Socioeconomic Disadvantage is Associated with Greater Mortality after High-Risk Emergency General Surgery. Cain BT, Horns JJ, Huang LC, McCrum ML. J Trauma Acute Care Surg. 2022 Apr 1;92(4):691-700.
A great deal has been published on the impact of socioeconomic (SE) disparity as a social determinant of health in surgical outcomes. Poor socioeconomic status has been associated with worse mortality, increased lengths of stay, and higher rates of failure to rescue. These data are primarily in the realm of elective surgery - hence, Dr. Cain and colleagues publish their effort in identifying the impact of SE status on emergency general surgery outcomes. An interesting facet of this paper is that instead of using single measures as surrogates for SE status (e.g., income or education level), the authors use the multifactorial Area Deprivation Index (ADI) to take advantage of a more comprehensive assessment of an individual patient’s socioeconomic milieu. The authors then looked at outcomes associated with common high-risk (e.g., colectomy, stomach repairs), as well as low-risk (e.g., cholecystectomy, appendectomy) emergency surgical procedures.
The authors reviewed outcomes from HCUP datasets in 2014 for the states of Iowa, Florida, Utah, Wisconsin, New York, and Washington. A total of 103,749 admissions were analyzed. After multivariable analysis, the odds of non-home discharge were increased in the high SE deprivation cohort after a low-risk procedure. Furthermore, patients from neighborhoods with high SE deprivation had a 30% higher risk-adjusted odds of mortality compared with patients from areas with low socioeconomic deprivation when undergoing high-risk procedures.
In summary, the authors note that high SE disadvantage is independently associated with worse postoperative outcomes after EGS. In addition, they note that the support services available at level 1 trauma centers and safety net hospitals did not impact these outcomes. This study is, of course, unable to elucidate causation. Prior work has suggested patients from poor SE background present more severely ill and with more advanced or poorly controlled comorbidities. Furthermore, lack of health insurance, lack of a primary care provider, and language barriers may all predispose to the presentation of disease processes (e.g., symptomatic gallbladder disease) in an emergent rather than elective fashion.
These findings corroborate much of what has been published previously albeit with a bent towards outcomes in EGS. The authors note that to substantially improve patient outcomes in the future interventions targeting health care access, social programs, and policies directed at barriers to timely medical care will need to be prioritized.
Effect of Antibiotic Duration in Emergency General Surgery Patients with Intra-Abdominal Infection Managed with Open vs Closed Abdomen. Diaz JJ, Zielinski MD, Chipman AM, et al. J Am Coll Surg. 2022 Apr 1;234(4):419-427.
In 2015, the STOP-IT trial published results demonstrating that after source control is achieved after a laparotomy for complicated intra-abdominal infections, a short course of antibiotics (3-5 days) is equally as efficacious as longer durations. However, these results are reflective of single laparotomies and may not be applicable to damage control situations where a temporary abdominal closure is utilized. Hence, Dr. Diaz and colleagues present their study elucidating the effect of antibiotic duration in EGS patients managed with an open abdomen compared with those who are managed with a closed abdomen.
This study is a prospective, observational, multicenter, international trial of patients with intra-abdominal infection (IAI) requiring emergency surgery. 752 patients met study criteria. IAIs were considered, in general, to be gangrenous or perforated GI tract organs. The duration of IV antibiotics was followed. The primary outcomes were surgical infection (e.g., SSI, pneumonia, UTI, etc.) and in-hospital mortality. Of the enrolled patients, 23.8% developed at least one surgical infection. The authors note that patients who develop SI had worse vital signs on initial presentation, had preoperative vasopressor use, and had higher ASA, CCI, SOFA, and APACHE II scores. Furthermore, these patients had a higher mortality rate and LOS. Most relevant, however, was that patients who developed SI were treated with antibiotics for significantly longer than those who did not develop a SI and were twice as likely to develop an SI if managed with an open abdomen.
The complications of prolonged antibiotic therapy are well-known - the development of antibiotic resistance, increased cost, the development of Clostridium difficile colitis, etc. In addition, longer durations may mask the manifestations of SI development without preventing their onset and potentially delay adequate source control and more appropriate antibiotic treatment. As noted by the authors, other studies have shown that prolonged durations of antibiotics therapy are associated with extra-abdominal infections and increased mortality. The authors demonstrate that longer duration of antibiotics is associated with a higher rate of surgical infections, but the classic conundrum of correlation remains - do the prolonged antibiotics cause these infections or were these patients on antibiotics for a longer duration due to lack of source control, etc. Nevertheless, this study demonstrates that increased duration of antibiotics does not have a protective effect in these patients and the clinician should tailor their antibiotic therapy and regimens accordingly.