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This paper proposes an integrated approach for the long-term planning and surgery allocation problem with downstream constraints. It is motivated by a case study in the Brazilian National Institute of Traumatology and Orthopedics, which provides elective high complexity surgeries for patients from the Brazilian public health system. We introduce an optimization problem that designs a periodic surgery allocation schedule as well as a recovery ward utilization plan, with a view at balancing patient arrivals and releases in the long term, in such a way that all surgeries are performed in a timely manner.

Linda M. McKinley Department of Infection Control, William S. Middleton Veterans Affairs Medical Center, Madison, Wisconsin, U.S.A.INTRODUCTIONMethicillin-resistant Staphylococcus aureus (MRSA), a major cause ofinfections in healthcare institutions (1) and more recently in the community(2,3), was first reported in 1961, two years after the introduction ofmethicillin for treatment of penicillin-resistant S. aureus infections (4,5).Since then, despite extensive infection control efforts, methicillin resistanceamong isolates of S. aureus has steadily increased. Data from the NationalHealthcare Safety Network (NHSN) at the Centers for Disease Controland Prevention (CDC) show that 50% to 60% of healthcare-associatedS. aureus isolates from ICUs are now resistant to methicillin. Figure 1shows resistance trends in S. aureus over time (6). Multidrug-resistantstrains of staphylococci are also being reported with increasing frequencyworldwide, including isolates that are resistant to methicillin, lincosamides,macrolides, aminoglycosides, fluoroquinolones, or combinations of theseantibiotics (7). Recently, the emergence of S. aureus strains with inter-mediate resistance to vancomycin has been reported (8-10). For decades,vancomycin has been the only uniformly effective treatment against seriousMRSA infections and the development of resistance to it is deeply con-cerning. MRSA infections are associated with prolonged hospitalization

Central line-associated bloodstream infections (CLABSI) are associated with considerable morbidity, mortality and economic costs. In most cases, catheter removal is considered an essential component of managing CLABSI. However, in patients with poor access, catheter salvage may have to be attempted rather than removal and replacement of catheters. Anti-infective lock therapy (ALT) – instilling an antibiotic or antiseptic into the catheter lumen – is a novel way of treating CLABSI while attempting to salvage the catheter. However, data on the efficacy of ALT for catheter salvage is limited. In this systematic review, we critically review the evidence regarding the use of ALT for catheter salvage. We identified 8 studies including a total of 396 patients that compared ALT with systemic antibiotic therapy alone or an alternate method of catheter salvage (guidewire replacement). We found that the combination of systemic antibiotics and culture-guided lock therapy was superior to systemic antibiotics alone (OR: 0.20, 95% CI: 0.10–0.39), with 10% of locked patients requiring replacement compared to 33% of subjects without locks. There was a 20% relapse rate in the ALT group and a 30% relapse rate in the control group (OR: 0.43, 95% CI: 0.18–1.03). There was insufficient data on catheter exchange over a wire compared with ALT to permit conclusions. Our data support the use of ALT in conjunction with systemic antibiotics for catheter salvage. Large randomized controlled trials of ALT examining dose, dwell times and relapse rates stratified by infecting pathogen are needed.