for this finding. Mortality occurred in 8.6% and 8.8% of those without IBD who had DVT or PE, and those with IBD who had DVT or PE, respectively.

They also found no support for one prior study’s finding of an increased risk of arterial thromboembolic events in patients with IBD, but they noted that the current study may have been limited by the lack of data on arterial thrombotic events not involving the coronary or cerebral vessels.

"It may be that if arterial thromboembolism were a reported NSQIP complication, such a relationship would appear," they said.

Although this study is limited by the fact that the NSQIP was designed to compare overall outcomes across many hospitals rather than to answer specific research questions regarding specific diseases or procedures, its strengths – namely the fact that the data were gathered by specially trained nurses who were accountable to a rigid quality-assurance program, and who were working from a well-defined data dictionary – likely outweigh any potential sources of bias, they said.

The authors reported that they had no disclosures.

Patients with inflammatory bowel disease who undergo surgery have a twofold increase in the risk of deep vein thrombosis or pulmonary embolism, compared with those without IBD, and the risk is even greater among those with IBD who undergo nonintestinal surgery, according to findings from the American College of Surgeons National Surgical Quality Improvement Program.

In a retrospective cohort study of nearly 269,000 patients from the National Surgical Quality Improvement Program (NSQIP) 2008, 2,249 (0.8%) had IBD. Deep vein thrombosis (DVT) or pulmonary embolism (PE) occurred in 1% of those without IBD, in 2.5% of those with IBD, and in 5% of those with IBD who underwent nonintestinal surgery.

Dr. Andrea Merrill of Massachusetts General Hospital and Dr. Frederick Millham of Newton Wellesley Hospital, both in Boston, reported the research online in the Oct. 17 issue of Archives of Surgery. The findings suggest that the standard DVT and PE prophylaxis for patients undergoing surgery should be reconsidered for those with IBD, they concluded.

After adjustment for more than 30 possible confounders available in the NSQIP that add to the power to predict DVT or PE, a significant association remained between IBD and DVT or PE overall (odds ratio, 2.03) and among those undergoing nonintestinal surgery (OR, 4.45), the investigators found (Arch. Surg. 2011 Oct. 17 [doi:10.1001/archsurg.2011.297]).

No difference was seen between the patients with and without IBD in regard to the occurrence of cerebrovascular accident or myocardial infarction, with 0.4% of patients in both groups experiencing such events.

Although IBD has long been known to be associated with an increased risk of thromboembolic events, data on those undergoing surgery has been scarce, and standard DVT and PE prophylaxis guidelines in the IBD population have not been adjusted to include enhanced prophylaxis.

In light of one recent study suggesting a very high risk of postoperative DVT in those undergoing surgery, the investigators sought to evaluate the risk among IBD patients in the NSQIP, which collected data from 170 hospitals in 2008, resulting in a Participant Use Data File (PUF). The de-identified research database is made available to the participating hospitals.

"As such, the NSQIP PUF data set presents an opportunity to examine the relationship of DVT and PE with IBD in a large group of patients for whom data on comorbid conditions and other potential confounding variables are available and well defined. Furthermore, hospitals participating in the NSQIP, having invested in quality improvement, might be expected to treat patients with best practices, at least with respect to DVT prophylaxis," the investigators said, explaining that this would reduce the opportunity for treatment bias between centers.

The finding of an increased risk of DVT or PE in IBD patients was consistent with others in both surgical and nonsurgical IBD patients, they found.

An exception is with the lethality of DVT or PE in the setting of IBD. One prior study demonstrated an increased risk of death among IBD patients with DVT or PE, but the investigators of the current study found no support for this finding. Mortality occurred in 8.6% and 8.8% of those without IBD who had DVT or PE, and those with IBD who had DVT or PE, respectively.

They also found no support for one prior study’s finding of an increased risk of arterial thromboembolic events in patients with IBD, but they noted that the current study may have been limited by the lack of data on arterial thrombotic events not involving the coronary or cerebral vessels.

"It may be that if arterial thromboembolism were a reported NSQIP complication, such a relationship would appear," they said.

Although this study is limited by the fact that the NSQIP was designed to compare overall outcomes across many hospitals rather than to answer specific research questions regarding specific diseases or procedures, its strengths – namely the fact that the data were gathered by specially trained nurses who were accountable to a rigid quality-assurance program, and who were working from a well-defined data dictionary – likely outweigh any potential sources of bias, they said.

The authors reported that they had no disclosures.

Patients with inflammatory bowel disease who undergo surgery have a twofold increase in the risk of deep vein thrombosis or pulmonary embolism, compared with those without IBD, and the risk is even greater among those with IBD who undergo nonintestinal surgery, according to findings from the American College of Surgeons National Surgical Quality Improvement Program.

In a retrospective cohort study of nearly 269,000 patients from the National Surgical Quality Improvement Program (NSQIP) 2008, 2,249 (0.8%) had IBD. Deep vein thrombosis (DVT) or pulmonary embolism (PE) occurred in 1% of those without IBD, in 2.5% of those with IBD, and in 5% of those with IBD who underwent nonintestinal surgery.

Dr. Andrea Merrill of Massachusetts General Hospital and Dr. Frederick Millham of Newton Wellesley Hospital, both in Boston, reported the research online in the Oct. 17 issue of Archives of Surgery. The findings suggest that the standard DVT and PE prophylaxis for patients undergoing surgery should be reconsidered for those with IBD, they concluded.

After adjustment for more than 30 possible confounders available in the NSQIP that add to the power to predict DVT or PE, a significant association remained between IBD and DVT or PE overall (odds ratio, 2.03) and among those undergoing nonintestinal surgery (OR, 4.45), the investigators found (Arch. Surg. 2011 Oct. 17 [doi:10.1001/archsurg.2011.297]).

No difference was seen between the patients with and without IBD in regard to the occurrence of cerebrovascular accident or myocardial infarction, with 0.4% of patients in both groups experiencing such events.

Although IBD has long been known to be associated with an increased risk of thromboembolic events, data on those undergoing surgery has been scarce, and standard DVT and PE prophylaxis guidelines in the IBD population have not been adjusted to include enhanced prophylaxis.

In light of one recent study suggesting a very high risk of postoperative DVT in those undergoing surgery, the investigators sought to evaluate the risk among IBD patients in the NSQIP, which collected data from 170 hospitals in 2008, resulting in a Participant Use Data File (PUF). The de-identified research database is made available to the participating hospitals.

"As such, the NSQIP PUF data set presents an opportunity to examine the relationship of DVT and PE with IBD in a large group of patients for whom data on comorbid conditions and other potential confounding variables are available and well defined. Furthermore, hospitals participating in the NSQIP, having invested in quality improvement, might be expected to treat patients with best practices, at least with respect to DVT prophylaxis," the investigators said, explaining that this would reduce the opportunity for treatment bias between centers.

The finding of an increased risk of DVT or PE in IBD patients was consistent with others in both surgical and nonsurgical IBD patients, they found.

An exception is with the lethality of DVT or PE in the setting of IBD. One prior study demonstrated an increased risk of death among IBD patients with DVT or PE, but the investigators of the current study found no support for this finding. Mortality occurred in 8.6% and 8.8% of those without IBD who had DVT or PE, and those with IBD who had DVT or PE, respectively.

They also found no support for one prior study’s finding of an increased risk of arterial thromboembolic events in patients with IBD, but they noted that the current study may have been limited by the lack of data on arterial thrombotic events not involving the coronary or cerebral vessels.

"It may be that if arterial thromboembolism were a reported NSQIP complication, such a relationship would appear," they said.

Although this study is limited by the fact that the NSQIP was designed to compare overall outcomes across many hospitals rather than to answer specific research questions regarding specific diseases or procedures, its strengths – namely the fact that the data were gathered by specially trained nurses who were accountable to a rigid quality-assurance program, and who were working from a well-defined data dictionary – likely outweigh any potential sources of bias, they said.

The authors reported that they had no disclosures.

PROVIDENCE, R.I. – A short course of the urinary antibiotic nitrofurantoin after midurethral sling placement for stress incontinence reduced the incidence of postprocedure urinary tract infection by nearly 50%, according to Dr. Daniel Jackson.

"In the last 10 years, the literature has shown that the incidence of UTIs after sling placement ranges from 8.9% to 34%," said Dr. Jackson of the University of Missouri–Columbia. "We asked whether the incidence of postoperative bladder infection related to midurethral sling placement could be significantly reduced by a short course of a common, inexpensive urinary antibiotic."

In this prospective, double-blind study, 159 women from two academic medical centers scheduled to undergo outpatient vaginal surgery for stress incontinence were randomized to receive either nitrofurantoin (100 mg twice daily) or placebo for 3 days after surgery. Data were analyzed from 74 women who received an antibiotic and 75 women who received placebo. All patients received preoperative treatment with a third-generation cephalosporin. At the 6-week visit, a positive diagnosis depended on a positive review of systems for dysuria and frequency and a negative review of systems for vaginal discharge or irritation, as well as a positive urine dip and urine culture.

Almost one-quarter of women who underwent midurethral sling placement (n = 37/149, 24.8%) were diagnosed with a UTI during the study period. Treatment with an antibiotic significantly reduced the incidence of UTIs, from 32% in the placebo group to 17.6% in the nitrofurantoin group, he reported at the annual meeting of the American Urogynecologic Society.

Multivariate analysis indicated that two variables, antibiotic use and no postoperative catheter use, were independently associated with a reduced risk of UTI development.

No adverse events were reported. One woman developed a peripheral neuropathy and discontinued her study medication, but after the study was unblinded, it was discovered she was in the placebo group.

In response to a question from the audience, Dr. Jackson said that the choice of antibiotic, nitrofurantoin, was based on its cost and his institution’s preferences, but he said he had no definitive evidence regarding whether other urinary antibiotics would produce comparable or better results.

Dr. Jackson said he had no relevant financial disclosures.

PROVIDENCE, R.I. – A short course of the urinary antibiotic nitrofurantoin after midurethral sling placement for stress incontinence reduced the incidence of postprocedure urinary tract infection by nearly 50%, according to Dr. Daniel Jackson.

"In the last 10 years, the literature has shown that the incidence of UTIs after sling placement ranges from 8.9% to 34%," said Dr. Jackson of the University of Missouri–Columbia. "We asked whether the incidence of postoperative bladder infection related to midurethral sling placement could be significantly reduced by a short course of a common, inexpensive urinary antibiotic."

In this prospective, double-blind study, 159 women from two academic medical centers scheduled to undergo outpatient vaginal surgery for stress incontinence were randomized to receive either nitrofurantoin (100 mg twice daily) or placebo for 3 days after surgery. Data were analyzed from 74 women who received an antibiotic and 75 women who received placebo. All patients received preoperative treatment with a third-generation cephalosporin. At the 6-week visit, a positive diagnosis depended on a positive review of systems for dysuria and frequency and a negative review of systems for vaginal discharge or irritation, as well as a positive urine dip and urine culture.

Almost one-quarter of women who underwent midurethral sling placement (n = 37/149, 24.8%) were diagnosed with a UTI during the study period. Treatment with an antibiotic significantly reduced the incidence of UTIs, from 32% in the placebo group to 17.6% in the nitrofurantoin group, he reported at the annual meeting of the American Urogynecologic Society.

Multivariate analysis indicated that two variables, antibiotic use and no postoperative catheter use, were independently associated with a reduced risk of UTI development.

No adverse events were reported. One woman developed a peripheral neuropathy and discontinued her study medication, but after the study was unblinded, it was discovered she was in the placebo group.

In response to a question from the audience, Dr. Jackson said that the choice of antibiotic, nitrofurantoin, was based on its cost and his institution’s preferences, but he said he had no definitive evidence regarding whether other urinary antibiotics would produce comparable or better results.

Dr. Jackson said he had no relevant financial disclosures.

PROVIDENCE, R.I. – A short course of the urinary antibiotic nitrofurantoin after midurethral sling placement for stress incontinence reduced the incidence of postprocedure urinary tract infection by nearly 50%, according to Dr. Daniel Jackson.

"In the last 10 years, the literature has shown that the incidence of UTIs after sling placement ranges from 8.9% to 34%," said Dr. Jackson of the University of Missouri–Columbia. "We asked whether the incidence of postoperative bladder infection related to midurethral sling placement could be significantly reduced by a short course of a common, inexpensive urinary antibiotic."

In this prospective, double-blind study, 159 women from two academic medical centers scheduled to undergo outpatient vaginal surgery for stress incontinence were randomized to receive either nitrofurantoin (100 mg twice daily) or placebo for 3 days after surgery. Data were analyzed from 74 women who received an antibiotic and 75 women who received placebo. All patients received preoperative treatment with a third-generation cephalosporin. At the 6-week visit, a positive diagnosis depended on a positive review of systems for dysuria and frequency and a negative review of systems for vaginal discharge or irritation, as well as a positive urine dip and urine culture.

Almost one-quarter of women who underwent midurethral sling placement (n = 37/149, 24.8%) were diagnosed with a UTI during the study period. Treatment with an antibiotic significantly reduced the incidence of UTIs, from 32% in the placebo group to 17.6% in the nitrofurantoin group, he reported at the annual meeting of the American Urogynecologic Society.

Multivariate analysis indicated that two variables, antibiotic use and no postoperative catheter use, were independently associated with a reduced risk of UTI development.

No adverse events were reported. One woman developed a peripheral neuropathy and discontinued her study medication, but after the study was unblinded, it was discovered she was in the placebo group.

In response to a question from the audience, Dr. Jackson said that the choice of antibiotic, nitrofurantoin, was based on its cost and his institution’s preferences, but he said he had no definitive evidence regarding whether other urinary antibiotics would produce comparable or better results.

Dr. Jackson said he had no relevant financial disclosures.