Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs

The Global Alliance for Infections in Surgery : defining a model for antimicrobial stewardship-results from an international cross-sectional survey

Background: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. Methods: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. Results: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p <0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). Conclusion: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.Peer reviewe

Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action

Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or “golden rules,” for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice

Cervical spine evaluation in the bluntly injured patient

Cervical spine injuries causing spinal cord trauma are rare in blunt trauma yet lead to devastating morbidity and mortality when they occur. There exists considerable debate in the literature about the best way for clinicians to proceed in ruling out cervical spine injuries in alert or obtunded blunt trauma patients. We reviewed the current literature and practice management guidelines to generate clinical recommendations for the detection and clearance of cervical spine injuries in the blunt trauma patient. The NEXUS and Canadian C-Spine Rules are clinical tools to guide in the clearance of the cervical spine of patients who have sustained low risk trauma and who are pain free, with the Canadian C-Spine Rules having superior sensitivity and specificity. In the alert, high risk patient with pain (or without, if over the age of 65 years), follow up imaging is required. The best imaging modality to use is Computerized Tomography (CT) of the cervical spine. In the obtunded trauma patient, CT clearance of c-spine injury is adequate, unless there is soft tissue injury or any non-bony abnormalities detected. At such point, definitive clearance may be obtained with Magnetic Resonance Imaging (MRI). It is imperative to assume cervical spine injury in the blunt trauma patient. Clinical decision rules for cervical clearance may be used in low risk patients, avoiding imaging. High risk patients require imaging in the form of CT scan of the cervical spine. •Not all cervical spine injuries require imaging.•Clinical guidelines exist for clearance.•In patients who are obtunded, CT scan is adequate to clear the cervical spine in blunt trauma

Trauma in Canada: A Spirit of Equity & Collaboration

The delivery of equitable trauma care in Canada is not without challenges within our universal health care system. Notably, the tyranny of geography is intermittently at odds with adequate access for our rural, indigenous, and impoverished populations. Other differences exist when compared with neighbouring trauma systems, for example in the United States.As a critical review, we chose to compare and critique the overall system of trauma organization and perceived societal expectations of a high-income, North American country (Canada) to assist with discussions on trauma systems for the future.Tele-technology is providing some early solutions. Trauma systems and delivery of care in Canada differ from the United States due to our single-payer system, regionalization and universal provision. Care for injured Canadians has a long history of being multidisciplinary, with collaborative research programs. Canada also has a history of global surgical endeavours, beginning with Dr. Norman Bethune and his recognition of the political causes of trauma and continuing as a global public health concern for all.While challenges continue to exist for the provision of equitable trauma care in Canada, unique multidisciplinary, collaborative and technology-based solutions continue to be developed, both locally and globally, to address this critical public health issue

Geo-demographics of gunshot wound injuries in Miami-Dade county, 2002–2012

Abstract Background We evaluated correlates of gunshot wound (GSW) injuries in Miami-Dade County, Florida. Firearm-related injury has previously been linked to socio- and geo-demographic indicators such as occupation, income, neighborhood and race in other metropolitan areas, but remains understudied in Miami. Methods We reviewed 4,547 cases from a Level I trauma center’s patient registry involving an intentional firearm-related injury occurring from 2002 to 2012. During this eleven-year study period, this trauma center was the only one in Miami-Dade County, and thus representative of countywide injuries. Results The crude morbidity rate of GSW injury over the 11-year period was 15 per 100,000 persons with a crude mortality rate of 0.27 per 100,000 persons. The case fatality rate of injured patients was 15.4%. Both morbidity and mortality increased modestly over the 11-year study period. The total number of GSW patients rose annually during the study period and patients were disproportionately young, black males, though we observed higher severity of injury in white populations. Geo-demographic analysis revealed that both GSW incident locations and patient home addresses are spatially clustered in predominantly poor, black neighborhoods near downtown Miami, and that these patterns persisted throughout the study period. Using spatial regression, we observed that census tract-level GSW incidence rates (coded by home address) were associated with a census tract’s proportion of black residents (P < .001), single-parent households (P < .001), and median age (P < .001) (R 2 = .42). Conclusions These findings represent the first representative geo-demographic analysis of GSW injuries in Miami-Dade County, and offer evidence to support urgent, targeted community engagement and prevention strategies to reduce local firearm violence