Background:Critically ill patients are at risk of nosocomial infections, acquisition of multidrug-resistant pathogens, and substantial antimicrobial consumption. We assessed whether bathing with chlorhexidine reduces these outcomes compared to standard practices. Methods:We conducted an open-label, cluster-randomised crossover trial in 22 Brazilian intensive care units comparing daily chlorhexidine bathing versus soap and water bathing (control). Centres were randomised to 3- or 6-months chlorhexidine or control periods, separated by a 1-month washout. Primary outcome was nosocomial infection rate (central line-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia) during ICU stay. Secondary outcomes included specific nosocomial infections incidence, multi-drug resistant cultures, antibiotic use, length of stay, and mortality. This completed trial is registered at ClinicalTrials.gov, NCT05485051. Findings:From August 1st, 2022 to December 31, 2023, we included 15,935 patients (8247 chlorhexidine and 7688 control group). Mean age was 64·4 years (SD 17·3) in the chlorhexidine group [4315 (52·3%) male] and 64·2 years (SD 17·4) in the control group [4035 (52·5%) male]. A total of 201 nosocomial infections occurred in the chlorhexidine group, compared to 165 in the control group. There was no statistically significant difference in the overall nosocomial infections rate between groups [3·99 per 1000 patient-days in the chlorhexidine group and 3·45 per 1000 patient-days in the control group (rate-ratio, 1·09; 95% CI 0·95-1·25; p = 0·22)]. Patients in the chlorhexidine group had lower rates of multi-drug resistant cultures compared to the control group (14·42 vs. 20·13 per 1000 patient-days, rate-ratio, 0·73; 95% CI 0·59-0·91; p = 0·0092). Although overall antimicrobial consumption defined by WHO's DDD did not differ between groups (rate-ratio, 0·91; 95% CI 0·80-1·03; p = 0·14), there was a statistically significant difference in the consumption of antimicrobials in the Reserve group of WHO's AWaRe classification (rate-ratio, 0·73; 95% CI 0·59-0·90; p = 0·0071) in the chlorhexidine group. This reduction was not associated with higher mortality. Interpretation:Chlorhexidine bathing did not reduce the incidence of nosocomial infections in a general ICU population, but contributed to lower rates of multi-drug resistant pathogen isolation, and lower use of Reserve antimicrobials, potentially leading to a qualitative modification of antimicrobial use. Funding:This study was funded by the Brazilian Health Ministry through the Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (PROADI-SUS).
BACKGROUND:Uncertainties persist regarding the allocation of apical lymph nodes in colorectal cancer, the approaches to lymph node dissection and mesocolic excision, which may contribute to inconsistent surgical practices. The aim of this study is to assess surgeons' practices in lymph node dissection and mesocolic excision approaches and to identify areas lacking standardization. METHODS:A multinational pilot survey of 22 colorectal surgeons from 6 countries was conducted during the FICARE colorectal meeting. The survey consisted of 21 Likert-scale questions on surgical practices and lymph node allocation in colorectal cancer surgery. RESULTS:Majority of the respondents (90.9%) recognized conceptual differences in apical lymph node stratification between right- and left-sided colon cancers, whereas D3 LND for left-sided cancer should include mesocolic tissue along the inferior mesenteric artery from its origin to the last sigmoid artery. Complete lymph node dissection requires excision of mesocolic tissue along inferior mesenteric artery for left colon cancer and superior mesenteric artery for right colon cancer according to 81.8% of respondents. At the same time, 95.5% agreed that intermediate and paracolic lymph nodes are located within a 10-cm resection margin proximally and distally from tumor, while 81.9% of respondents supported the concept of tumor-specific mesocolic excision to be sufficient enough for adequate paracolic and intermediate lymph node dissection. CONCLUSIONS:A multinational snapshot showed an existing contraindication in surgeons' perception of lymph node stratification and the variability in mesocolic excision and LND. Further Delphi consensus is needed to prove the suggested concepts.
The KEYNOTE-522 regimen is the standard of care for stage II-III triple-negative breast cancer (TNBC). However, older patients were underrepresented in the pivotal trial. We evaluated the effectiveness and safety of this regimen in patients aged ≥65 years enrolled in the Neo-Real/GBECAM-0123 multicenter real-world study conducted across institutions in Brazil and Argentina. Among 724 patients, 80 (11%) were aged ≥65 years and presented distinct baseline characteristics, including lower frequencies of grade 3 tumors, Ki67 ≥ 50%, and germline BRCA1/2 mutations, alongside a higher prevalence of impaired performance status. The pathologic complete response (pCR) rate in older patients was 54.9% in comparison with 64.5% in younger patients, although age was not independently associated with pCR in multivariable analysis, including other relevant baseline variables. Older patients experienced a significantly higher toxicity burden, with increased rates of treatment discontinuation, dose reductions, treatment delays, hospitalizations, and grade ≥3 neutropenia. Taken together, these data indicate that older patients with TNBC harbor distinct biological and clinical features with numerically lower pCR rates, and that the increased toxicity burden underscores the need for personalized treatment strategies and dedicated research in this population.
