Surgical Infections

Fungal necrotizing soft tissue infections (NSTIs) are often diagnosed late due to the low likelihood, resulting in poor patient outcomes. Traditionally NSTI are treated with emergent surgical debridement followed by serial interventions. Adjunctive antibiotics are aimed at common bacterial infections along with toxin reduction; however, fungal treatment is often delayed. This study aimed to identify predictors, treatment patterns, and outcomes in fungal NSTIs.

A retrospective review of patients with NSTIs (n = 634) from a single tertiary academic center was conducted from 2011 to 2023, with patients stratified by fungal presence in wound cultures. Primary outcomes were mortality along with the number of serial debridement. Secondary outcomes were length of stay, intensive care requirements, acute kidney injury, and 30-days readmission. Logistic regression was utilized to identify predictors of fungal infection.

Of 634 patients, 110 (17.4%) had fungal-positive wound cultures, with Candida albicans being the most common (47.3%). Patients with positive fungal cultures more frequently had Type 2 diabetes mellitus (74.5% vs. 61.6%, p = 0.014). Patients with positive fungal wound cultures were more likely to require ≥ 3 operative debridement (p < 0.001), had a longer length of stay (19 vs. 12 d, p < 0.001), require mechanical ventilation (p < 0.001), and had greater 90-days mortality (20% vs. 12%, p = 0.03). Female gender (OR: 1.73, 95% CI: [1.09–2.76], p = 0.021), diabetes mellitus (OR: 1.75, 95% CI: [1.07–2.93], p = 0.030), vasopressor use (OR: 1.71, 95% CI: [1.04–2.81], p = 0.034), and VRE infection (OR: 12.2, 95% CI: [4.16–41.3], p < 0.001) were predictive of fungal infection.

Fungal NSTIs are associated with worse patient outcomes. Early empirical antifungal therapy may be considered in high-risk patients, particularly those with diabetes, as part of comprehensive NSTI management.

Emergency surgery (ES) is associated with a significantly higher risk of perioperative complications, including infectious, compared with elective surgery. This study aimed to identify the impact of time to surgical procedure and operative duration on infectious complications after ES.

The 2013–2017 American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify all ES patients ≥18 years using the variable “Emergency.” Delayed surgical procedure was defined as >12 h and prolonged surgical procedure as >2 h. Multivariable logistic regression adjusting for age, comorbidities, and surgical approach was used to investigate the impact of delayed and prolonged surgical procedure on postoperative infection, defined as the presence of sepsis, septic shock, surgical site infection (i.e., superficial, deep incisional, and organ space), pneumonia, and urinary tract infection. Sensitivity analyses were performed to examine the same relationship in emergency general surgery (EGS), identified with Current Procedural Terminology codes, and three subsets of EGS patients: exploratory laparotomy, cholecystectomy, and appendectomy.

Out of 4,299,148 patients, 264,213 were included, of which 24,921 (9.4%) had postoperative infections. Patients with infectious complications were more likely to have comorbidities (e.g., obesity, diabetes), an open surgical approach, delayed surgical procedure (50.4% vs. 39.4%, p < 0.001), and prolonged surgical procedure (31.6% vs. 14.3%, p < 0.001). On multivariable analyses, delayed surgical procedure was significantly associated with a 14% higher risk of postoperative infection (adjusted odds ratios [aOR] 1.14; 95% confidence interval [CI] 1.1–1.18), and prolonged surgical procedure was significantly associated with twice the risk (aOR: 1.99; CI: 1.91–2.08). Similarly, delayed and prolonged surgical procedure were significantly associated with infectious complications in the subset of EGS patients (aOR: 1.16; CI: 1.11–1.22, aOR: 1.91; CI: 1.82–2.02, respectively). When examining the 3 sensitivity subsets of patients, prolonged surgical procedure was significantly associated with infectious complications in all cohorts (aOR: 1.45; CI: 1.28–1.64 in exploratory laparotomy, aOR: 1.93; CI: 1.52–2.46 in cholecystectomy, aOR: 2.06; CI: 1.69–2.53 in appendectomy), whereas delayed surgical procedure was significantly associated with infectious complications only in exploratory laparotomy (aOR: 1.23; CI: 1.13–1.33).

Delayed and prolonged surgical procedure are independently associated with increased risk of infectious complications in ES patients, including those undergoing EGS procedures. These findings highlight the importance of early and efficient surgical interventions in ES.

To evaluate the impact of the Safe Surgery Program on surgical site infection (SSI) rates in spinal procedures and total hip and knee arthroplasties. The analysis compared the pre-implementation (2006–2010) and post-implementation (2010–2022) periods to determine the effect of the program on SSI rate reduction.

We conducted a nested case–control study including adults (>18 y). Cases were patients with SSI matched 1:1 to controls by procedure type, gender, age, and operation date. Risk factors, antimicrobial agent use, hospital costs, and checklist adherence were analyzed.

A total of 142 patients were included in the analysis (71 cases and 71 matched controls). Most surgical procedures (84.5%) occurred after the implementation of the Safe Surgery Program, with 78.3% adherence to the World Health Organization checklist. In the analysis, blood transfusion was significantly associated with SSI (odds ratio = 2.67; 95% confidence interval: 1.04–6.82; p = 0.040), whereas a longer operative time showed a borderline trend (p = 0.050). SSI rates decreased from 2.0% to 0.7% after program implementation (p = 0.017). Hospital-wide antimicrobial agent consumption increased for cefazolin (+75 defined daily doses per 1,000 patient-days), cefuroxime (+10.6), and vancomycin (+10.2) during the same period, reflecting broader compliance with surgical prophylaxis protocols. Hospital costs were significantly lower among patients without SSI (p = 0.024).

Implementation of the Safe Surgery Program was associated with reduced SSI incidence and hospital costs in complex orthopedic procedures. Blood transfusion remained an important risk factor, highlighting the value of optimization of peri-operative management and adherence to surgical safety practices.

Surgical site infections (SSIs) are a substantial contributor to morbidity and mortality rates. 405 nm visible light disinfection (VLD) has been shown to reduce bacterial burden in operating rooms (ORs); however, its effect on SSIs is poorly described. Therefore, we investigated whether the usage of VLD correlated with a decrease in SSI rates.

A prospective cohort study was conducted by comparing three operating rooms equipped with VLD and three operating rooms equipped with standard lights. Bacterial loads within the six ORs of interest were obtained before and after initiation of VLD. Patients of various surgical subspecialties were randomly assigned to rooms. SSI rates were tracked from July 2019 to June 2022. The primary outcome of interest was the SSI rate.

A total of 11,381 patients were included in the study, comprising 5,036 in VLD rooms and 6,345 in control rooms. Although age, gender, and body mass index were similar between the groups, there were differences in American Society of Anesthesiologists class, operation length, and wound class. There was a 66% reduction in bacterial load in the VLD rooms. No substantial difference was observed in SSI rates between the control and VLD rooms (0.8% vs. 0.8%, p = 0.71). There was no substantial difference in SSI rates by specialty. After adjusting for covariates, VLD was not independently associated with SSI rate.

VLD effectively reduced overall operating room bacterial burden; however, this did not result in a substantial reduction in SSI rates. The cause of SSIs is multi-factorial and may be influenced more by patient and technical factors than overall operating room bacterial burden.

Robot-assisted radical prostatectomy (RARP) is a widely used minimally invasive procedure for the treatment of localized prostate cancer. Although pre-operative bacteriuria has been associated with post-operative infections after open prostatectomy, evidence in the RARP era remains limited. The clinical significance of post-operative bacteriuria also remains unclear.

We retrospectively reviewed the records of patients who underwent RARP at our institution between 2019 and 2025. Urinalysis and urine cultures were routinely performed pre-operatively and on post-operative day 4. Infectious complications, including surgical site and urinary tract infections, were assessed within 30 days of operation. We analyzed the association between peri-operative urinary findings and post-operative infections.

Among 257 patients, post-operative infections occurred in 11 cases (4.3%). Pre-operative pyuria was significantly more common in the infection group than in the non-infection group (18.2% vs. 3.7%, p = 0.049), whereas pre-operative bacteriuria was not. Post-operative bacteriuria was observed in 45.5% of infected cases compared with 3.3% of non-infected cases (p < 0.001), whereas post-operative pyuria did not differ significantly between the groups. However, severe post-operative pyuria (>50 white blood cells per high-power field) was more frequent in the bacteriuria-positive group than in the bacteriuria-negative group (46.2% vs. 4.1%, p < 0.001).

Pre-operative bacteriuria was not associated with post-operative infections following RARP. In contrast, post-operative bacteriuria was strongly associated with infectious complications. These findings suggest that routine pre-operative urine cultures may be unnecessary in patients without symptoms. However, post-operative bacteriuria may indicate an increased risk of infection, and urine cultures should be considered, particularly in cases with severe pyuria.

Periprosthetic joint infection (PJI) is a major complication following total knee arthroplasty (TKA). Antibiotic-loaded cement (ALBC) is commonly used as a preventative measure, though it remains controversial. Despite guidelines from organizations including the American Academy of Orthopedic Surgeons (AAOS) and the International Consensus Meeting on Musculoskeletal Infection (ICM), ALBC usage in primary TKA varies. The purpose of this study was to evaluate the effectiveness of guideline-directed ALBC utilization in reducing PJI in primary TKA.

A retrospective cohort study was conducted at a single center, including 6,429 primary cemented TKAs performed between 2019 and 2022. ALBC was used in 21.6% of cases. PJI rates were analyzed using univariate, multivariate, and propensity score-matched analyses. Adherence to guidelines from New England Baptist Hospital (NEBH), AAOS, and ICM was assessed. Cost analysis was performed to compare differences between ALBC and plain cement.

The incidence of PJI was 0.22%, with no significant difference between ALBC (0.43%) and plain cement (0.16%) groups. Multivariate analysis revealed no significant predictors of PJI, including ALBC use (p > 0.05). Adherence to guidelines was low across all criteria, ranging from 23.5% (ICM) to 41% (NEBH), and did not reduce PJI risk. Cost analysis showed $210,000 in ALBC use.

Guideline-directed ALBC use did not significantly reduce PJI rates in primary TKA, and overall adherence to guidelines was limited. Had all primary TKA cases in this analysis utilized plain cement, the hospital would have saved more than $200,000 on primary TKA alone. These findings suggest that current criteria guiding ALBC use in primary TKA for PJI prophylaxis may overestimate its value.

This study aims to identify epidemiological, microbiological, and laboratory characteristics of cerebrospinal fluid (CSF) shunt infections in children and evaluate associated risk factors.

Patients aged 0–18 years who underwent ventricular shunt placement at Gazi University Faculty of Medicine Hospital between January 1, 2010, and December 31, 2022, were retrospectively reviewed.

A total of 201 shunt procedures performed in 176 patients were analyzed, with infection occurring in 32 cases (15.9%). Infection rates were higher in subgaleal shunts (60%) than ventriculoperitoneal shunts (15.2%) (p = 0.018). Shunt infections developed in 31.7% of procedures involving at least one risk factor, compared with 5.7% of procedures without identified risk factors (p < 0.001). Preterm infants (<37 wks) had a higher infection rate (49%) than those born ≥37 weeks (14.5%) (p < 0.001). Gram-positive microorganisms accounted for 56.3% of infections, most commonly Staphylococcus sp., whereas Pseudomonas aeruginosa and Klebsiella species were the most frequent gram-negative pathogens (each 12.5%). Patients with gram-negative meningitis had a significantly higher intensive care unit admission rate than those with gram-positive meningitis (p = 0.021). In multivariate analysis, subgaleal shunt placement was associated with increased odds of shunt infection (OR: 12.13; CI: 1.36–107.69) (p = 0.025). In regression analysis, preterm birth was independently associated with an increased risk of shunt infection (OR: 6.12; CI: 2.02–18.56).

Shunt infection rates and microbial patterns align with existing literature. Preterm birth emerged as a major risk factor for shunt infection, whereas subgaleal shunt placement appeared to be a potential risk factor that warrants cautious interpretation and further validation. The increased severity of gram-negative infections underscores the need for stringent monitoring and preventive strategies in high-risk populations.

Acute appendicitis remains one of the most common surgical emergencies, yet its pathogenesis is incompletely understood. Although mechanical luminal obstruction has traditionally been considered the initiating factor, emerging evidence suggests that the appendix hosts a unique microbial community that may influence disease onset and severity.

We conducted a narrative review that summarizes current data on the role of microbiota in appendicitis, while focusing on differences between complicated and uncomplicated presentations.

High-throughput sequencing studies have identified key taxa associated with inflamed appendices, including Fusobacterium, Prevotella, and oral cavity genera such as Gemella and Parvimonas. On the contrary, protective commensals such as Faecalibacterium prausnitzii and Akkermansia muciniphila appear depleted. Studies suggest that there is significant variation regarding the microbial composition of complicated and uncomplicated cases. We also examine the role of the appendix as a microbial reservoir and the potential health consequences of its removal. Finally, we discuss how microbiome-based approaches may improve treatment, particularly antibiotic agent selection both in operative and non-operative management.

Current evidence supports that appendicitis may represent a disease spectrum carrying multiple rather than a single microbial signature that dictates different pathophysiologic processes.

Clostridium sordellii infections are rare and highly lethal. They are most associated with medical abortions and other genitourinary procedures. We report a fatal case of C. sordellii bacteremia from a perforated low rectal cancer with rectovaginal fistula.

A 60-year-old female presented with 10 days of abdominal pain, loose stools, and hematochezia. She developed rapidly progressive septic shock. Imaging identified a perforated rectal mass, pneumovagina, and a large pelvic abscess. She underwent fecal diversion and drainage of the pelvic abscess. Despite this intervention, she had refractory septic shock with multisystem organ failure resulting in death. Blood cultures grew C. sordellii post-mortem.

C. sordellii infections are often fatal if not treated immediately. Clinicians must have a high index of suspicion in rectal cancer with associated gynecological involvement.