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Re: Body Mass Index and the Risk of Infections in Institutionalised Geriatric Patients
DIAGNOSTIC UROLOGY, URINARY DIVERSION AND PERIOPERATIVE CARE
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Re: Microperforations of Surgical Gloves in Urology: Minimally Invasive Versus Open Surgeries T. Feng, J. Yohannan, A. Gupta, M. E. Hyndman and M. Allaf James Buchanan Brady Urological Institute, Department of Urology, Johns Hopkins Medical Institutions, Baltimore, Maryland Can J Urol 2011; 18: 5615–5618.
Introduction: Surgical glove integrity is important in preventing wound infections and reducing patient mortality. Rates of perforations have been studied in many surgical subspecialties, but glove perforations specific to urology have not been investigated previously. This study aims to determine the incidence of glove perforations during urological surgeries and to investigate differences between open, laparoscopic, and endoscopic procedures. Materials and Methods: A total of 180 gloves were collected from various urological procedures performed at our institution: 59 from endoscopic, 72 from laparoscopic, and 49 from open cases. The gloves were tested for defects by both the water load test and electrical conductance testing. The frequency of defects for each type of procedure along with the length of wear, surgeon experience, and glove brand was analyzed. Results: Glove defects were detected in 29% of all cases. Microperforations encompassed the majority of the glove defects (23.3%) and were detected in 15.2%, 25.0 %, and 30.6% of the endoscopy, laparoscopic and open surgical cases, respectively. The frequency of perforations noted in the minimally invasive procedures was significantly different across the groups (p ⬍0.01). There was no statistical significant correlation between glove defects and operation time, surgeon experience, and glove brand. Conclusions: The rates of glove perforation (29%) in urological procedures were higher than expected. Given the high rates of glove perforations found, double gloving in urological surgeries may offer a solution to the increased risk for cross contamination from microscopic perforations. Editorial Comment: The risk of microperforations in surgical gloves is well known but there are few such data in urological surgery. The authors sought to look at urological procedures, including open, endoscopic and laparoscopic cases. Perforations were noted in all 3 categories, with endoscopic procedures having the least number (15.2%) and open cases having the greatest (30.6%), for an overall incidence of 23.3%. They could not find any statistical correlation with operative time, surgeon experience or glove manufacturer and incidence of perforation. The authors conclude that given the relatively high incidence of microperforations in gloves, double gloving may be protective and help to reduce the potential for cross-contamination during urological surgery. Richard K. Babayan, M.D.
Geriatrics Re: Body Mass Index and the Risk of Infections in Institutionalised Geriatric Patients T. E. Dorner, F. Schwarz, A. Kranz, W. Freidl, A. Rieder and C. Gisinger Institute of Social Medicine and Epidemiology, Medical University Graz, Graz, Austria Br J Nutr 2010; 103: 1830 –1835.
The objective was to examine the effect of BMI on the incidence of various infectious diseases in institutionalised, geriatric subjects. In a retrospective cohort study we analysed medical records of 619 patients aged 75 years and older (mean age 87.6 (sd 6.4) years) who were treated in a geriatric hospital in Vienna, Austria. The total incidence rate of infection in this population was 0.80 per person-year. The most frequent infections were urinary tract infections (0.30 per person-year), followed by infections of the lower respiratory tract (0.19 per person-year), diarrhoea (0.12 per
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GERIATRICS
person-year) and other infections (0.20 per person-year). Incidence risk ratios were obtained by a multiplicative Poisson regression model. There was a J-shaped curve in the incidence of infections recorded by BMI with a nadir at 27–28 kg/m2. Compared with the reference group with a BMI of 24 –27.9 kg/m2, subjects with a lower BMI had a higher incidence rate of infections. The incidence risk ratios, adjusted for sex, age and chronic diseases, were 1.62 (95 % CI 1.21, 2.17) for those with a BMI of ⬍ 20 kg/m2 and 1.84 (95 % CI 1.40, 2.42) for those with a BMI of 20 –23.9 kg/m2. However, also patients with a BMI of 28 kg/m2 and above had a higher incidence rate of infections, with an incidence risk ratio of 1.54 (95 % CI 1.07, 2.22). These results show that both underweight and obesity are associated with a higher risk of infections in institutionalised geriatric patients. Editorial Comment: Obesity has been linked to a variety of negative health conditions, including coronary artery disease, diabetes, hypertension, stroke and arthritis. Some surgical studies looking at several variables have shown that obese elderly patients actually fare better than those who are underweight, perhaps due to increased functional reserve capacity. In contrast, there have been few studies examining the associations between body mass index and infectious outcomes, particularly in older adults. Nosocomial infections are common in institutional settings. In this study urinary tract infection was by far the leading type of infection seen in the institutionalized geriatric population. It is noteworthy that obese and significantly underweight elders were more likely to experience clinically significant infections. These results highlight the importance of proper nutrition and body composition to maintain overall condition, including urological health. Tomas L. Griebling, M.D., M.P.H.
Re: Urine Cultures From Indwelling Bladder Catheters in Nursing Home Patients: A Point Prevalence Study in a Swedish County K. Jonsson, B. E. Claesson and H. Hedelin Departments of Research and Development, and Clinical Microbiology, Unilabs, Skaraborgs, Skövde, Sweden Scand J Urol Nephrol 2011; 45: 265–269.
Objectives: To survey the bacterial flora and antibiotic resistance in urinary strains from patients with indwelling bladder catheters residing in nursing homes within a geographically defined region. Material and methods. Urine was sampled for culture from 163 catheter patients (126 men and 37 women) during a 2 week period in March 2010. Susceptibility testing of the isolated bacteria was compared with all urinary strains (n ⫽ 9994) from hospitals and primary healthcare in the same geographical area cultured during the first 6 months of 2010 (control group). Results: Bacteriuria was found in 159 of 163 urine samples (98%). Enterococcus faecalis and Escherichia coli were the most common species, one or both being detected in 72% of the urine samples, while Proteus species were found in10% and a single isolate of Providentia species was seen. Strains in the study patients were more resistant to antibiotics than in the control group. Particularly large differences were noted for ciprofloxacin in E. coli (16.9% vs 7.9%) and for trimethoprim-sulfamethoxazole in E. faecalis (39.1% vs 24.8%). One extended spectrum -lactamase (ESBL)-producing E. coli was cultured (1.3%), compared with 1.6% in the control group. No vancomycin-resistant enterococci (VRE) or methicillin-resistant Staphylococcus aureus (MRSA) were detected. Conclusions: Proteus mirabilis and Providentia species were rarely isolated, in sharp contrast to previous studies from geriatric hospital wards where they have often been in the majority. The limited incidence of ESBL and the absence of VRE and MRSA is gratifying, but the high resistance to antibiotics needs to be assessed on a continuous basis. Editorial Comment: The use of indwelling urinary catheters to manage incontinence and other genitourinary problems in elderly nursing home residents has decreased significantly in recent years. This change is due in large part to an increased understanding of the risks associated with indwelling catheter use, including bacterial colonization, uroli-
2267
Re: Microperforations of Surgical Gloves in Urology: Minimally Invasive Versus Open Surgeries T. Feng, J. Yohannan, A. Gupta, M. E. Hyndman and M. Allaf James Buchanan Brady Urological Institute, Department of Urology, Johns Hopkins Medical Institutions, Baltimore, Maryland Can J Urol 2011; 18: 5615–5618.
Introduction: Surgical glove integrity is important in preventing wound infections and reducing patient mortality. Rates of perforations have been studied in many surgical subspecialties, but glove perforations specific to urology have not been investigated previously. This study aims to determine the incidence of glove perforations during urological surgeries and to investigate differences between open, laparoscopic, and endoscopic procedures. Materials and Methods: A total of 180 gloves were collected from various urological procedures performed at our institution: 59 from endoscopic, 72 from laparoscopic, and 49 from open cases. The gloves were tested for defects by both the water load test and electrical conductance testing. The frequency of defects for each type of procedure along with the length of wear, surgeon experience, and glove brand was analyzed. Results: Glove defects were detected in 29% of all cases. Microperforations encompassed the majority of the glove defects (23.3%) and were detected in 15.2%, 25.0 %, and 30.6% of the endoscopy, laparoscopic and open surgical cases, respectively. The frequency of perforations noted in the minimally invasive procedures was significantly different across the groups (p ⬍0.01). There was no statistical significant correlation between glove defects and operation time, surgeon experience, and glove brand. Conclusions: The rates of glove perforation (29%) in urological procedures were higher than expected. Given the high rates of glove perforations found, double gloving in urological surgeries may offer a solution to the increased risk for cross contamination from microscopic perforations. Editorial Comment: The risk of microperforations in surgical gloves is well known but there are few such data in urological surgery. The authors sought to look at urological procedures, including open, endoscopic and laparoscopic cases. Perforations were noted in all 3 categories, with endoscopic procedures having the least number (15.2%) and open cases having the greatest (30.6%), for an overall incidence of 23.3%. They could not find any statistical correlation with operative time, surgeon experience or glove manufacturer and incidence of perforation. The authors conclude that given the relatively high incidence of microperforations in gloves, double gloving may be protective and help to reduce the potential for cross-contamination during urological surgery. Richard K. Babayan, M.D.
Geriatrics Re: Body Mass Index and the Risk of Infections in Institutionalised Geriatric Patients T. E. Dorner, F. Schwarz, A. Kranz, W. Freidl, A. Rieder and C. Gisinger Institute of Social Medicine and Epidemiology, Medical University Graz, Graz, Austria Br J Nutr 2010; 103: 1830 –1835.
The objective was to examine the effect of BMI on the incidence of various infectious diseases in institutionalised, geriatric subjects. In a retrospective cohort study we analysed medical records of 619 patients aged 75 years and older (mean age 87.6 (sd 6.4) years) who were treated in a geriatric hospital in Vienna, Austria. The total incidence rate of infection in this population was 0.80 per person-year. The most frequent infections were urinary tract infections (0.30 per person-year), followed by infections of the lower respiratory tract (0.19 per person-year), diarrhoea (0.12 per
2268
GERIATRICS
person-year) and other infections (0.20 per person-year). Incidence risk ratios were obtained by a multiplicative Poisson regression model. There was a J-shaped curve in the incidence of infections recorded by BMI with a nadir at 27–28 kg/m2. Compared with the reference group with a BMI of 24 –27.9 kg/m2, subjects with a lower BMI had a higher incidence rate of infections. The incidence risk ratios, adjusted for sex, age and chronic diseases, were 1.62 (95 % CI 1.21, 2.17) for those with a BMI of ⬍ 20 kg/m2 and 1.84 (95 % CI 1.40, 2.42) for those with a BMI of 20 –23.9 kg/m2. However, also patients with a BMI of 28 kg/m2 and above had a higher incidence rate of infections, with an incidence risk ratio of 1.54 (95 % CI 1.07, 2.22). These results show that both underweight and obesity are associated with a higher risk of infections in institutionalised geriatric patients. Editorial Comment: Obesity has been linked to a variety of negative health conditions, including coronary artery disease, diabetes, hypertension, stroke and arthritis. Some surgical studies looking at several variables have shown that obese elderly patients actually fare better than those who are underweight, perhaps due to increased functional reserve capacity. In contrast, there have been few studies examining the associations between body mass index and infectious outcomes, particularly in older adults. Nosocomial infections are common in institutional settings. In this study urinary tract infection was by far the leading type of infection seen in the institutionalized geriatric population. It is noteworthy that obese and significantly underweight elders were more likely to experience clinically significant infections. These results highlight the importance of proper nutrition and body composition to maintain overall condition, including urological health. Tomas L. Griebling, M.D., M.P.H.
Re: Urine Cultures From Indwelling Bladder Catheters in Nursing Home Patients: A Point Prevalence Study in a Swedish County K. Jonsson, B. E. Claesson and H. Hedelin Departments of Research and Development, and Clinical Microbiology, Unilabs, Skaraborgs, Skövde, Sweden Scand J Urol Nephrol 2011; 45: 265–269.
Objectives: To survey the bacterial flora and antibiotic resistance in urinary strains from patients with indwelling bladder catheters residing in nursing homes within a geographically defined region. Material and methods. Urine was sampled for culture from 163 catheter patients (126 men and 37 women) during a 2 week period in March 2010. Susceptibility testing of the isolated bacteria was compared with all urinary strains (n ⫽ 9994) from hospitals and primary healthcare in the same geographical area cultured during the first 6 months of 2010 (control group). Results: Bacteriuria was found in 159 of 163 urine samples (98%). Enterococcus faecalis and Escherichia coli were the most common species, one or both being detected in 72% of the urine samples, while Proteus species were found in10% and a single isolate of Providentia species was seen. Strains in the study patients were more resistant to antibiotics than in the control group. Particularly large differences were noted for ciprofloxacin in E. coli (16.9% vs 7.9%) and for trimethoprim-sulfamethoxazole in E. faecalis (39.1% vs 24.8%). One extended spectrum -lactamase (ESBL)-producing E. coli was cultured (1.3%), compared with 1.6% in the control group. No vancomycin-resistant enterococci (VRE) or methicillin-resistant Staphylococcus aureus (MRSA) were detected. Conclusions: Proteus mirabilis and Providentia species were rarely isolated, in sharp contrast to previous studies from geriatric hospital wards where they have often been in the majority. The limited incidence of ESBL and the absence of VRE and MRSA is gratifying, but the high resistance to antibiotics needs to be assessed on a continuous basis. Editorial Comment: The use of indwelling urinary catheters to manage incontinence and other genitourinary problems in elderly nursing home residents has decreased significantly in recent years. This change is due in large part to an increased understanding of the risks associated with indwelling catheter use, including bacterial colonization, uroli-