SIS Annual Meeting

BALTIMORE – Screening based on a new chest x-ray infiltrate or fever correctly identified more microbiologically confirmed cases of ventilator-associated pneumonia than did a traditional screening tool, in a study of patients in a surgical intensive care unit.

The findings were reported at the annual meeting of the Surgical Infection Society.

In the study, the Clinical Pulmonary Infection Score (CPIS) clinical score (using the threshold of 6) would have missed almost 80% of the cases of microbiologically confirmed VAP.

The finding of a new chest x-ray infiltrate was highly sensitive for diagnosing VAP, identifying most cases of VAP, followed by fever as the next most sensitive variable. Each had a sensitivity of about 90%, according to Dr. Fredric Pieracci of the department of surgery, Denver Health Medical Center, University of Colorado.

Another notable finding of the study was that the presence of organisms on gram stain in the early VAP window (within 5 days of intubation) was highly sensitive for diagnosing VAP, he added.

VAP is the most common nosocomial infection in intubated, critically ill surgical patients and is the most common reason antibiotics are prescribed in the surgical intensive care unit (SICU), he said. Screening criteria for VAP vary widely, but every algorithm includes some variation of the CPIS, with a score that ranges from 0 to 12. Although the CPIS screening tool, which uses variables that include tracheal secretions and chest x-ray results, has come under scrutiny, it is commonly used, with a result over 6 used as the threshold for both obtaining a lower respiratory tract culture and initiating empiric treatment.

The investigators analyzed the results of 1,013 bronchoalveolar lavage cultures from 497 SICU patients aged 18-88 years, over a 3-year period (2009-2012). Most of the patients (81%) were males and 71% were trauma patients; cultures were obtained a median of 8 days after intubation (range, 1-109 days), and patients had a median of two cultures.

VAP was defined microbiologically as at least 10⁵ CFU/mL if no antibiotics had been given within the previous 72 hours; or at least 10⁴ CFU/mL if antibiotics had been given within the previous 72 hours. CPIS scores were calculated retrospectively.

Of the 1,013 cultures, 438 (43%) met the VAP criteria, and 310 of the 497 patients (62%) had at least one episode of VAP.

Most of the CPIS clinical scores were 4, 5, or 6. When the likelihood of VAP was analyzed, CPIS clinical scores from 1 to 9 all correlated with about a 40% chance of VAP, Dr. Pieracci said.

The median CPIS clinical score was 5 for those diagnosed with VAP as well as those not diagnosed with VAP, based on the microbiologic criteria.

The sensitivity of the CPIS clinical score, when the threshold of greater than 6 was used, was only 21%, so by using the CPIS, "we would have missed almost 80% of the VAP cases in this group of patients," he pointed out.

Every case of VAP had at least one of the following: fever, a new chest x-ray infiltrate, or the presence of organisms on gram stain.

Of the individual components of the CPIS, the most sensitive for diagnosing VAP were the new finding on chest x-ray (a sensitivity of 91.1%), and fever (a sensitivity of 89.0%).

When the gram stain results were added to the CPIS clinical score, there was a marginal improvement in sensitivity, "but it was still a very poor screening tool," Dr. Pieracci said.

However, the presence of organisms on the gram stain "was highly sensitive for diagnosing VAP, with a reasonably high negative predictive value" in the early VAP window, when cultures were sent within 5 days of intubation, he said.

The results indicate that the CPIS clinical score in the study "had poor discriminative ability for diagnosing VAP in all the clinical scenarios we tested," and it had a sensitivity that was acceptable only at a threshold lower than 6, according to Dr. Pieracci.

"Based on these data, we recommend abandoning the CPIS clinical score as a screening tool for VAP," and instead, adopting the three criteria and withholding antibiotic therapy in patients with no organisms on gram stain in the early VAP window.

"What we’ve adopted and are now studying is a screening algorithm that differentiates between the early and late period, and is based on either fever or new chest x-ray finding," Dr. Pieracci said. If the gram stain is negative in the early VAP window, then withholding empiric antibiotics is recommended; this is the only scenario identified in which empiric antibiotics could be safely withheld, he added.

emechcatie@frontlinemedcom.com

BALTIMORE – Screening based on a new chest x-ray infiltrate or fever correctly identified more microbiologically confirmed cases of ventilator-associated pneumonia than did a traditional screening tool, in a study of patients in a surgical intensive care unit.

The findings were reported at the annual meeting of the Surgical Infection Society.

In the study, the Clinical Pulmonary Infection Score (CPIS) clinical score (using the threshold of 6) would have missed almost 80% of the cases of microbiologically confirmed VAP.

The finding of a new chest x-ray infiltrate was highly sensitive for diagnosing VAP, identifying most cases of VAP, followed by fever as the next most sensitive variable. Each had a sensitivity of about 90%, according to Dr. Fredric Pieracci of the department of surgery, Denver Health Medical Center, University of Colorado.

Another notable finding of the study was that the presence of organisms on gram stain in the early VAP window (within 5 days of intubation) was highly sensitive for diagnosing VAP, he added.

VAP is the most common nosocomial infection in intubated, critically ill surgical patients and is the most common reason antibiotics are prescribed in the surgical intensive care unit (SICU), he said. Screening criteria for VAP vary widely, but every algorithm includes some variation of the CPIS, with a score that ranges from 0 to 12. Although the CPIS screening tool, which uses variables that include tracheal secretions and chest x-ray results, has come under scrutiny, it is commonly used, with a result over 6 used as the threshold for both obtaining a lower respiratory tract culture and initiating empiric treatment.

The investigators analyzed the results of 1,013 bronchoalveolar lavage cultures from 497 SICU patients aged 18-88 years, over a 3-year period (2009-2012). Most of the patients (81%) were males and 71% were trauma patients; cultures were obtained a median of 8 days after intubation (range, 1-109 days), and patients had a median of two cultures.

VAP was defined microbiologically as at least 10⁵ CFU/mL if no antibiotics had been given within the previous 72 hours; or at least 10⁴ CFU/mL if antibiotics had been given within the previous 72 hours. CPIS scores were calculated retrospectively.

Of the 1,013 cultures, 438 (43%) met the VAP criteria, and 310 of the 497 patients (62%) had at least one episode of VAP.

Most of the CPIS clinical scores were 4, 5, or 6. When the likelihood of VAP was analyzed, CPIS clinical scores from 1 to 9 all correlated with about a 40% chance of VAP, Dr. Pieracci said.

The median CPIS clinical score was 5 for those diagnosed with VAP as well as those not diagnosed with VAP, based on the microbiologic criteria.

The sensitivity of the CPIS clinical score, when the threshold of greater than 6 was used, was only 21%, so by using the CPIS, "we would have missed almost 80% of the VAP cases in this group of patients," he pointed out.

Every case of VAP had at least one of the following: fever, a new chest x-ray infiltrate, or the presence of organisms on gram stain.

Of the individual components of the CPIS, the most sensitive for diagnosing VAP were the new finding on chest x-ray (a sensitivity of 91.1%), and fever (a sensitivity of 89.0%).

When the gram stain results were added to the CPIS clinical score, there was a marginal improvement in sensitivity, "but it was still a very poor screening tool," Dr. Pieracci said.

However, the presence of organisms on the gram stain "was highly sensitive for diagnosing VAP, with a reasonably high negative predictive value" in the early VAP window, when cultures were sent within 5 days of intubation, he said.

The results indicate that the CPIS clinical score in the study "had poor discriminative ability for diagnosing VAP in all the clinical scenarios we tested," and it had a sensitivity that was acceptable only at a threshold lower than 6, according to Dr. Pieracci.

"Based on these data, we recommend abandoning the CPIS clinical score as a screening tool for VAP," and instead, adopting the three criteria and withholding antibiotic therapy in patients with no organisms on gram stain in the early VAP window.

"What we’ve adopted and are now studying is a screening algorithm that differentiates between the early and late period, and is based on either fever or new chest x-ray finding," Dr. Pieracci said. If the gram stain is negative in the early VAP window, then withholding empiric antibiotics is recommended; this is the only scenario identified in which empiric antibiotics could be safely withheld, he added.

emechcatie@frontlinemedcom.com

BALTIMORE – Screening based on a new chest x-ray infiltrate or fever correctly identified more microbiologically confirmed cases of ventilator-associated pneumonia than did a traditional screening tool, in a study of patients in a surgical intensive care unit.

The findings were reported at the annual meeting of the Surgical Infection Society.

In the study, the Clinical Pulmonary Infection Score (CPIS) clinical score (using the threshold of 6) would have missed almost 80% of the cases of microbiologically confirmed VAP.

The finding of a new chest x-ray infiltrate was highly sensitive for diagnosing VAP, identifying most cases of VAP, followed by fever as the next most sensitive variable. Each had a sensitivity of about 90%, according to Dr. Fredric Pieracci of the department of surgery, Denver Health Medical Center, University of Colorado.

Another notable finding of the study was that the presence of organisms on gram stain in the early VAP window (within 5 days of intubation) was highly sensitive for diagnosing VAP, he added.

VAP is the most common nosocomial infection in intubated, critically ill surgical patients and is the most common reason antibiotics are prescribed in the surgical intensive care unit (SICU), he said. Screening criteria for VAP vary widely, but every algorithm includes some variation of the CPIS, with a score that ranges from 0 to 12. Although the CPIS screening tool, which uses variables that include tracheal secretions and chest x-ray results, has come under scrutiny, it is commonly used, with a result over 6 used as the threshold for both obtaining a lower respiratory tract culture and initiating empiric treatment.

The investigators analyzed the results of 1,013 bronchoalveolar lavage cultures from 497 SICU patients aged 18-88 years, over a 3-year period (2009-2012). Most of the patients (81%) were males and 71% were trauma patients; cultures were obtained a median of 8 days after intubation (range, 1-109 days), and patients had a median of two cultures.

VAP was defined microbiologically as at least 10⁵ CFU/mL if no antibiotics had been given within the previous 72 hours; or at least 10⁴ CFU/mL if antibiotics had been given within the previous 72 hours. CPIS scores were calculated retrospectively.

Of the 1,013 cultures, 438 (43%) met the VAP criteria, and 310 of the 497 patients (62%) had at least one episode of VAP.

Most of the CPIS clinical scores were 4, 5, or 6. When the likelihood of VAP was analyzed, CPIS clinical scores from 1 to 9 all correlated with about a 40% chance of VAP, Dr. Pieracci said.

The median CPIS clinical score was 5 for those diagnosed with VAP as well as those not diagnosed with VAP, based on the microbiologic criteria.

The sensitivity of the CPIS clinical score, when the threshold of greater than 6 was used, was only 21%, so by using the CPIS, "we would have missed almost 80% of the VAP cases in this group of patients," he pointed out.

Every case of VAP had at least one of the following: fever, a new chest x-ray infiltrate, or the presence of organisms on gram stain.

Of the individual components of the CPIS, the most sensitive for diagnosing VAP were the new finding on chest x-ray (a sensitivity of 91.1%), and fever (a sensitivity of 89.0%).

When the gram stain results were added to the CPIS clinical score, there was a marginal improvement in sensitivity, "but it was still a very poor screening tool," Dr. Pieracci said.

However, the presence of organisms on the gram stain "was highly sensitive for diagnosing VAP, with a reasonably high negative predictive value" in the early VAP window, when cultures were sent within 5 days of intubation, he said.

The results indicate that the CPIS clinical score in the study "had poor discriminative ability for diagnosing VAP in all the clinical scenarios we tested," and it had a sensitivity that was acceptable only at a threshold lower than 6, according to Dr. Pieracci.

"Based on these data, we recommend abandoning the CPIS clinical score as a screening tool for VAP," and instead, adopting the three criteria and withholding antibiotic therapy in patients with no organisms on gram stain in the early VAP window.

"What we’ve adopted and are now studying is a screening algorithm that differentiates between the early and late period, and is based on either fever or new chest x-ray finding," Dr. Pieracci said. If the gram stain is negative in the early VAP window, then withholding empiric antibiotics is recommended; this is the only scenario identified in which empiric antibiotics could be safely withheld, he added.

emechcatie@frontlinemedcom.com

BALTIMORE – Screening based on a new chest x-ray infiltrate or fever correctly identified more cases of microbiologically confirmed cases of ventilator-associated pneumonia than a traditional screening tool, in a study of patients in a surgical intensive care unit reported at the annual meeting of the Surgical Infection Society.

In the study, the Clinical Pulmonary Infection Score (CPIS) clinical score (using the threshold of 6) would have missed almost 80% of the cases of microbiologically confirmed VAP. The finding of a new chest x-ray infiltrate was highly sensitive for diagnosing VAP, identifying most cases of VAP, followed by fever as the next most sensitive variable. Each had a sensitivity of about 90%, said Dr. Fredric Pieracci of the department of surgery, Denver Health Medical Center, University of Colorado.

Another notable finding of the study was that the presence of organisms on gram stain in the early VAP window (within 5 days of intubation) was highly sensitive for diagnosing VAP, he added.

VAP is the most common nosocomial infection in intubated, critically ill surgical patients and is the most common reason antibiotics are prescribed in the surgical intensive care unit (SICU), he said. Screening criteria for VAP vary widely, but every algorithm includes some variation of the CPIS, with a score that ranges from 0 to 12. Although the CPIS screening tool, which uses variables that include tracheal secretions and chest x-ray results, has come under scrutiny, it is commonly used, with a result over 6 used as the threshold for both obtaining a lower respiratory tract culture and initiating empiric treatment.

The study analyzed the results of 1,013 bronchoalveolar lavage cultures from 497 SICU patients aged 18-88 years, over a 3-year period (2009-2012). Most of the patients (81%) were males and 71% were trauma patients; cultures were obtained a median of 8 days after intubation (range, 1-109 days), and patients had a median of two cultures. VAP was defined microbiologically as at least 10⁵ CFU/mL if no antibiotics had been given within the previous 72 hours; or at least 10⁴ CFU/mL if antibiotics had been given within the previous 72 hours. CPIS scores were calculated retrospectively.

Of the 1,013 cultures, 438 (43%) met the VAP criteria, and 310 of the 497 patients (62%) had at least one episode of VAP.

Most of the CPIS clinical scores were 4, 5, or 6. When the likelihood of VAP was analyzed, CPIS clinical scores from 1 to 9 all correlated with about a 40% chance of VAP, Dr. Pieracci said. The median CPIS clinical score was 5 for those diagnosed with VAP as well as those not diagnosed with VAP, based on the microbiologic criteria.

The sensitivity of the CPIS clinical score, when the threshold of greater than 6 was used, was only 21%, so by using the CPIS, "we would have missed almost 80% of the VAP cases in this group of patients," he pointed out.

Every case of VAP had at least one of the following: fever, a new chest x-ray infiltrate, or the presence of organisms on gram stain.

Of the individual components of the CPIS, the most sensitive for diagnosing VAP were the new finding on chest x-ray (a sensitivity of 91.1%), and fever (a sensitivity of 89.0%).

When the gram stain results were added to the CPIS clinical score, there was a marginal improvement in sensitivity, "but it was still a very poor screening tool," he said. However, the presence of organisms on the gram stain "was highly sensitive for diagnosing VAP, with a reasonably high negative predictive value" in the early VAP window, when cultures were sent within 5 days of intubation, he said.

The results indicate that the CPIS clinical score in the study "had poor discriminative ability for diagnosing VAP in all the clinical scenarios we tested," and it had a sensitivity that was acceptable only at a threshold lower than 6, Dr. Pieracci said. "Based on these data, we recommend abandoning the CPIS clinical score as a screening tool for VAP," and instead, adopting the three criteria and withholding antibiotic therapy in patients with no organisms on gram stain in the early VAP window.

"What we’ve adopted and are now studying is a screening algorithm that differentiates between the early and late period, and is based on either fever or new chest x-ray finding," Dr. Pieracci said. If the gram stain is negative in the early VAP window, then withholding empiric antibiotics is recommended; this is the only scenario identified in which empiric antibiotics could be safely withheld, he added.

The study was funded through institutional monies. Dr. Pieracci had no relevant disclosures.

emechcatie@frontlinemedcom.com

BALTIMORE – Screening based on a new chest x-ray infiltrate or fever correctly identified more cases of microbiologically confirmed cases of ventilator-associated pneumonia than a traditional screening tool, in a study of patients in a surgical intensive care unit reported at the annual meeting of the Surgical Infection Society.

In the study, the Clinical Pulmonary Infection Score (CPIS) clinical score (using the threshold of 6) would have missed almost 80% of the cases of microbiologically confirmed VAP. The finding of a new chest x-ray infiltrate was highly sensitive for diagnosing VAP, identifying most cases of VAP, followed by fever as the next most sensitive variable. Each had a sensitivity of about 90%, said Dr. Fredric Pieracci of the department of surgery, Denver Health Medical Center, University of Colorado.

Another notable finding of the study was that the presence of organisms on gram stain in the early VAP window (within 5 days of intubation) was highly sensitive for diagnosing VAP, he added.

VAP is the most common nosocomial infection in intubated, critically ill surgical patients and is the most common reason antibiotics are prescribed in the surgical intensive care unit (SICU), he said. Screening criteria for VAP vary widely, but every algorithm includes some variation of the CPIS, with a score that ranges from 0 to 12. Although the CPIS screening tool, which uses variables that include tracheal secretions and chest x-ray results, has come under scrutiny, it is commonly used, with a result over 6 used as the threshold for both obtaining a lower respiratory tract culture and initiating empiric treatment.

The study analyzed the results of 1,013 bronchoalveolar lavage cultures from 497 SICU patients aged 18-88 years, over a 3-year period (2009-2012). Most of the patients (81%) were males and 71% were trauma patients; cultures were obtained a median of 8 days after intubation (range, 1-109 days), and patients had a median of two cultures. VAP was defined microbiologically as at least 10⁵ CFU/mL if no antibiotics had been given within the previous 72 hours; or at least 10⁴ CFU/mL if antibiotics had been given within the previous 72 hours. CPIS scores were calculated retrospectively.

Of the 1,013 cultures, 438 (43%) met the VAP criteria, and 310 of the 497 patients (62%) had at least one episode of VAP.

Most of the CPIS clinical scores were 4, 5, or 6. When the likelihood of VAP was analyzed, CPIS clinical scores from 1 to 9 all correlated with about a 40% chance of VAP, Dr. Pieracci said. The median CPIS clinical score was 5 for those diagnosed with VAP as well as those not diagnosed with VAP, based on the microbiologic criteria.

The sensitivity of the CPIS clinical score, when the threshold of greater than 6 was used, was only 21%, so by using the CPIS, "we would have missed almost 80% of the VAP cases in this group of patients," he pointed out.

Every case of VAP had at least one of the following: fever, a new chest x-ray infiltrate, or the presence of organisms on gram stain.

Of the individual components of the CPIS, the most sensitive for diagnosing VAP were the new finding on chest x-ray (a sensitivity of 91.1%), and fever (a sensitivity of 89.0%).

When the gram stain results were added to the CPIS clinical score, there was a marginal improvement in sensitivity, "but it was still a very poor screening tool," he said. However, the presence of organisms on the gram stain "was highly sensitive for diagnosing VAP, with a reasonably high negative predictive value" in the early VAP window, when cultures were sent within 5 days of intubation, he said.

The results indicate that the CPIS clinical score in the study "had poor discriminative ability for diagnosing VAP in all the clinical scenarios we tested," and it had a sensitivity that was acceptable only at a threshold lower than 6, Dr. Pieracci said. "Based on these data, we recommend abandoning the CPIS clinical score as a screening tool for VAP," and instead, adopting the three criteria and withholding antibiotic therapy in patients with no organisms on gram stain in the early VAP window.

"What we’ve adopted and are now studying is a screening algorithm that differentiates between the early and late period, and is based on either fever or new chest x-ray finding," Dr. Pieracci said. If the gram stain is negative in the early VAP window, then withholding empiric antibiotics is recommended; this is the only scenario identified in which empiric antibiotics could be safely withheld, he added.

The study was funded through institutional monies. Dr. Pieracci had no relevant disclosures.

emechcatie@frontlinemedcom.com

BALTIMORE – Screening based on a new chest x-ray infiltrate or fever correctly identified more cases of microbiologically confirmed cases of ventilator-associated pneumonia than a traditional screening tool, in a study of patients in a surgical intensive care unit reported at the annual meeting of the Surgical Infection Society.

In the study, the Clinical Pulmonary Infection Score (CPIS) clinical score (using the threshold of 6) would have missed almost 80% of the cases of microbiologically confirmed VAP. The finding of a new chest x-ray infiltrate was highly sensitive for diagnosing VAP, identifying most cases of VAP, followed by fever as the next most sensitive variable. Each had a sensitivity of about 90%, said Dr. Fredric Pieracci of the department of surgery, Denver Health Medical Center, University of Colorado.

Another notable finding of the study was that the presence of organisms on gram stain in the early VAP window (within 5 days of intubation) was highly sensitive for diagnosing VAP, he added.

VAP is the most common nosocomial infection in intubated, critically ill surgical patients and is the most common reason antibiotics are prescribed in the surgical intensive care unit (SICU), he said. Screening criteria for VAP vary widely, but every algorithm includes some variation of the CPIS, with a score that ranges from 0 to 12. Although the CPIS screening tool, which uses variables that include tracheal secretions and chest x-ray results, has come under scrutiny, it is commonly used, with a result over 6 used as the threshold for both obtaining a lower respiratory tract culture and initiating empiric treatment.

The study analyzed the results of 1,013 bronchoalveolar lavage cultures from 497 SICU patients aged 18-88 years, over a 3-year period (2009-2012). Most of the patients (81%) were males and 71% were trauma patients; cultures were obtained a median of 8 days after intubation (range, 1-109 days), and patients had a median of two cultures. VAP was defined microbiologically as at least 10⁵ CFU/mL if no antibiotics had been given within the previous 72 hours; or at least 10⁴ CFU/mL if antibiotics had been given within the previous 72 hours. CPIS scores were calculated retrospectively.

Of the 1,013 cultures, 438 (43%) met the VAP criteria, and 310 of the 497 patients (62%) had at least one episode of VAP.

Most of the CPIS clinical scores were 4, 5, or 6. When the likelihood of VAP was analyzed, CPIS clinical scores from 1 to 9 all correlated with about a 40% chance of VAP, Dr. Pieracci said. The median CPIS clinical score was 5 for those diagnosed with VAP as well as those not diagnosed with VAP, based on the microbiologic criteria.

The sensitivity of the CPIS clinical score, when the threshold of greater than 6 was used, was only 21%, so by using the CPIS, "we would have missed almost 80% of the VAP cases in this group of patients," he pointed out.

Every case of VAP had at least one of the following: fever, a new chest x-ray infiltrate, or the presence of organisms on gram stain.

Of the individual components of the CPIS, the most sensitive for diagnosing VAP were the new finding on chest x-ray (a sensitivity of 91.1%), and fever (a sensitivity of 89.0%).

When the gram stain results were added to the CPIS clinical score, there was a marginal improvement in sensitivity, "but it was still a very poor screening tool," he said. However, the presence of organisms on the gram stain "was highly sensitive for diagnosing VAP, with a reasonably high negative predictive value" in the early VAP window, when cultures were sent within 5 days of intubation, he said.

The results indicate that the CPIS clinical score in the study "had poor discriminative ability for diagnosing VAP in all the clinical scenarios we tested," and it had a sensitivity that was acceptable only at a threshold lower than 6, Dr. Pieracci said. "Based on these data, we recommend abandoning the CPIS clinical score as a screening tool for VAP," and instead, adopting the three criteria and withholding antibiotic therapy in patients with no organisms on gram stain in the early VAP window.

"What we’ve adopted and are now studying is a screening algorithm that differentiates between the early and late period, and is based on either fever or new chest x-ray finding," Dr. Pieracci said. If the gram stain is negative in the early VAP window, then withholding empiric antibiotics is recommended; this is the only scenario identified in which empiric antibiotics could be safely withheld, he added.

The study was funded through institutional monies. Dr. Pieracci had no relevant disclosures.

emechcatie@frontlinemedcom.com

BALTIMORE – Implementing a bundle of preventive interventions led to a significant drop in pressure ulcers acquired during hospitalization among high-risk surgical patients, according to a prospective study.

Moreover, the beneficial effect of the program was sustained for more than a year after the program was implemented, reported Dr. Sylvia Martinez of Baylor College of Medicine and the Michael E. DeBakey VA Medical Center in Houston.

Elizabeth Mechcatie/Frontline Medical News

Dr. Martinez pointed out that strategies used to prevent hospital-acquired pressure ulcers are not standardized, and that in an effort to improve quality of care, save money, and reduce mortality, the Centers for Medicare & Medicaid Services no longer reimburses medical facilities for stage III and IV hospital-acquired pressure ulcers.

More than 7,000 high-risk patients were included in the study. During the 6 months before the plan was implemented at the medical center, the mean pressure ulcer rate overall was 3.37, dropping to 1.45 during the 6 months after implementation, a significant difference (P = .004). At 18 months, the rate was 0.89. During this time, the mean rates of hospital-acquired pressure ulcers in the entire VA system did not significantly change, ranging from 1.68 to 1.85, Dr. Martinez reported at the annual meeting of the Surgical Infection Society.

The study was done to address the relatively high rate of pressure ulcers in the medical center’s surgical service. Dr. Martinez and her associates evaluated the impact of an evidence-based hospital-acquired pressure ulcer prevention bundle, developed by an interdisciplinary team.

Patients were classified as high risk if they met at least two of four criteria (age greater than 62 years, albumin less than 3.5 g/dL, ASA score greater than 3, and surgery lasting for more than 3 hours).

The components of the program included:

• Comprehensive skin assessment and documentation and identification of any ulcers on admission, transfer, and discharge.

• Use of operating room beds with pressure redistributing mattresses, with careful positioning and padding of pressure points.

• Turning of patients every 2 hours with pressure point relief via wedges, heel pads, and pillows, as well as massages of bony prominences.

• Assessment of patients for pressure ulcers on daily rounds (led by the unit nurse manager) and use of daily checklists in high-risk patients.

The pressure ulcer rate was calculated by the number of discharged acute-care patients with a stage II or greater hospital-acquired pressure ulcer, divided by number patient days in the hospital (the discharge date minus the admission date for all discharged acute-care patients who were hospitalized for at least 48 hours).

During the period studied, 21,377 operations were performed. Almost 5,000 (4,692) were during the 6-month period prior to implementation of the program, from January to June 2012, and 16,685 were done in the 18 months after implementation (including 4,461 during the first 6 months). Overall, 34% of the patients were determined to be at high risk.

The rates dropped significantly in different parts of the surgical service: In the surgical intensive care unit, the rate dropped from 2.93 before implementation to 1.25 at 6 months and 0.86 at 18 months post implementation. In the surgical wards, the rate dropped from 2.93 to 0.83 at 6 months, and was 0.86 at 18 months.

Implementation of this bundle "may decrease hospital-acquired pressure ulcer rates in high risk surgical patients," with sustained lower rates, which "can lead to decreased costs, complications, and length of stay, and improved quality of life for our patients," Dr. Martinez concluded.

Among the study’s limitations were that it was conducted at one hospital and it did not evaluate which elements of the prevention bundle were most important, she said.

Dr. Martinez had no disclosures. The study was funded by the U.S. Department of Veterans Affairs.

emechcatie@frontlinemedcom.com

BALTIMORE – Implementing a bundle of preventive interventions led to a significant drop in pressure ulcers acquired during hospitalization among high-risk surgical patients, according to a prospective study.

Moreover, the beneficial effect of the program was sustained for more than a year after the program was implemented, reported Dr. Sylvia Martinez of Baylor College of Medicine and the Michael E. DeBakey VA Medical Center in Houston.

Elizabeth Mechcatie/Frontline Medical News

Dr. Martinez pointed out that strategies used to prevent hospital-acquired pressure ulcers are not standardized, and that in an effort to improve quality of care, save money, and reduce mortality, the Centers for Medicare & Medicaid Services no longer reimburses medical facilities for stage III and IV hospital-acquired pressure ulcers.

More than 7,000 high-risk patients were included in the study. During the 6 months before the plan was implemented at the medical center, the mean pressure ulcer rate overall was 3.37, dropping to 1.45 during the 6 months after implementation, a significant difference (P = .004). At 18 months, the rate was 0.89. During this time, the mean rates of hospital-acquired pressure ulcers in the entire VA system did not significantly change, ranging from 1.68 to 1.85, Dr. Martinez reported at the annual meeting of the Surgical Infection Society.

The study was done to address the relatively high rate of pressure ulcers in the medical center’s surgical service. Dr. Martinez and her associates evaluated the impact of an evidence-based hospital-acquired pressure ulcer prevention bundle, developed by an interdisciplinary team.

Patients were classified as high risk if they met at least two of four criteria (age greater than 62 years, albumin less than 3.5 g/dL, ASA score greater than 3, and surgery lasting for more than 3 hours).

The components of the program included:

• Comprehensive skin assessment and documentation and identification of any ulcers on admission, transfer, and discharge.

• Use of operating room beds with pressure redistributing mattresses, with careful positioning and padding of pressure points.

• Turning of patients every 2 hours with pressure point relief via wedges, heel pads, and pillows, as well as massages of bony prominences.

• Assessment of patients for pressure ulcers on daily rounds (led by the unit nurse manager) and use of daily checklists in high-risk patients.

The pressure ulcer rate was calculated by the number of discharged acute-care patients with a stage II or greater hospital-acquired pressure ulcer, divided by number patient days in the hospital (the discharge date minus the admission date for all discharged acute-care patients who were hospitalized for at least 48 hours).

During the period studied, 21,377 operations were performed. Almost 5,000 (4,692) were during the 6-month period prior to implementation of the program, from January to June 2012, and 16,685 were done in the 18 months after implementation (including 4,461 during the first 6 months). Overall, 34% of the patients were determined to be at high risk.

The rates dropped significantly in different parts of the surgical service: In the surgical intensive care unit, the rate dropped from 2.93 before implementation to 1.25 at 6 months and 0.86 at 18 months post implementation. In the surgical wards, the rate dropped from 2.93 to 0.83 at 6 months, and was 0.86 at 18 months.

Implementation of this bundle "may decrease hospital-acquired pressure ulcer rates in high risk surgical patients," with sustained lower rates, which "can lead to decreased costs, complications, and length of stay, and improved quality of life for our patients," Dr. Martinez concluded.

Among the study’s limitations were that it was conducted at one hospital and it did not evaluate which elements of the prevention bundle were most important, she said.

Dr. Martinez had no disclosures. The study was funded by the U.S. Department of Veterans Affairs.

emechcatie@frontlinemedcom.com

BALTIMORE – Implementing a bundle of preventive interventions led to a significant drop in pressure ulcers acquired during hospitalization among high-risk surgical patients, according to a prospective study.

Moreover, the beneficial effect of the program was sustained for more than a year after the program was implemented, reported Dr. Sylvia Martinez of Baylor College of Medicine and the Michael E. DeBakey VA Medical Center in Houston.

Elizabeth Mechcatie/Frontline Medical News

Dr. Martinez pointed out that strategies used to prevent hospital-acquired pressure ulcers are not standardized, and that in an effort to improve quality of care, save money, and reduce mortality, the Centers for Medicare & Medicaid Services no longer reimburses medical facilities for stage III and IV hospital-acquired pressure ulcers.

More than 7,000 high-risk patients were included in the study. During the 6 months before the plan was implemented at the medical center, the mean pressure ulcer rate overall was 3.37, dropping to 1.45 during the 6 months after implementation, a significant difference (P = .004). At 18 months, the rate was 0.89. During this time, the mean rates of hospital-acquired pressure ulcers in the entire VA system did not significantly change, ranging from 1.68 to 1.85, Dr. Martinez reported at the annual meeting of the Surgical Infection Society.

The study was done to address the relatively high rate of pressure ulcers in the medical center’s surgical service. Dr. Martinez and her associates evaluated the impact of an evidence-based hospital-acquired pressure ulcer prevention bundle, developed by an interdisciplinary team.

Patients were classified as high risk if they met at least two of four criteria (age greater than 62 years, albumin less than 3.5 g/dL, ASA score greater than 3, and surgery lasting for more than 3 hours).

The components of the program included:

• Comprehensive skin assessment and documentation and identification of any ulcers on admission, transfer, and discharge.

• Use of operating room beds with pressure redistributing mattresses, with careful positioning and padding of pressure points.

• Turning of patients every 2 hours with pressure point relief via wedges, heel pads, and pillows, as well as massages of bony prominences.

• Assessment of patients for pressure ulcers on daily rounds (led by the unit nurse manager) and use of daily checklists in high-risk patients.

The pressure ulcer rate was calculated by the number of discharged acute-care patients with a stage II or greater hospital-acquired pressure ulcer, divided by number patient days in the hospital (the discharge date minus the admission date for all discharged acute-care patients who were hospitalized for at least 48 hours).

During the period studied, 21,377 operations were performed. Almost 5,000 (4,692) were during the 6-month period prior to implementation of the program, from January to June 2012, and 16,685 were done in the 18 months after implementation (including 4,461 during the first 6 months). Overall, 34% of the patients were determined to be at high risk.

The rates dropped significantly in different parts of the surgical service: In the surgical intensive care unit, the rate dropped from 2.93 before implementation to 1.25 at 6 months and 0.86 at 18 months post implementation. In the surgical wards, the rate dropped from 2.93 to 0.83 at 6 months, and was 0.86 at 18 months.

Implementation of this bundle "may decrease hospital-acquired pressure ulcer rates in high risk surgical patients," with sustained lower rates, which "can lead to decreased costs, complications, and length of stay, and improved quality of life for our patients," Dr. Martinez concluded.

Among the study’s limitations were that it was conducted at one hospital and it did not evaluate which elements of the prevention bundle were most important, she said.

Dr. Martinez had no disclosures. The study was funded by the U.S. Department of Veterans Affairs.

emechcatie@frontlinemedcom.com

BALTIMORE – A study of patients with intraabdominal infection indicates that a shorter course of antibiotics is as effective as the standard, longer course, leading researchers to recommend a new standard of care.

The rates of recurrent infections and other outcomes were similar in patients with intraabdominal infections treated with antibiotics for 4 days following source control and among those who received a longer course of treatment based on when their clinical symptoms resolved, in a study reported at the annual meeting of the Surgical Infection Society.

The results support the use of the shorter treatment strategy in this setting, said Dr. Robert Sawyer, who presented the results of the study, SIS Multicenter Study of Duration of Antibiotics for Intraabdominal Infection.

Elizabeth Mechcatie/Frontline Medical News

While antibiotics are used as an adjunct to treat intraabdominal infections, the appropriate duration of treatment is not clear, and reducing the time exposed to antibiotics "could be worthwhile," said Dr. Sawyer, professor of surgery and public health sciences and chief of acute care surgery at the University of Virginia, Charlottesville.

The randomized, multicenter, unblinded study compared a shorter vs. a longer course of antibiotic therapy in 518 patients with intraabdominal infections: 4 days in 258 patients or treatment that continued for 2 days after resolution of the patient’s fever, leukocytosis, and ileus, with a maximum of 10 days of treatment in total, in 260 patients. The patients had similar APACHE II scores; their mean age was in the early 50s; and the colon or rectum was the most common source of infection, followed by the appendix and the small bowel. Antibiotics were administered intravenously or orally. Patients with inadequate source control and a high risk of death within 72 hours were excluded.

Within 30 days, the primary outcome – a composite of surgical site infection, recurrent intraabdominal infection, and death – was similar between the two groups, at about 21.7% in the 4-day treatment group vs. 22.7% in the group treated for 2 days after symptoms resolved.

There were no significant differences in the individual endpoints between the two groups. There were also no differences in the composite endpoints in different subgroups, and when those with percutaneous drainage or patients whose source of infection was the appendix were excluded. Among sicker patients with APACHE scores of 10 or higher, there was a numerical benefit favoring those treated for 4 days (22.1% vs. 29.8% among those treated for the longer duration), but the difference was not statistically significant, although it was reassuring, Dr. Sawyer said.

There were no differences between the two groups in the rates of secondary infections or subsequent infection with resistant pathogens or Clostridium difficile, which were secondary endpoints.

Based on these results, "after source control is obtained, we recommend 4 days of antimicrobial therapy for all patients with intraabdominal infections as the new standard of care," Dr. Sawyer concluded.

Although they had positive comments about the study, several members of the audience commented that a larger study would be a better base for a recommendation to change the standard of care.

This study was one of several studies presented at the meeting that addressed the issue of reducing the time on antibiotic therapy in patients with surgical infections.

The study was sponsored by the National Institutes of Health. Dr. Sawyer had no disclosures.

emechcatie@frontlinemedcom.com

BALTIMORE – A study of patients with intraabdominal infection indicates that a shorter course of antibiotics is as effective as the standard, longer course, leading researchers to recommend a new standard of care.

The rates of recurrent infections and other outcomes were similar in patients with intraabdominal infections treated with antibiotics for 4 days following source control and among those who received a longer course of treatment based on when their clinical symptoms resolved, in a study reported at the annual meeting of the Surgical Infection Society.

The results support the use of the shorter treatment strategy in this setting, said Dr. Robert Sawyer, who presented the results of the study, SIS Multicenter Study of Duration of Antibiotics for Intraabdominal Infection.

Elizabeth Mechcatie/Frontline Medical News

While antibiotics are used as an adjunct to treat intraabdominal infections, the appropriate duration of treatment is not clear, and reducing the time exposed to antibiotics "could be worthwhile," said Dr. Sawyer, professor of surgery and public health sciences and chief of acute care surgery at the University of Virginia, Charlottesville.

The randomized, multicenter, unblinded study compared a shorter vs. a longer course of antibiotic therapy in 518 patients with intraabdominal infections: 4 days in 258 patients or treatment that continued for 2 days after resolution of the patient’s fever, leukocytosis, and ileus, with a maximum of 10 days of treatment in total, in 260 patients. The patients had similar APACHE II scores; their mean age was in the early 50s; and the colon or rectum was the most common source of infection, followed by the appendix and the small bowel. Antibiotics were administered intravenously or orally. Patients with inadequate source control and a high risk of death within 72 hours were excluded.

Within 30 days, the primary outcome – a composite of surgical site infection, recurrent intraabdominal infection, and death – was similar between the two groups, at about 21.7% in the 4-day treatment group vs. 22.7% in the group treated for 2 days after symptoms resolved.

There were no significant differences in the individual endpoints between the two groups. There were also no differences in the composite endpoints in different subgroups, and when those with percutaneous drainage or patients whose source of infection was the appendix were excluded. Among sicker patients with APACHE scores of 10 or higher, there was a numerical benefit favoring those treated for 4 days (22.1% vs. 29.8% among those treated for the longer duration), but the difference was not statistically significant, although it was reassuring, Dr. Sawyer said.

There were no differences between the two groups in the rates of secondary infections or subsequent infection with resistant pathogens or Clostridium difficile, which were secondary endpoints.

Based on these results, "after source control is obtained, we recommend 4 days of antimicrobial therapy for all patients with intraabdominal infections as the new standard of care," Dr. Sawyer concluded.

Although they had positive comments about the study, several members of the audience commented that a larger study would be a better base for a recommendation to change the standard of care.

This study was one of several studies presented at the meeting that addressed the issue of reducing the time on antibiotic therapy in patients with surgical infections.

The study was sponsored by the National Institutes of Health. Dr. Sawyer had no disclosures.

emechcatie@frontlinemedcom.com

BALTIMORE – A study of patients with intraabdominal infection indicates that a shorter course of antibiotics is as effective as the standard, longer course, leading researchers to recommend a new standard of care.

The rates of recurrent infections and other outcomes were similar in patients with intraabdominal infections treated with antibiotics for 4 days following source control and among those who received a longer course of treatment based on when their clinical symptoms resolved, in a study reported at the annual meeting of the Surgical Infection Society.

The results support the use of the shorter treatment strategy in this setting, said Dr. Robert Sawyer, who presented the results of the study, SIS Multicenter Study of Duration of Antibiotics for Intraabdominal Infection.

Elizabeth Mechcatie/Frontline Medical News

While antibiotics are used as an adjunct to treat intraabdominal infections, the appropriate duration of treatment is not clear, and reducing the time exposed to antibiotics "could be worthwhile," said Dr. Sawyer, professor of surgery and public health sciences and chief of acute care surgery at the University of Virginia, Charlottesville.

The randomized, multicenter, unblinded study compared a shorter vs. a longer course of antibiotic therapy in 518 patients with intraabdominal infections: 4 days in 258 patients or treatment that continued for 2 days after resolution of the patient’s fever, leukocytosis, and ileus, with a maximum of 10 days of treatment in total, in 260 patients. The patients had similar APACHE II scores; their mean age was in the early 50s; and the colon or rectum was the most common source of infection, followed by the appendix and the small bowel. Antibiotics were administered intravenously or orally. Patients with inadequate source control and a high risk of death within 72 hours were excluded.

Within 30 days, the primary outcome – a composite of surgical site infection, recurrent intraabdominal infection, and death – was similar between the two groups, at about 21.7% in the 4-day treatment group vs. 22.7% in the group treated for 2 days after symptoms resolved.

There were no significant differences in the individual endpoints between the two groups. There were also no differences in the composite endpoints in different subgroups, and when those with percutaneous drainage or patients whose source of infection was the appendix were excluded. Among sicker patients with APACHE scores of 10 or higher, there was a numerical benefit favoring those treated for 4 days (22.1% vs. 29.8% among those treated for the longer duration), but the difference was not statistically significant, although it was reassuring, Dr. Sawyer said.

There were no differences between the two groups in the rates of secondary infections or subsequent infection with resistant pathogens or Clostridium difficile, which were secondary endpoints.

Based on these results, "after source control is obtained, we recommend 4 days of antimicrobial therapy for all patients with intraabdominal infections as the new standard of care," Dr. Sawyer concluded.

Although they had positive comments about the study, several members of the audience commented that a larger study would be a better base for a recommendation to change the standard of care.

This study was one of several studies presented at the meeting that addressed the issue of reducing the time on antibiotic therapy in patients with surgical infections.

The study was sponsored by the National Institutes of Health. Dr. Sawyer had no disclosures.

emechcatie@frontlinemedcom.com

BALTIMORE – Hypoalbuminemia was identified as a significant risk factor for increased mortality and morbidity in obese patients undergoing elective general surgery, in a large study of patients from the ACS National Surgical Quality Improvement Program (NSQIP) database, Dr. Zachary C. Dietch reported at the annual meeting of the Surgical Infection Society.

The results suggest that surgeons may need to be more careful in evaluating protein deficiency in obese patients before surgery, said Dr. Dietch, a surgical resident at the University of Virginia, Charlottesville.

Elizabeth Mechcatie/Frontline Medical News

Protein-calorie deficiency is a well-known risk factor for complications, including infections and other surgical complications, but the risks of protein deficiency in different weight classes have not been well described. And while serum albumin is commonly used as an index for nutritional status and is known to correlate with adverse surgical outcomes, its use "as an index for nutrition status remains controversial," he noted.

But based on the results, "We feel that these risks likely reflect protein deficiency, and we feel that serum albumin appropriately reflects protein status in this population," he commented.

To evaluate the association of preoperative serum albumin and surgical complications by weight class, Dr. Dietch and his associates evaluated 240,000 general elective surgery patients, from the 2011 NSQIP database who had an elective procedure. After excluding certain groups of patients including those with systemic infections, cirrhosis, as well as those who were pregnant and those who had no preoperative albumin results available, they were left with about 86,000 patients.

Of these patients, 2,088 (about 2.4%) had a low serum albumin (below 3.0 g/dL); these patients tended to be older and tended to be in lower weight categories. Of those with hypoalbuminemia, 6.2% had a body mass index of 40 kg/m² and greater and almost 22% had a BMI between 30-39 (a BMI of 30 and greater falls in the obese category), and they had higher rates of comorbidities.

After controlling for factors that included comorbidities, surgical wound classification, operation type and complexity, the interaction of hypoalbuminemia and BMI conferred a statistically significant increase in the risk of mortality among those with a BMI of 40 and above, with an odds ratio of 18.98; and among those with a BMI between 30 and 39, with an odds ratio of 3.14 – when compared with patients in lower weight categories, who had low serum albumin, Dr. Dietch said.

Among those with a BMI of 40 and greater who had hypoalbuminemia, the risk of all complications was significantly increased (OR, 3.13) and the risk of all infectious complications was significantly increased (2.59). The risk of all complications was not significantly increased among those with a BMI of 30-39.

"The impact of protein deficiency on outcomes among patients may not be appreciated by surgeons," he concluded. This was a hypothesis-generating study and future studies "should prospectively investigate preoperative nutritional interventions in at-risk patients regardless of BMI," he added, noting that the next step would be a pilot study.

The limitations of the study included the possibility that the NSQIP data did not capture confounding disease states, and no causal relationship between protein status and surgical complications could be established because of the observational nature of the study, he noted.

In response to an audience member’s comment that a low albumin can be a reflection of a proinflammatory state, Dr. Dietch said that he and his coinvestigators recognized this and attempted to eliminate patients with proinflammatory states, such as those with systemic infections and those with systemic inflammatory response syndrome.

The study was funded by a National Institutes of Health training grant. Dr. Dietch had no disclosures

emechcatie@frontlinemedcom.com

BALTIMORE – Hypoalbuminemia was identified as a significant risk factor for increased mortality and morbidity in obese patients undergoing elective general surgery, in a large study of patients from the ACS National Surgical Quality Improvement Program (NSQIP) database, Dr. Zachary C. Dietch reported at the annual meeting of the Surgical Infection Society.

The results suggest that surgeons may need to be more careful in evaluating protein deficiency in obese patients before surgery, said Dr. Dietch, a surgical resident at the University of Virginia, Charlottesville.

Elizabeth Mechcatie/Frontline Medical News

Protein-calorie deficiency is a well-known risk factor for complications, including infections and other surgical complications, but the risks of protein deficiency in different weight classes have not been well described. And while serum albumin is commonly used as an index for nutritional status and is known to correlate with adverse surgical outcomes, its use "as an index for nutrition status remains controversial," he noted.

But based on the results, "We feel that these risks likely reflect protein deficiency, and we feel that serum albumin appropriately reflects protein status in this population," he commented.

To evaluate the association of preoperative serum albumin and surgical complications by weight class, Dr. Dietch and his associates evaluated 240,000 general elective surgery patients, from the 2011 NSQIP database who had an elective procedure. After excluding certain groups of patients including those with systemic infections, cirrhosis, as well as those who were pregnant and those who had no preoperative albumin results available, they were left with about 86,000 patients.

Of these patients, 2,088 (about 2.4%) had a low serum albumin (below 3.0 g/dL); these patients tended to be older and tended to be in lower weight categories. Of those with hypoalbuminemia, 6.2% had a body mass index of 40 kg/m² and greater and almost 22% had a BMI between 30-39 (a BMI of 30 and greater falls in the obese category), and they had higher rates of comorbidities.

After controlling for factors that included comorbidities, surgical wound classification, operation type and complexity, the interaction of hypoalbuminemia and BMI conferred a statistically significant increase in the risk of mortality among those with a BMI of 40 and above, with an odds ratio of 18.98; and among those with a BMI between 30 and 39, with an odds ratio of 3.14 – when compared with patients in lower weight categories, who had low serum albumin, Dr. Dietch said.

Among those with a BMI of 40 and greater who had hypoalbuminemia, the risk of all complications was significantly increased (OR, 3.13) and the risk of all infectious complications was significantly increased (2.59). The risk of all complications was not significantly increased among those with a BMI of 30-39.

"The impact of protein deficiency on outcomes among patients may not be appreciated by surgeons," he concluded. This was a hypothesis-generating study and future studies "should prospectively investigate preoperative nutritional interventions in at-risk patients regardless of BMI," he added, noting that the next step would be a pilot study.

The limitations of the study included the possibility that the NSQIP data did not capture confounding disease states, and no causal relationship between protein status and surgical complications could be established because of the observational nature of the study, he noted.

In response to an audience member’s comment that a low albumin can be a reflection of a proinflammatory state, Dr. Dietch said that he and his coinvestigators recognized this and attempted to eliminate patients with proinflammatory states, such as those with systemic infections and those with systemic inflammatory response syndrome.

The study was funded by a National Institutes of Health training grant. Dr. Dietch had no disclosures

emechcatie@frontlinemedcom.com

BALTIMORE – Hypoalbuminemia was identified as a significant risk factor for increased mortality and morbidity in obese patients undergoing elective general surgery, in a large study of patients from the ACS National Surgical Quality Improvement Program (NSQIP) database, Dr. Zachary C. Dietch reported at the annual meeting of the Surgical Infection Society.

The results suggest that surgeons may need to be more careful in evaluating protein deficiency in obese patients before surgery, said Dr. Dietch, a surgical resident at the University of Virginia, Charlottesville.

Elizabeth Mechcatie/Frontline Medical News

Protein-calorie deficiency is a well-known risk factor for complications, including infections and other surgical complications, but the risks of protein deficiency in different weight classes have not been well described. And while serum albumin is commonly used as an index for nutritional status and is known to correlate with adverse surgical outcomes, its use "as an index for nutrition status remains controversial," he noted.

But based on the results, "We feel that these risks likely reflect protein deficiency, and we feel that serum albumin appropriately reflects protein status in this population," he commented.

To evaluate the association of preoperative serum albumin and surgical complications by weight class, Dr. Dietch and his associates evaluated 240,000 general elective surgery patients, from the 2011 NSQIP database who had an elective procedure. After excluding certain groups of patients including those with systemic infections, cirrhosis, as well as those who were pregnant and those who had no preoperative albumin results available, they were left with about 86,000 patients.

Of these patients, 2,088 (about 2.4%) had a low serum albumin (below 3.0 g/dL); these patients tended to be older and tended to be in lower weight categories. Of those with hypoalbuminemia, 6.2% had a body mass index of 40 kg/m² and greater and almost 22% had a BMI between 30-39 (a BMI of 30 and greater falls in the obese category), and they had higher rates of comorbidities.

After controlling for factors that included comorbidities, surgical wound classification, operation type and complexity, the interaction of hypoalbuminemia and BMI conferred a statistically significant increase in the risk of mortality among those with a BMI of 40 and above, with an odds ratio of 18.98; and among those with a BMI between 30 and 39, with an odds ratio of 3.14 – when compared with patients in lower weight categories, who had low serum albumin, Dr. Dietch said.

Among those with a BMI of 40 and greater who had hypoalbuminemia, the risk of all complications was significantly increased (OR, 3.13) and the risk of all infectious complications was significantly increased (2.59). The risk of all complications was not significantly increased among those with a BMI of 30-39.

"The impact of protein deficiency on outcomes among patients may not be appreciated by surgeons," he concluded. This was a hypothesis-generating study and future studies "should prospectively investigate preoperative nutritional interventions in at-risk patients regardless of BMI," he added, noting that the next step would be a pilot study.

The limitations of the study included the possibility that the NSQIP data did not capture confounding disease states, and no causal relationship between protein status and surgical complications could be established because of the observational nature of the study, he noted.

In response to an audience member’s comment that a low albumin can be a reflection of a proinflammatory state, Dr. Dietch said that he and his coinvestigators recognized this and attempted to eliminate patients with proinflammatory states, such as those with systemic infections and those with systemic inflammatory response syndrome.

The study was funded by a National Institutes of Health training grant. Dr. Dietch had no disclosures

emechcatie@frontlinemedcom.com