Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

P91 PHARYNGO-OESOPHAGEAL PERFORATION FOLLOWING CERVICAL SPINE SURGERY: A SINGLE CENTRE EXPERIENCE

Abstract Aim Pharyngo-oesophageal perforation is a rare, life-threatening complication of cervical spine surgery. Only isolated cases are reported in the English literature and correct management of these patients remains poorly defined. The aim of this study is to review our experience to better clarify the appropriate treatment of this dreadful complication. Background and Methods Data regarding demographics, clinical course, diagnosis, management and outcomes of 13 patients (8 M, 5F, mean age 49 years) with oesophageal perforation after cervical spine surgery were collected during the period from 2002 to 2019. Results Pharyngo-oesophageal perforation occurred at a median of 8 days (range 0-4745 days) after cervical spine surgery. Clinical manifestations included neck abscess in 7 cases, fever in 3 cases, dysphagia and regurgitation in 3 cases. In 2 patients conservative management with fasting and antibiotics was attempted but, in both cases, a subsequent surgical intervention was required. All patients underwent surgical treatment. A step-up approach with initial surgical drainage of a purulent cervical collection was performed in 7 patients, delaying definitive surgery after resolution of cervical infection. Definitive surgical treatment with total or partial removal of spine fixation devices, autologous bone graft insertion or plate/cage replacement, anatomical suture of the fistula and suture line reinforcement with myoplasty (either with sternocleidomastoid or pectoralis major muscle flap) was performed in 10 patients. Perforation recurred in two cases, requiring further surgical management. At a median follow-up of 23 months (range 5-149 months) all patients exhibited permanent resolution of the perforation. Conclusions Pharyngo-oesophageal perforation following cervical spine surgery is a rare but dreadful complication: prompt recognition and treatment of these injuries is critical to minimize morbidity and mortality. Partial or total removal of the fixation devices, direct suture of the oesophageal defect and coverage with tissue flaps seems to be an effective surgical approach in these patients. </jats:sec

Foodborne botulism presenting as small bowel obstruction: a case report

Abstract Background Small bowel obstruction is one of the leading reasons for accessing to the Emergency Department. Food poisoning from Clostridium botulinum has emerged as a very rare potential cause of small bowel obstruction. The relevance of this case report regards the subtle onset of pathognomonic neurological symptoms, which can delay diagnosis and subsequent life-saving treatment. Case presentation A 24-year-old man came to our Emergency Department complaining of abdominal pain, fever and sporadic self-limiting episodes of diplopia, starting 4 days earlier. Clinical presentation and radiological imaging suggested a case of small bowel obstruction. Non-operative management was adopted, which was followed by worsening of neurological signs. On specifically questioning the patient, we discovered that his parents had experienced similar, but milder symptoms. The patient also recalled eating home-made preserves some days earlier. A clinical diagnosis of foodborne botulism was established and antitoxin was promptly administered with rapid clinical resolution. Conclusions Though very rare, botulism can mimic small bowel obstruction, and could be associated with a rapid clinical deterioration if misdiagnosed. An accurate family history, frequent clinical reassessments and involvement of different specialists can guide to identify this unexpected diagnosis. </jats:sec

Could the Pittsburgh Severity Score guide the treatment of esophageal perforation? Experience of a single referral center.

Esophageal perforation (EP) is characterized by high morbidity and mortality. The Pittsburgh Severity Score (PSS) is a scoring system based on clinical factors at the time of EP presentation, intended to guide treatment. The aim of the study is to verify PSS usefulness in stratifying EP severity and in guiding clinical decisions