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Background This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January–October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection. Results This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery before and 4371 (59.1 per cent) during the pandemic. Overall, 4.3 per cent (187 of 4371) developed postoperative SARS-CoV-2 in the pandemic cohort. The pulmonary complication rate was similar (7.1 per cent (216 of 3031) versus 6.3 per cent (274 of 4371); P = 0.158) but the mortality rate was significantly higher (0.7 per cent (20 of 3031) versus 2.0 per cent (87 of 4371); P < 0.001) among patients who had surgery during the pandemic. The adjusted odds of death were higher during than before the pandemic (odds ratio (OR) 2.72, 95 per cent c.i. 1.58 to 4.67; P < 0.001). In mediation analysis, 54.8 per cent of excess postoperative deaths during the pandemic were estimated to be attributable to SARS-CoV-2 (OR 1.73, 1.40 to 2.13; P < 0.001). Conclusion Although providers may have selected patients with a lower risk profile for surgery during the pandemic, this did not mitigate the likelihood of death through SARS-CoV-2 infection. Care providers must act urgently to protect surgical patients from SARS-CoV-2 infection.

INTRODUC TI ONUrinary tract infections (UTI) are a commonly treated infection in the emergency department (ED), accounting for approximately 3 million visits annually, and 15% of all outpatient antibiotics in the United States (US). [1][2][3][4] Enterobacterales remain the most common cause of UTIs and are associated with increased rates of in vitro resistance to commonly prescribed antibioitics. 5,6 In particular, the prevalence of Escherichia coli resistance to commonly prescribed antibiotics such as trimethoprim/sulfamethoxazole (TMP/SMX), fluroquinolones (FQ; e.g., ciprofloxacin and levofloxacin), and beta-lactams has continued to increase in most regions of the United States, and underscores the importance of using local antibiograms for selecting empiric treatment in patients diagnosed with a UTI in the ED. 5,7 Many geographic regions in the United States are reporting prevalences of FQ-resistant (FQR) and TMP/SMX-resistant Enterobacterales of >10%, with some areas with rates >20%, exceeding threshold rates (>10%) recommended by the Infectious

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