IMPORTANCEThe use of perioperative, prophylactic, intravenous antibiotics is standard practice to reduce the risk of surgical site infection after oncologic resection and complex endoprosthetic reconstruction for lower extremity bone tumors. However, evidence guiding the duration of prophylactic treatment remains limited.OBJECTIVE To assess the effect of a 5-day regimen of postoperative, prophylactic, intravenous antibiotics compared with a 1-day regimen on the rate of surgical site infections within 1 year after surgery.DESIGN, SETTING, AND PARTICIPANTS This randomized clinical superiority trial was performed at 48 clinical sites in 12 countries from January 1, 2013, to October 29, 2019. The trial included patients with a primary bone tumor or a soft tissue sarcoma that had invaded the femur or tibia or oligometastatic bone disease of the femur or tibia with expected survival of at least 1 year who required surgical management by excision and endoprosthetic reconstruction. A total of 611 patients were enrolled, and 7 were excluded for ineligibility.INTERVENTIONS A 1-or 5-day regimen of postoperative prophylactic intravenous cephalosporin (cefazolin or cefuroxime) that began within 8 hours after skin closure and was administered every 8 hours thereafter. Those randomized to the 1-day regimen received identical saline doses every 8 hours for the remaining 4 days; patients, care providers, and outcomes assessors were blinded to treatment regimen. MAIN OUTCOMES AND MEASURESThe primary outcome in this superiority trial was a surgical site infection (superficial incisional, deep incisional, or organ space) classified according to the criteria established by the Centers for Disease Control and Prevention within 1 year after surgery. Secondary outcomes included antibiotic-related complications, unplanned additional operations, oncologic and functional outcomes, and mortality. RESULTSOf the 604 patients included in the final analysis (mean [SD] age, 41.2 [21.9] years; 361 [59.8%] male; 114 [18.9%] Asian, 43 [7.1%] Black, 34 [5.6%] Hispanic, 15 [2.5%] Indigenous, 384 [63.8%] White, and 12 [2.0%] other), 293 were randomized to a 5-day regimen and 311 to a 1-day regimen. A surgical site infection occurred in 44 patients (15.0%) allocated to the 5-day regimen and in 52 patients (16.7%) allocated to the 1-day regimen (hazard ratio, 0.93; 95% CI, 0.62-1.40; P = .73). Antibiotic-related complications occurred in 15 patients (5.1%) in the 5-day regimen and in 5 patients (1.6%) allocated to the 1-day regimen (hazard ratio, 3.24; 95% CI, 1.17-8.98; P = .02). Other secondary outcomes did not differ significantly between treatment groups.CONCLUSIONS AND RELEVANCE This randomized clinical trial did not confirm the superiority of a 5-day regimen of postoperative intravenous antibiotics over a 1-day regimen in preventing surgical site infections after surgery for lower extremity bone tumors that required an endoprosthesis. The 5-day regimen group had significantly more antibiotic-related complications.
Background: In line with recent guidance from both ASPEN/ESPEN to cluster care to minimize healthcare team exposure by relying on other providers or telehealth to collect relevant nutrition assessment, our nutrition support team has adopted a modified workflow, leveraging information technology to provide parenteral nutrition (PN) remotely in a safe and timely manner. We aim to compare our prescribing adequacy and PN-related complications before and during COVID-19 outbreak using the modified workflow in non-critically ill patients. Method: This study reviewed a prospectively recruited cohort of adults (>18 years old) started on PN in the general wards or high dependency units from 5 th of December 2019 to 15 th of April 2020. Demographic data, nutrition assessment, PN prescriptions, blood results, electronic notes, capillary blood glucose (CBG) monitoring and CRBSI rates were reviewed for patients who received PN. Result: In our study, we found that patients who started PN during COVID-19 were more malnourished with lower BMI and higher proportion of SGA B/C(52 (92.9%) vs 36 (73.5%) p<0.005). Proportion of patients who achieved target calories within 5 days were similar in both groups. Protein prescription was >1g/kg/day in both groups, though there was a trend of higher protein prescription during COVID-19. Complications were similar in both groups. Conclusion: Our study demonstrates that minimal contact with effective multidisciplinary communication using the modified workflow can allow for safe and timely PN administration.
Introduction: Reported clinical outcomes for elderly patients with acute intestinal failure receiving parenteral nutrition (PN) in the acute hospital setting is limited. Our study aims to characterize the use of PN in the elderly and compare clinical outcomes against younger patients. Methods: A retrospective review of inpatients administered PN from 1st January 2019 to 31st December 2019 was performed. Demographics, indications for PN, biochemical results and clinical outcomes were compared. Patients were categorized into < 65 (younger) or ≥ 65 years old (elderly). Results: 235 patients were included. There were 103 patients in the elderly group with a mean age of 73.9 years (± 6.9 years) and 132 patients in the younger group with a mean age of 52.4 years (± 12.5 years). There was a significantly higher Charlson Comorbidity Index and comordities and lower Karnofsky score in the elderly group. Indications for PN were similar between both groups. There was more younger patients who required PN for ≥28 days. The elderly group received a significantly lower total calorie, dextrose and protein compared to the younger group (20.8 (7.8) vs 22.8 (6.3) kcal/kg/day ; 3.1 (1.4) vs 3.6 (1.4) g/kg/day ; 1.1 (0.4) vs 1.2 (0.3) g/kg/day ). Mean length of stay was significantly longer in the younger group than in the elderly group (59.8 (± 55.3 ) vs 35.9 (± 21.3) days). There was no significant difference in clinical outcomes: line sepsis, hypoglycemia, hyperglycemia, fluid overload, inpatient mortality and total mortality between the two groups. Conclusion: The usage of PN in elderly patients with acute intestinal failure was not associated with an increased rate of PN related complications nor worse clinical outcomes when compared with younger patients. and hence should not be denied when appropriate indications are present.
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