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Intensive care unit management of intra-abdominal infection
Abstract
To review the biologic characteristics of, and management approaches to, intra-abdominal infection in the critically ill patient.
Narrative review.
Medline review focussed on intra-abdominal infection in the critically ill patient.
Restricted to studies involving human subjects.
None.
Intra-abdominal infections are an important cause of morbidity and mortality in the intensive care unit (ICU). Peritonitis can be classified as primary, secondary, or tertiary, the unique pathologic features reflecting the complex nature of the endogenous gut flora and the gut-associated immune system, and the alterations of these that occur in critical illness. Outcome is dependent on timely and accurate diagnosis, vigorous resuscitation and antibiotic support, and decisive implementation of optimal source control measures, specifically the drainage of abscesses and collections of infected fluid, the debridement of necrotic infected tissue, and the use of definitive measures to prevent further contamination and to restore anatomy and function.
Optimal management of intra-abdominal infection in the critically ill patient is based on the synthesis of evidence, an understanding of biologic principles, and clinical experience. An algorithm outlining a clinical approach to the ICU patient with complex intra-abdominal infection is presented.
... Enteric gram-negative organisms including E. coli, klebsiella and Enterobacteriaceae are the most common causative agents for primary and secondary peritonitis. 364,365 Other organisms include gram-positive bacteria (such as Enterococcus) as well as anaerobes (i.e. Bacteroides). ...
... Bacteroides). 365 Tertiary peritonitis is usually due to opportunistic and nosocomial drug resistant bacteria and fungi. Various organisms reported are Enterococcus, Candida, Staphylococcus and enterobacter. ...
... The antibiotics effective in secondary peritonitis are beta lactam/beta lactamase inhibitors (piperacillintazobactam), quinolones, carbapenems, aminoglycosides and metronidazole. 365,372,373 When enterococci are considered, addition of vancomycin or linezolid is required for a spectrum adequacy rate of more than 95%. 374 The average duration of antibiotic therapy is 10 to 14 days. ...
How to cite this article: Khilnani GC, Zirpe K, Hadda V, Mehta Y, Madan K, Kulkarni A, Mohan A, Dixit S, Guleria R, Bhattacharya P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian Journal of Critical Care Medicine 2019;23 (Suppl 1):1-63.
... IAIs is a wide term that encompasses a number of infectious processes which include peritonitis, diverticulitis, cholecystitis, cholangitis, pancreatitis, chronic liver failure, and intestinal perforation [2]. According to the Infectious Diseases Society of America, complicated IAIs is defined as an infection that extends beyond the wall of a hollow viscous of source into the abdominal cavity while being related with an abscess or peritonitis [3]. Etiology of the organism responsible for the IAI can be conditional, based on the location of the organ originally infected, since the residential Gastrointestinal flora is typically the cause in the IAIs. ...
... For example, infections occurring in the stomach and proximal small intestine mostly involve Gram-positive organisms, whereas those in the distal small intestine involve more Gram-negative aerobic and facultative anaerobic bacilli. Even more distally, infections in the colon consist mainly of obligate anaerobic organisms [3,4]. Management of IAIs requires the involvement of multiple modalities such as surgeries as well as treatment with antimicrobials [5]. ...
Objective: The objective of the study is to find out the resistance pattern of pathogenic organisms isolated from intra-abdominal infection (IAI). Methods: A total of 500 samples were collected from suspected IAIs of patients reporting to the hospital and cultured. Identification of the isolates was done using standard identification protocol. Antimicrobial susceptibility was performed by Kirby-Bauer disc diffusion method and interpretation was done using Central Laboratory Standard Institute guidelines. Results: Out of 500 samples, 170 were culture positive and 330 showed no growth. Gram-negative organisms (n=127) outnumbered the Gram-positive organisms (n=23). Among the Gram-negative organisms, Escherichia coli (n=67) was the most commonly isolated bacilli followed by Klebsiella sp. (n=32), Pseudomonas sp. (n=25), Acinetobacter baumannii (n=18), and Klebsiella oxytoca (n=05). Among Gram-positive organisms Staphylococcus aureus (n=17) and Enterococcus spp (n=06) isolates of were grown in culture. Among Gram-negative bacilli, Imipenem followed by Gentamicin was the most effective drug but in Acinetobacter spp. The second most effective drug was Tigecycline. Among Gram-positive isolates, Linezolid was the most effective drug. Conclusion: Prompt starting of empirical antimicrobials based on the local susceptibility pattern, followed by modification of treatment in accordance with the antimicrobial susceptibility report can significantly reduce the morbidity and the mortality associated with IAIs.
... IAIs is a wide term that encompasses a number of infectious processes which include peritonitis, diverticulitis, cholecystitis, cholangitis, pancreatitis, chronic liver failure, and intestinal perforation [2]. According to the Infectious Diseases Society of America, complicated IAIs is defined as an infection that extends beyond the wall of a hollow viscous of source into the abdominal cavity while being related with an abscess or peritonitis [3]. Etiology of the organism responsible for the IAI can be conditional, based on the location of the organ originally infected, since the residential Gastrointestinal flora is typically the cause in the IAIs. ...
... For example, infections occurring in the stomach and proximal small intestine mostly involve Gram-positive organisms, whereas those in the distal small intestine involve more Gram-negative aerobic and facultative anaerobic bacilli. Even more distally, infections in the colon consist mainly of obligate anaerobic organisms [3,4]. Management of IAIs requires the involvement of multiple modalities such as surgeries as well as treatment with antimicrobials [5]. ...
Objective: The objective of the study is to find out the resistance pattern of pathogenic organisms isolated from intra-abdominal infection (IAI). Methods: A total of 500 samples were collected from suspected IAIs of patients reporting to the hospital and cultured. Identification of the isolates was done using standard identification protocol. Antimicrobial susceptibility was performed by Kirby-Bauer disc diffusion method and interpretation was done using Central Laboratory Standard Institute guidelines. Results: Out of 500 samples, 170 were culture positive and 330 showed no growth. Gram-negative organisms (n=127) outnumbered the Gram-positive organisms (n=23). Among the Gram-negative organisms, Escherichia coli (n=67) was the most commonly isolated bacilli followed by Klebsiella sp. (n=32), Pseudomonas sp. (n=25), Acinetobacter baumannii (n=18), and Klebsiella oxytoca (n=05). Among Gram-positive organisms Staphylococcus aureus (n=17) and Enterococcus spp (n=06) isolates of were grown in culture. Among Gram-negative bacilli, Imipenem followed by Gentamicin was the most effective drug but in Acinetobacter spp. The second most effective drug was Tigecycline. Among Gram-positive isolates, Linezolid was the most effective drug. Conclusion: Prompt starting of empirical antimicrobials based on the local susceptibility pattern, followed by modification of treatment in accordance with the antimicrobial susceptibility report can significantly reduce the morbidity and the mortality associated with IAIs.
... Infections can also occur if the bowel wall integrity is compromised, for example, by ischemia or trauma. 2,3 As for adults, general treatment principles for cIAIs in children involve surgical or percutaneous radiologic intervention followed by antimicrobial therapy 4 and the recommended regimens, including aminoglycosides, carbapenems, β-lactam/β-lactamase inhibitor combination or advanced-generation cephalosporins. 4 Moxifloxacin (MXF) is a fourth-generation fluoroquinolone antimicrobial with good in vitro activity against most causative organisms involved in cIAIs. ...
... The mean (range) duration of treatment was 8.7 (1-24) days for MXF and 8.7 (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14) days for COMP. The mean (range) duration of intravenous treatment was 6.2 (1-15) days for MXF and 6.3 (1-14) days for COMP, and oral treatment was 4.4 (1-12) days for MXF and 4.3 (1-11) days for COMP, respectively. ...
Background:
This study was designed to evaluate primarily the safety and also the efficacy of moxifloxacin (MXF) in children with complicated intra-abdominal infections (cIAIs).
Methods:
In this multicenter, randomized, double-blind, controlled study, 451 pediatric patients aged 3 months to 17 years with cIAIs were treated with intravenous/oral MXF (N = 301) or comparator (COMP, intravenous ertapenem followed by oral amoxicillin/clavulanate; N = 150) for 5 to 14 days. Doses of MXF were selected based on the results of a Phase 1 study in pediatric patients (NCT01049022). The primary endpoint was safety, with particular focus on cardiac and musculoskeletal safety; clinical and bacteriological efficacy at test of cure were also investigated.
Results:
The proportion of patients with adverse events (AEs) was comparable between the two treatment arms (MXF: 58.1% and COMP: 54.7%). The incidence of drug-related AEs was higher in the MXF arm than the COMP arm (14.3% and 6.7%, respectively). No cases of QTc interval prolongation-related morbidity or mortality were observed. The proportion of patients with musculoskeletal AEs was comparable between treatment arms; no drug-related events were reported. Clinical cure rates were 84.6% and 95.5% in the MXF and COMP arms, respectively, in patients with confirmed pathogen(s) at baseline.
Conclusions:
MXF treatment was well tolerated in children with cIAIs. However, a lower clinical cure rate was observed with MXF treatment compared with COMP. This study does not support a recommendation of MXF for children with cIAIs when alternative more efficacious antibiotics with better safety profile are available.
... Diagnosis and decisions in all patients regarding ICU admission, medical treatments, source control measures of infection, and surgery needs (e.g., drainage of abscesses/ collections of infected fluid, debridement of necrotic infected tissue) were evaluated daily by the attending ICU physicians and by the surgical team, in accordance with current recommendations [4]. Antibiotic use and microbiologic data were reviewed daily by the investigators. ...
... Data on ICU admission and during ICU stay were extracted from the medical record of each patient and recorded prospectively in a database. Variables were selected and agreed on by the authors based on those from previous studies [2][3][4][5][6][7][8]. The following information was recorded within 24 hours of ICU admission: Demographic data, medical history and co-morbidities, inflammatory response and arterial lactate (on ICU admission), surgical indication and type of surgical procedure on hospital admission (scheduled or urgent), surgical technique, intra-operative variables such as number of drainages, microbiologic findings, and treatment characteristics. ...
Background:
Critically ill surgical patients remain at a high risk of adverse outcomes as a result of secondary peritonitis (SP). The risk is even higher if tertiary peritonitis (TP) develops. Factors related to the development of TP, however, are scarce in the literature. The main aim of our study was to identify factors associated with the development of TP in patients with SP in the intensive care unit (ICU), and also to report differences in microbiologic patterns and antibiotic therapy in patients with the two conditions.
Patients and methods:
A prospective, observational study was conducted at our institution from 2010 to 2014. Baseline characteristics on admission, outcomes, microbiologic results, and antibiotic therapy were recorded for analysis.
Results:
We included 343 patients with SP, of whom TP developed in 185 (53.9%). Almost two-thirds (64.4%) were male; mean age was 63.7???14.3 years, and mean APACHE was 19.4???7.8. In-hospital death was 42.6% (146). Multivariable analysis showed that longer ICU stay (odds ratio [OR]: 1.019; 95% confidence interval [CI]: 1.004-1.034; p?=?0.010), urgent operation on hospital admission (OR: 3.247; 95% CI: 1.392-7.575; p?=?0.006), total parenteral nutrition (TPN) (OR: 3.079; 95% CI: 1.535-6.177; p?=?0.002) and stomach-duodenum as primary infection site (OR: 4.818; 95% CI: 1.429-16.247; p?=?0.011) were factors associated with the development of TP, whereas patients with localized peritonitis were less prone to have TP develop (OR: 0.308; 95% CI: 0.152-0.624; p?=?0.001). Higher incidences of Candida spp. (OR: 1.275; 95% CI: 1.096-1.789; p?=?0.016), Enterococcus faecium (OR: 1.085; 95% CI: 1.018-1.400; p?=?0.002), and Enterococcus spp. (OR: 1.370; 95% CI: 1.139-1.989; p?=?0.047) were found in TP, and higher rates of cephalosporin use in SP (OR: 3.51; 95% CI: 1.139-10.817; p?=?0.035).
Conclusions:
Complicated peritonitis remains a cause of a high numbers of deaths in the ICU. The need for TPN, urgent operation on hospital admission, and particularly surgical procedures in the proximal gastrointestinal tract were factors associated with development of TP and may potentially help to identify patients with SP at risk for development of TP. Physicians should be aware concerning multi-drug-resistant germs when treating these patients.
... Source control has been summarized as drainage of infected fluid collections, debridement of necrotic infected tissue, and definitive measures to control contamination and restore normal gastrointestinal anatomy and function [34]. Source control should not only reduce bacterial and toxin load by removing the focus of infection and ongoing contamination, but also transform the local environment such that further microbial growth is impeded and host defenses can be optimized [126][127][128][129][130]. Studies of patients with IAI have demonstrated repeatedly that a failure to obtain adequate source control is one of the factors most strongly associated with an adverse outcome, including death (Supplementary Table B; see online supplementary [37,48,51,61,71,84]. ...
... To provide adequate antimicrobial therapy to higher-risk patients, use of broad-spectrum empiric antimicrobial regimens is recommended [4,6,13,127]. To avoid excessive exposure of the patient to broad-spectrum antimicrobial therapy and potential selection of further resistant microorganisms, however, de-escalation of therapy based on culture results is also recommended [4,6,[196][197][198]. ...
Background: Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.
Methods: Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.
Results: This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.
Summary: The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.
... Only infections with microbiological confirmation and antibiotic susceptibility testing available were included in the current analysis. Each episode was diagnosed by the physician according to international guidelines (Marshall and Innes, 2003;O'Grady et al., 2011;Centers for Disease Control and Prevention [CDC], 2023) details are reported in the Supplementary materials. ...
Introduction
In patients admitted to intensive care units (ICUs), Gram-negative bacteria (GNB) infections pose significant challenges due to their contribution to morbidity, mortality, and healthcare costs. During the SARS-CoV-2 pandemic, Italy witnessed a rise in healthcare-associated infections (HAIs), with GNBs involved in a substantial proportion of cases. Concerningly, carbapenem-resistant GNBs (CR-GNBs) have increased worldwide, posing therapeutic challenges.
Methods
Retrospective multicentre study analysing data from over 299,000 patients admitted to Italian ICUs from 2013 to 2022.
Results
The study revealed an average of 1.5 infections per patient, with HAIs peaking during the pandemic years. Ventilator associated pneumonia (VAP) emerged as the most common HAI, with Klebsiella spp. and Pseudomonas aeruginosa predominating. Alarmingly, CR-GNBs accounted for a significant proportion of infections, particularly in VAP, bloodstream infections, and intra-abdominal infections.
Discussion
Our findings underscore the pressing need for enhanced infection control measures, particularly in the ICU setting, to mitigate the rising prevalence of CR-GNBs and their impact on patient outcomes. The study provides valuable insights into the epidemiology of HAIs in Italian ICUs and highlights the challenges posed by CR-GNBs, especially in the context of the SARS-CoV-2 pandemic, which exacerbated the issue and may serve as a crucial example for the management of future viral pandemics.
... Jansson and colleagues thus postulated that peritoneal cytokines in humans respond more extensively compared to systemic cytokine, and that a normal postoperative course is characterized by decreasing levels of peritoneal cytokines based on studies of both elective and emergency surgery [109]. Overall, the peritoneal cytokine response is much higher than the systemic response in peritonitis [107,[110][111][112]. Hendriks and colleagues demonstrated that peritoneal cytokine levels (especially IL-6, TNF-α [113], and IL-10) were dramatically different in rats who either survived or succumbed to an IAS model in the 24 h after cytokine determination [110]. Finally, recent work suggests that blood filters designed to hemofiltrate blood endotoxins and cytokines may improve hemodynamics, organ dysfunction and even mortality in the critically ill [114][115][116][117]. ...
Background
Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) (https://clinicaltrials.gov/ct2/show/NCT03163095). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.
Methods
The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.
Discussion
OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of “damage control”; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.
Trial registration: National Institutes of Health (https://clinicaltrials.gov/ct2/show/NCT03163095).
... It was followed by aerobic Gram-positive bacteria in 22.7% and 28.4%, anaerobic bacteria in 7.7% and 11.3%, and fungi in 6.4% and 10.1% cases, respectively [20,21]. were also more commonly isolated in tertiary intra-abdominal infections associated with healthcare-associated infections [35]. ...
The guidelines are intended to provide practical information for the correct use of antibiotics for intra-abdominal infections in Korea. With the aim of realizing evidence-based treatment, these guidelines for the use of antibiotics were written to help clinicians find answers to key clinical questions that arise in the course of patient care, using the latest research results based on systematic literature review. The guidelines were prepared in consideration of the data on the causative pathogens of intra-abdominal infections in Korea, the antibiotic susceptibility of the causative pathogens, and the antibiotics available in Korea.
... Most pathogenic microorganisms responsible for panperitonitis are gram-negative bacilli. 32 Conversely, pneumonia-causing pathogenic microorganisms, particularly those that cause community-acquired pneumonia, are nonbacterial or gram-positive cocci 33 that do not produce endotoxins. 34 Infections caused by gram-negative bacilli have a larger quantity of endotoxin production than those caused by nonbacterial or gram-positive cocci 35 ; additionally, endotoxins induce cytokine production. ...
Background:
The acrylonitrile-co-methallyl sulfonate surface-treated (AN69ST) membrane has cytokine adsorption capacity and is used for treating sepsis. This study aimed to compare the effects of continuous renal replacement therapy (CRRT) using the AN69ST membrane with those of CRRT using other membranes for patients with pneumonia-associated sepsis.
Methods:
This retrospective, propensity score-matched, cohort study was based on a nationwide Japanese inpatient database. We included data from adults hospitalized with a primary diagnosis of pneumonia, who received CRRT using either the AN69ST membrane or another membrane within 2 days of admission, and who were discharged from the hospitals between September 2014, and March 2017. Propensity score matching was used to compare in-hospital mortality between the two groups.
Results:
Eligible patients (N = 2,393) were categorized into an AN69ST group (N = 631) and a non-AN69ST group (N = 1,762). The overall in-hospital mortality rate was 38.9%. Among the 545 propensity-matched patient pairs, the in-hospital mortality rate was significantly lower in the AN69ST group than in the non-AN69ST group (35.8 vs. 41.8%, P = 0.046).
Conclusions:
Among patients with pneumonia-associated sepsis treated with CRRT, CRRT with the AN69ST membrane was associated with a significantly lower in-hospital mortality than CRRT with standard membranes.
... -Les recommandations préconisent un débridement complet des tissus ischémiques, nécrosés, infectés, etc., associé à un lavage abondant et parfois des drainages en plus du traitement de la cause [125,126] ...
Titre : Antibiothérapie en chirurgie digestive
Auteur : El Faria Walid
Mots clé : Antibiotique- Microbiote intestinal- Antibioprophylaxie- Antibiothérapie curative-
Chirurgie digestive.
Une nouvelle ère de prise en charge des pathologies chirurgicales digestive s’est ouverte avec l’avènement des antibiotiques qui sont devenus indispensable dans le traitement de plusieurs pathologies.
La diversité du microbiote du tube digestif rend le choix d’antibiotique, qu’il soit en prophylactique qu’en curatif, complexe. La densité bactérienne augmente progressivement depuis l’estomac jusqu’au colon, et les espèces bactériennes varient en fonction des caractéristiques physiologiques de l’organe en question.
Avant chaque intervention chirurgicale, la première préoccupation du chirurgien est l’asepsie, ainsi il doit se poser la question sur l’indication de l’antibioprophylaxie, en se référant à la classification d’Altemeier, en prenant en considération le terrain du patient et en respectant les règles d’hygiène générale.
Certaines pathologies chirurgicales digestives sont d’origine infectieuse et relèvent donc d’une antibiothérapie curative. Le choix de l’antibiotique dans ce cas se basent sur l’écologie bactérienne de l’organe infecté, ainsi que des données microbiologiques sur les germes les fréquemment en cause de l’infection en question. L’antibiotique est généralement administré de façon empirique puis adapté après l’obtention des résultats de l’étude bactériologique.
Certes, l’antibiothérapie constitue un pilier irremplaçable dans la prise en charge de plusieurs pathologies en chirurgie viscérale, cependant l’intervention chirurgicale reste indispensable dans la plupart des cas.
Chaque structure hospitalière doit disposer d’un comité référant en antibiothérapie, veillant sur le respect des recommandations d’usage des antibiotiques et assurant la notification et la surveillance des phénomènes de résistance bactérienne aux antibiotiques.
... Infection of the ascitic fluid is a serious complication associated with high morbidity and mortality [3]. Abdominal infections are among the most common infections in the intensive care unit (ICU) [4], and they carry a substantial increase in the risk of mortality [5,6]. ...
Objectives:
Infections of the ascitic fluid are serious conditions that require rapid diagnosis and treatment. Ascites is often accompanied by other critical pathologies such as gastrointestinal bleeding and bowel perforation, and infection increases the risk of mortality in intensive care patients. Owing to a relatively low success rate of conventional culture methods in identifying the responsible pathogens, new methods may be helpful to guide antimicrobial therapy and to refine empirical regimens. Here, we aim to assess outcomes and to identify responsible pathogens in ascitic fluid infections, in order to improve patients' care and to guide empirical therapy.
Methods:
Between October 2019 and March 2021, we prospectively collected 50 ascitic fluid samples from ICU patients with suspected infection. Beside standard culture-based microbiology methods, excess fluid underwent DNA isolation and was analyzed by next- and third-generation sequencing (NGS) methods.
Results:
NGS-based methods had higher sensitivity in detecting additional pathogenic bacteria such as E. faecalis and Klebsiella in 33 out of 50 (66%) ascitic fluid samples compared with culture-based methods (26%). Anaerobic bacteria were especially identified by sequencing-based methods in 28 samples (56%), in comparison with only three samples in culture. Analysis of clinical data showed a correlation between sequencing results and various clinical parameters such as peritonitis and hospitalization outcomes.
Conclusions:
Our results show that, in ascitic fluid infections, NGS-based methods have a higher sensitivity for the identification of clinically relevant pathogens than standard microbiological culture diagnostics, especially in detecting hard-to-culture anaerobic bacteria. Patients with such infections may benefit from the use of NGS methods by the possibility of earlier and better targeted antimicrobial therapy, which has the potential to lower the high morbidity and mortality in critically ill patients with ascitic bacterial infection.
... SBR is a rare cause of secondary peritonitis, which needs to be differentiated from primary peritonitis (such as spontaneous bacterial peritonitis) and tertiary peritonitis (such as intra-abdominal abscess) [1][2][3][4][5]11,18]. Accurate diagnosis and treatment for SBR are important; however, if left undiagnosed and untreated, SBR is a recurring condition, leading to a poor prognosis [19]. ...
Since generalized peritonitis is a fatal disease, accurate diagnosis and treatment are important. In this paper, we report a case of recurrent generalized peritonitis associated with spontaneous urinary bladder rupture (SBR). A 65 year old woman, who underwent radiotherapy 21 years prior, was diagnosed with generalized peritonitis. Although the cause of the generalized peritonitis could not be identified, the patient recovered with conservative treatment in short period. However, recurrent episodes of generalized peritonitis occurred four times. We diagnosed the patient with urinary ascites due to SBR, based on a history of radiotherapy and dysuria. No recurrence of generalized peritonitis had occurred after accurate diagnosis and treatment with long-term bladder catheter placement. Since SBR often occurs as a late complication after radiotherapy, it is difficult to diagnose SBR, which leads to delayed treatment. This case and literature review of similar cases suggest that the information of the following might be helpful in the diagnosis of SBR: (i) history of recurrent generalized peritonitis, (ii) pseudo-renal failure, (iii) history of radiotherapy, (iv) dysuria, and (v) increase or decrease of ascites in a short period. It is important to list SBR in the differential diagnosis by knowing the disease and understanding its clinical features. This case and literature review will serve as a reference for future practices.
... Abdominal sepsis is associated with significant morbidity and mortality due to multiorgan failure caused by systemic inflammatory response [1][2][3]. In abdominal sepsis, a local source such as hollow organ perforation or mesenteric ischemia results in local and systemic inflammatory response. ...
Objectives
Open abdomen technique with negative pressure therapy (NPT) is widely used in patients with severe abdominal sepsis. The aim of this study was to evaluate cytokine clearance in serum and peritoneal fluid during NPT.
Methods
This prospective pilot study included six patients with severe abdominal sepsis requiring discontinuity resection and NPT for 48 h followed by planned reoperation. Cytokines (IL6, IL8, IL10, TNFalpha, and IL1beta) were measured in the serum and peritoneal fluid during index operation, on postoperative days 0, 1, and 2.
Results
Concentrations of cytokines in peritoneal fluid were higher than in serum. IL10 showed a clearance both in serum (to 16.6%, p=0.019) and peritoneal fluid (to 40.9%, p=0.014). IL6 cleared only in serum (to 24.7%, p=0.001) with persistently high levels in peritoneal fluid. IL8 remained high in both serum and peritoneal fluid. TNFalpha and IL1beta were both low in serum with wide range of high peritoneal concentrations. Only TNFalpha in peritoneal fluid showed significant differences between patients with ischemia vs. perforation (p=0.006).
Conclusions
The present pilot study suggests that cytokines display distinct patterns of clearance or persistence in the peritoneal fluid and serum over the first 48 h of treatment in severe abdominal sepsis with NPT.
... study also differ from those of patients in the previous study. The majority of pathogenic microorganisms responsible for panperitonitis are gram-negative bacilli, which produce endotoxin [38]. On the other hand, pathogenic microorganisms causing pneumonia, particularly those that cause community-acquired pneumonia, are non-bacterial or gram-positive cocci, which do not produce endotoxins [39,40]. ...
Background: Cytokine removal therapy is one of the available therapies for sepsis. Acrylonitrile-co-methallyl sulfonate surface-treated (AN69ST, sepXiris®) membrane has cytokine adsorption capacity and has been widely used for treating sepsis in Japan. The aim of this study was to compare the effects of continuous renal replacement therapy (CRRT) with AN69ST membrane and conventional CRRT for patients with pneumonia-associated sepsis.
Methods: We conducted a retrospective cohort study using the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan. We identified adult patients who were hospitalized due to pneumonia and received CRRT within 2 days of admission from September 2014 to March 2017. We included patients who received CRRT with AN69ST membrane within 2 days of admission in the treatment group (AN69ST group); those who received CRRT with other membranes within 2 days of admission were included in the control group (non-AN69ST group). Propensity score matching was used to compare in-hospital mortality between the two groups.
Results: Eligible patients (n=2,393) were categorized into the AN69ST group (n=631) or the non-AN69ST group (n=1,762). The overall in-hospital mortality rate in pneumonia patients treated with CRRT was 38.9%. Propensity score matching created a matched cohort of 545 pairs of patients. The in-hospital mortality rate was significantly lower in the AN69ST group than in the non-AN69ST group (35.8 vs. 41.8%, p=0.046).
Conclusion: Our data suggest that CRRT with the AN69ST membrane was associated with a significantly lower in-hospital mortality than CRRT with standard membranes among patients with pneumonia-associated sepsis.
... Intra-abdominal infections are an important cause of ICU morbidity and mortality. Peritonitis develops as complication in 30% of the human patients with intra-abdominal infection in the ICU, increasing the mortality rates up to 50% (Delibegovic et al., 2011;Marshall and Innes, 2003). In veterinary medicine, peritonitis is a major problem in the ICU but there is no study to correlate this with the outcome of a case. ...
In the last decade, attempts to improve the quality of the services provided to the critically ill patients in the Intensive Care Unit (ICU) are of great interest in human medicine. The aim of the majority of the clinical studies is the correlation of the survival rate of a critically ill patient with specific prognostic factors at the time of admission. The detailed assessment of a patient at admission in the ICU and during hospitalization seems to affect the management and the outcome. The main aim of this study was to evaluate if the trans-diaphragmatic pressure measurement can be a prognostic factor of the outcome in the ICU in dogs. Thirty-one dogs, 21 male and 10 female was included in this prospective, cohort study. Age, breed, sex, body weight and clinical diagnosis were recorded. The type of admission, the mentation status, physiological and biochemical parameters were measured at the admission of the dog in the ICU. All the variables were assessed over the first 24 hours following ICU admission. The animals were allocated into sixgroups: peritonitis/intra-abdominal surgery, intra-thoracic surgery, respiratory disease, neurologic disease, neoplasia, and systematic disease. The trans-diaphragmatic pressure (Pdi) was measured under the same anesthetic level in all animals with two oesophageal balloon catheters. The most frequent problem for admission in ICU was peritonitis (5/31). Seventeen out of 31 were admitted in acute status while 14/31 had a chronic problem. Mean±standard deviation of Pdi was 10.7±5.6 mmHg and of lactate concentration 2.3±1.2 mmol/L. Both, they can predict outcome (p=0.071 and p=0.076, respectively). Seven out of 31 dogs died, 2 were euthanized and 22 were discharged from the ICU after hospitalization. The technique of Pdi measurement with balloon catheters can be successfully applied in dogs in the ICU. Pdi measurement, as well as lactate concentration may be used as prognostic indicators for the outcome, in dogs in the ICU. However, a bigger sample size is need to support these findings.
... Intra-abdominal infections are an important cause of ICU morbidity and mortality. Peritonitis develops as complication in 30% of the human patients with intra-abdominal infection in the ICU, increasing the mortality rates up to 50% (Delibegovic et al., 2011;Marshall and Innes, 2003). In veterinary medicine, peritonitis is a major problem in the ICU but there is no study to correlate this with the outcome of a case. ...
... In addition, sepsis and the mortality rate are very high (Brocco,2012). Although the mortality rate is 30% in primary IE, it is approximately 50% in recurrent cases (Marshall and Innes, 2003). At first, local peritonitis develops into IE and its eradication is often facilitated by local inflammatory mechanisms during this stage of the pathological process. ...
The aim of this study was to determine efficiency of a new molecule that was obtained by linking boric acid with ampicillin in treating intra-abdominal infection.Following intraperitoneal E. coli injection totwenty-one female Wistar albino rats, group 1 was administered boron-linked ampicillin, group 2 was administered only ampicillin and group 3 was injected intraperitoneally with physiological serum. IL-6, and a white blood cell analysis was performed from the blood before and on the seventh day of treatment.No statistically significant difference in blood WBC levels after treatment was found among the groups. There was no statistically significant difference in the IL-6 values of group 2 and group 3 before and after the treatment (p=0.195 and 0.193, respectively); however, the reduction in the serum IL-6 values of group 1 was statistically significant (p=0.003).Boric acid-linked ampicillin is a more effective intra-abdominal infection treatment compared with ampicillin alone. © 2019 Pakistan Journal of Pharmaceutical Sciences. All Rights Reserved.
... Una vez practicada una laparotomía para resolver el foco séptico, se presenta uno de los principales retos: ¿el proceso séptico está controlado?, ¿será necesaria una nueva laparotomía? Por lo anterior, es indispensable contar con estrategias que permitan responder estas incógnitas con el objetivo de disminuir la morbilidad y la mortalidad asociadas a la sepsis grave y al choque séptico de origen abdominal, optimizar los medios de tratamiento disponibles (resultando en una disminución de los costos para las instituciones de salud) y finalmente tratar de homogeneizar cuándo y en qué paciente debe plantearse una nueva intervención quirúrgica por persistencia o desarrollo de un evento de sepsis abdominal 3 . Las dos principales estrategias de reintervención en la sepsis de origen abdominal son la laparotomía exploradora a demanda y la programada. ...
Introduction:
It is crucial the timely detection of a new infection or the persistence of it to improve the survival rates, there is no index that can determine the need for relaparotomy.
Objective:
To evaluate the diagnostic certainty of the model elaborated by Kiewiet-Van Ruler.
Method:
A retrospective, descriptive, cross-sectional study, patients diagnosed with abdominal sepsis who underwent exploratory laparotomy between January 2013 to and May 2015.
Results:
We included 109 patients, 63 male patients and 46 female patients. Mortality of 16.5%. 68 cases had a score lower than or equal to 19, of which 17 -patients (43%) did need to reoperate. The second group with a score higher than 20 was 41 patients, of which 22 (56%) required reoperation. In the individual analysis of the variables, a significant value was determined in five of them, with p < 0.05. Only one variable (hemoglobin < 8.1 mg/dl) in the chi-square test and confidence interval was not significant and I do not help so much to predict reoperation.
Conclusions:
The utility of the model proposed by Kiewiet-Van Ruler results in an acceptable prediction value for re laparotomy.
... [29][30][31][32] Gut perforation seems to be the major cause of surgical patients to be admitted into the ICU, as the past literature showed the infectious component as main culprit of mortality despite the role for early nutritional intervention. 33,34 ...
... These measures should be instituted immediately on initial assessment of the patient and continued throughout the operative and post- operative period. Septic patients may require invasive monitoring with inotropic support and mechanical ventilation if these are available [5][6] . ...
p> Background : Control of the primary site of sepsis is the main determinant of good surgical outcome.
Objective : The purpose of the present study was to compare the efficiency between povidone iodine and normal saline lavage in the treatment of acute peritonitis.
Methodology : This was a randomized clinical trial conducted in the Department of Surgery at Dhaka Medical College & Hospital, Dhaka, Bangladesh. Patients with acute peritonitis due to gastrointestinal causes who were admitted in the different units of Dhaka Medical College Hospital during the study period were selected as study population. Among them patients who were treated with povidone iodine were enrolled in the present study in group A and patients who were treated with conventional normal saline were in group B.
Results : A total number of 1050 patients were recruited for this study. Among them 100 patients were enrolled in the present study of which group A (50 patients) for povidone iodine and group B (50 patients) for conventional normal saline. On 7 th POD wound infection was found in Group A and Group B were 11(22.4%) and 21(44.7%) respectively. Statistically significant difference in post operative complication of wound infection was observed on 7 th POD between the groups (p<0.05). Post operative hospital stay in Group A and Group B were 11.50 ± 4.48 and 13.46 ± 5.13 days respectively. There is statistically significant difference in post operative hospital stay between the groups (p<0.05).
Conclusion : Statistically significant difference observed in post operative complication of wound infection and burst abdomen on 7 th POD between the groups. The present study there is statistically significant difference in post operative hospital stay between the groups also observed.
Bangladesh Journal of Infectious Diseases 2017;4(1):15-20
</p
... Overall, the peritoneal cytokine response is much higher than the systemic response in peritonitis [81, [84][85][86]. Hendriks demonstrated that peritoneal cytokine levels (especially IL-6, TNF-α [87], and IL-10) were dramatically different in rats who either survived or succumbed to an intra-peritoneal sepsis model in the 24 h after cytokine determination [84]. Finally, the recent work suggests that blood filters designed to hemofiltrate blood endotoxins and cytokines may improve hemodynamics, organ dysfunction, and even mortality in the critically ill [88][89][90][91]. ...
Background
Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. Principles of treatment include early antibiotic administration and operative source control. A further therapeutic option may be open abdomen (OA) management with active negative peritoneal pressure therapy (ANPPT) to remove inflammatory ascites and ameliorate the systemic damage from SCIAS. Although there is now a biologic rationale for such an intervention as well as non-standardized and erratic clinical utilization, this remains a novel therapy with potential side effects and clinical equipoise.
Methods
The Closed Or Open after Laparotomy (COOL) study will constitute a prospective randomized controlled trial that will randomly allocate eligible surgical patients intra-operatively to either formal closure of the fascia or use of the OA with application of an ANPTT dressing. Patients will be eligible if they have free uncontained intra-peritoneal contamination and physiologic derangements exemplified by septic shock OR a Predisposition-Infection-Response-Organ Dysfunction Score ≥ 3 or a World-Society-of-Emergency-Surgery-Sepsis-Severity-Score ≥ 8. The primary outcome will be 90-day survival. Secondary outcomes will be logistical, physiologic, safety, bio-mediators, microbiological, quality of life, and health-care costs. Secondary outcomes will include days free of ICU, ventilation, renal replacement therapy, and hospital at 30 days from the index laparotomy. Physiologic secondary outcomes will include changes in intensive care unit illness severity scores after laparotomy. Bio-mediator outcomes for participating centers will involve measurement of interleukin (IL)-6 and IL-10, procalcitonin, activated protein C (APC), high-mobility group box protein-1, complement factors, and mitochondrial DNA. Economic outcomes will comprise standard costing for utilization of health-care resources.
Discussion
Although facial closure after SCIAS is considered the current standard of care, many reports are suggesting that OA management may improve outcomes in these patients. This trial will be powered to demonstrate a mortality difference in this highly lethal and morbid condition to ensure critically ill patients are receiving the best care possible and not being harmed by inappropriate therapies based on opinion only.
Trial registration
ClinicalTrials.gov, NCT03163095.
... There are some promising biomarkers for sepsis that are currently used for relatively few diagnostic purposes [10]. Studies are aimed to find a single marker at low cost, that can be measured quickly, to repeat measurement easy, and that measurement does not cause disturbances in patients [11]. From this group of biomarkers, CRP and PCT are most commonly used in clinical practice [10]. ...
AIM: To analyse the correlation of procalcitonin (PCT) and C-reactive protein (CRP) values with increased intra-abdominal pressure and to evaluate their predictive role in the progression of Intra-abdominal infections.
MATERIALS AND METHODS: A non-randomized prospective study conducted in the group of 80 patients. We have measured the PCT, CRP and intra-abdominal pressure (IAP).
RESULTS: According to IAH grades (G), there was a significant difference of PCT values: G I 3.6 ± 5.1 ng/ml, G II 10.9 ± 22.6 ng/ml, G III 15.2 ± 30.2 ng/ml (p = 0.045) until CRP values were increased in all IAH groups but without distinction between the groups: GI 183 ± 64.5, GII 196 ± 90.2, GIII 224 ± 96.3 (p = 0.17). According to the severity of the infection, we yielded increased values of PCT, IAP and CRP in septic shock, severe sepsis and SIRS/sepsis resulting in significant differences of PCT and IAP.
CONCLUSION: Based on the results of our research, we conclude that the correlation of PCT values with IAH grades is quite significant while the CRP results remain high in IAH but without significant difference between the different grades of IAH.
... Medical emergencies, including upper (variceal and non-variceal) and lower gastrointestinal bleeding, acute liver failure, severe sepsis/ septic shock, and respiratory insufficiency, occur frequently in patients admitted to gastroenterology wards [1][2][3][4][5]. Several risk assessment and scoring systems have been developed for upper gastrointestinal bleeding [1,2,6] and advanced liver disease [7]. ...
Purpose:
To compare the ability of a score based on vital signs and laboratory data with that of the modified early warning score (MEWS) to predict ICU transfer of patients with gastrointestinal disorders.
Materials and methods:
Consecutive events triggering medical emergency team activation in adult patients admitted to the gastroenterology wards of the Asan Medical Center were reviewed. Binary logistic regression was used to identify factors predicting transfer to the ICU. Gastrointestinal early warning score (EWS-GI) was calculated as the sum of simplified regression weights (SRW).
Results:
Of the 1219 included patients, 468 (38%) were transferred to the ICU. Multivariate analysis identified heart rate≥105bpm (SRW 1), respiratory rate≥26bpm (SRW 2), ACDU (Alert, Confused, Drowsy, Unresponsive) score≥1 (SRW 2), SpO2/FiO2 ratio<240 (SRW 2), creatinine ≥2.0mg/dL (SRW 2), total bilirubin ≥9.0mg/dL (SRW 2), prothrombin time/international normalized ratio (INR) ≥1.5 (SRW 2), and lactate ≥3.0mmol/L (SRW 2) for inclusion in EWS-GI. The area under the receiver operating characteristic curve of the EWS-GI was larger than that of MEWS (0.76 vs. 0.64; P<0.001).
Conclusions:
EWS-GI may predict ICU transfer among patients admitted to gastroenterology wards. The EWS-GI should be prospectively validated.
... Die häufigsten Erreger bei der sekundären, postoperativen Peritonitis (nach [40,49] ...
... Approximately 30% mortality rates have been reported in ICU patients with intra-abdominal infections. 1 Imageguided percutaneous catheter drainage (PCD) is now treatment of choice for management of abdominal abscesses and the fluid collections. The procedure involves percutaneous placement of a catheter into an abdominal collection or abscess with the help of imaging guidance. ...
· Background: Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL-trial)(https://clinicaltrials.gov/ct2/show/NCT03163095). Initially, the COOL-trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of patients allocated to the intervention (open) arm. In August 2022, the 3M/Acelity Corporation without consultation but within the terms of the contract cancelled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.
· Methods: The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or use of the OA with application of an NPPT dressing. Patients are eligible if they have free uncontained intra-peritoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.
· Discussion: OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of ‘damage control’, however improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL-trial trial seeks to expand potential sites and proceed with evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.
· Trial registration: National Institutes of Health (https://clinicaltrials.gov/ct2/show/NCT03163095).
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
Objective:
To assess the association between anatomical location of contamination and mortality in dogs with gastrointestinal and biliary origin of septic peritonitis.
Methods:
Medical records at two private referral hospitals between 2003 and 2020 were retrospectively reviewed. Cases were included if the origin of contamination was confirmed intraoperatively within the gastrointestinal or biliary tract. Cases were excluded if the dog died or was euthanized intraoperatively or where the data regarding the origin of contamination were not available. The association of anatomical origin with survival was assessed specifying the locations as stomach, small intestine, large intestine and biliary tract. The gastrointestinal tract origin was further subdivided into pylorus, nonpylorus, duodenum, jejunum, ileum, caecum and colon.
Results:
The overall survival rate was 75.9% (n = 44/58). There were no significant differences in survival among different anatomical origins of contaminations before or after subdivision (P = 0.349 and 0.832, respectively). Also, there was no association between isolated microorganism species in microbiological culture and the anatomical origin (P = 0.951) and the microorganism species was not associated with survival (P = 0.674).
Conclusions:
There was no association between anatomical location of leakage, microorganism species and survival although further studies are warranted to analyse the relationships between anatomical leakage site and microorganism species as well as microorganism species and mortality.
Background: The acrylonitrile-co-methallyl sulfonate surface-treated (AN69ST) membrane has cytokine adsorption capacity and is used for treating sepsis. This study aimed to compare the effects of continuous renal replacement therapy (CRRT) using the AN69ST membrane with CRRT using other membranes for patients with pneumonia-associated sepsis.
Methods: We conducted a retrospective cohort study using a nationwide Japanese inpatient database. We included data of those adults who were hospitalized with a primary diagnosis of pneumonia and received CRRT using either the AN69ST membrane or another membrane within 2 days of admission and were discharged from the hospitals between September 2014 and March 2017. Propensity-score matching was used to compare in-hospital mortality between the two groups.
Results: Eligible patients (N = 2,393) were categorized into an AN69ST group (N = 631) and a non-AN69ST group (N = 1,762). The overall in-hospital mortality rate was 38.9%. Among the 545 propensity-matched patient pairs, the in-hospital mortality rate was significantly lower in the AN69ST group than in the non-AN69ST group (35.8 vs. 41.8%, P = 0.046).
Conclusions: Among patients with pneumonia-associated sepsis treated with CRRT, CRRT with the AN69ST membrane was associated with a significantly lower in-hospital mortality than CRRT with standard membranes.
Objectives
The objective of this study was to evaluate the relationship between clinical features and the presence of infection on thoracic and abdominal tomography (CT) scans in emergency department (ED) patients with acute febrile illness without apparent source.
Methods
Patients aged 18 years and over who presented to ED with acute fever of unknown origin between January 1, 2020 and December 31, 2020 and underwent CT imaging (thoracic and abdomen) as a diagnostic test were included in the study retrospectively. Acute fever of unknown origin was defined as the absence of a history or physical examination finding that could explain the possible cause of fever, normal values of parameters that would suggest an infection in the urine analysis, and absence of infiltration on chest X-ray. The patients were divided into two groups according to the presence and absence of a source of infection on CT. The clinical and demographic data of the patients were evaluated. The effect of clinical factors on the presence of infection in CT scans was determined using the logistic regression analysis.
Results
Among the 173 patients included in the study, the CT scans were positive for the source of infection in 31.2% (n = 54) and negative in 68.8% (n = 119). In the multiple logistic regression analysis, age ≥ 65 years [odds ratio (OR): 2.72, 95% confidence interval (CI):1.15–4.35, p < 0.001), presence of comorbidity (OR:2.37, 95%CI:1.08–4.14, p = 0.033), and procalcitonin positivity (PCT) (OR: 2.54, 95%CI: 1.29–4.95, p = 0.006) were identified as risk factors for the presence of infection in CT.
Conclusion
Patient's age, presence of comorbidity and PCT level should be considered when deciding on the use of CT in determining the source of infection in acute febrile patients without clinical clues.
Peritonitis is a major killer in practice of clinical surgery. Over the past few decades, the mortality of severe secondary peritonitis (SP) has markedly reduced as a result of increased knowledge of the underlying pathophysiology, aggressive surgical techniques, broad-spectrum antimicrobial agents, and advanced life-support facilities. However, the surgeon not uncommonly encounters a clinical situation in which the abdominal infection persists and multiple organ failure develops despite optimal treatment. This syndrome, so-called tertiary peritonitis (TP), is a severe recurrent or persistent intra-abdominal infection after adequate surgical control of secondary peritonitis and is associated with high mortality. There is significant difference between the microbial flora in tertiary peritonitis and secondary peritonitis and TP comprises of mostly opportunistic and nosocomial facultative pathogenic bacteria and fungi. The development of multidrug resistance has also been observed in microbes causing TP due to use of broad-spectrum antibiotic therapy.
Objectives
Staged surgery (SS) and primary anastomosis (PA) are alternatives to emergency surgery in Crohn's disease (CD). This study aimed to compare postoperative patient outcomes and medical cost of SS and PA for CD emergencies.
Methods
Consecutive patients with CD undergoing emergency surgery between December 1997 and January 2017 in three centers were included. The PA and SS groups were compared regarding patient outcomes including postoperative complications and surgical recurrence, as well as hospitalization costs.
Results
Altogether 96 (39.5%) patients underwent an emergency PA, and 147 (60.5%) underwent an emergency SS. The incidence of intra‐abdominal septic complications (IASC) in the PA group was 15.6% compared with 7.5% in the SS group (P = 0.04). The length of hospitalization was longer (32.36 ± 1.76 d vs 19.33 ± 2.36 d, P <0.01) and the hospitalization cost was higher in the SS group (USD 15 811.1 ± 1697.1 vs USD 8345.3 ± 919.5, P <0.01) than the PA group. SS correlated with a lower surgical recurrence rate than PA (log‐rank test, P = 0.04). Presence of diffuse peritonitis, perforating or colonic disease, decision of operation choice made by a senior consultant and more than two concurrent surgical indications were related to the need for SS in emergencies. Localized peritonitis, body mass index (>18.5 kg/m²) and iatrogenic perforation were significantly associated with a low risk of IASC in the PA group.
Conclusion
SS can be performed with limited IASC and low surgical recurrence rates for surgical emergencies in CD, although it increases hospitalization costs and delays discharge.
How to cite this article: Khilnani GC, Zirpe K Evidence Statement Time-dependent antibiotics require drug concentrations greater than the minimum inhibitory concentration (MIC) for a certain period between doses, which usually ranges from 40 to 50% of the inter-dose interval for their best action. Continuous infusions are preferred over extended infusions for beta-lactam antibiotics and are associated with clinical benefits like a decrease in hospital stay, cost of therapy and mortality. For vancomycin, continuous infusion is associated with reduced toxicity and cost of therapy but no mortality benefit. Evidence Statement Streptococcus pneumoniae, gram-negative bacilli (including klebsiella, Haemophilus influenzae), atypical organisms (Mycoplasma pneumoniae) and viruses (including influenza) are common causes of community-acquired pneumonia (CAP) in intensive care unit (ICU). Staphylococcus aureus, Legionella, and Mycobacterium tuberculosis are less common causes of CAP in ICU. Pseudomonas aeruginosa is an important pathogen causing CAP in patients with structural lung disease. Methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant gram-negative organisms are relatively infrequent causes of CAP in India and are associated with risk factors such as structural lung disease and previous antimicrobial intake. Anaerobic organisms may cause CAP or co-infection in patients with risk factors for aspiration like elderly, altered sensorium, dysphagia, head, and neck malignancy. S. pneumoniae remains sensitive to beta-lactams and macrolides. Haemophilus influenzae has good sensitivity to beta-lactam with beta-lactamase inhibitors and fluoroquinolones. Recent studies show an increasing prevalence of extended spectrum β-lactamase (ESBL) producing Enterobacteriaceae.
Intra-abdominal hypertension has been identified as an independent risk factor for death in critically ill patients. Known risk factors for intra-abdominal hypertension indicate that intra-abdominal pressures should be measured and monitored. The Abdominal Compartment Society has identified medical and surgical interventions to relieve intra-abdominal hypertension or to manage the open abdomen if abdominal compartment syndrome occurs. The purpose of this article is to describe assessments and interventions for managing intra-abdominal hypertension and open abdomen that are within the scope of practice for direct-care nurses. These guidelines provide direction to critical care nurses caring for these patients.
Background:
This study evaluated the antimicrobial susceptibility of pathogens isolated from Korean patients with intraabdominal infections (IAIs).
Methods:
This multicenter study was conducted at 6 university-affiliated hospitals in Korea between 2016 and 2018. All patients with microbiologically proven IAIs were retrospectively included, while patients with spontaneous bacterial peritonitis or continuous ambulatory peritoneal dialysis peritonitis were excluded. Identification and antimicrobial susceptibility testing were performed using automated microbiology systems.
Results:
A total of 2,114 non-duplicated clinical isolates were collected from 1,571 patients. Among these pathogens, 510 (24.1%) were isolated from nosocomial infections, and 848 isolates (40.1%) were associated with complicated IAIs. The distribution of the microorganisms included aerobic gram-negative (62.6% of isolates), aerobic gram-positive (33.7%), anaerobic (0.9%), and fungal (2.8%) pathogens. The most common pathogens were Escherichia coli (23.8%), followed by Enterococcus spp. (23.1%) and Klebsiella spp. (19.8%). The susceptibility rates of E. coli and Klebsiella spp. to major antibiotics were as follows: amoxicillin/clavulanate (62.5%, 83.0%), cefotaxime (61.4%, 80.7%), ceftazidime (63.7%, 83.1%), cefepime (65.3%, 84.3%), ciprofloxacin (56.4%, 86.3%), piperacillin/tazobactam (99.0%, 84.8%), amikacin (97.4%, 98.3%), and imipenem (99.8%, 98.8%). The susceptibility rates of Enterococcus spp. to ampicillin were 61.0%, amoxicillin/clavulanate, 63.6%; ciprofloxacin, 49.7%; imipenem, 65.2%; and vancomycin, 78.2%. The susceptibility rates of Pseudomonas aeruginosa and Acinetobacter spp. to imipenem were 77.4% and 36.7%, respectively.
Conclusion:
Enterococcus spp. with susceptibility to limited antibiotics was one of the main pathogens in Korean IAIs, along with E. coli and Klebsiella spp., which were highly susceptible to imipenem, amikacin, and piperacillin/tazobactam. Meanwhile, the low susceptibilities of E. coli or Klebsiella spp. to amoxicillin/clavulanate, advanced-generation cephalosporins, and ciprofloxacin should be considered when determining empirical antibiotic therapy in clinical practice.
The study of pharmacology enables the principle method of intervention for critically ill patients. Because many variables exists that affect the efficacy and indications for drug intervention, a thorough knowledge of pharmacology is needed in the intensive care unit, just as it is needed in the operating room. Because pharmacology effects every system it may potentially be included in every type of question. In order to achieve a pharmacologic focus, much of this chapter emphasizes and infrequently seen but non-isoteric contact. Overall, chapter is designed to evaluate pharmacologic knowledge with highly clinical vignettes for the reader. Additionally, the reader will find an emphasis on practice pharmacologic elements of managing infectious diseases and complexities of sedation, which anesthesiologists will find reminiscent of the residency training with a critical care “twist”.
Purpose: To investigate the appropriate empirical antibacterial spectrum for lower gastrointestinal perforation. Materials and Methods: A total of 110 lower gastrointestinal perforation cases in which surgery was performed in our hospital between January 2011 and December 2016 were examined retrospectively. The correlation of detecting bacteria species for each perforation site, complication occurrence and outcome was investigated from ascites culture at the time of laparotomy. Result: The detection rates of Escherichia coli and Bacteroides were high regardless of the perforation site. Enterococcus and Klebsiella showed a correlation with the occurrence of complications as a result of univariate analysis. In particular, Klebsiella also showed a correlation with mortality. Conclusion: The appropriate empirical antibacterial spectrum for lower gastrointestinal perforation is considered to cover Escherichia coli, Bacteroides, Klebsiella and Enterococcus. Beta-lactamase inhibitor combinations may be more suitable as monotherapy.
Advanced peritonitis carries a high mortality rate. The mortality rate varies from 45.45 to 58.3% in developing countries. A management protocol was created to treat advanced peritonitis patients, to reduce the mortality rate to less than20%. A prospective study of effectiveness of this management protocol was done in a surgical unit of Gandhi hospital attached to Gandhi medical college secunderabad.
Management protocol incorporated 1. Algorithm for resuscitation based on surviving sepsis guidelines, 2.Preventive measures against the development of abdominal compartment syndrome as per the guidelines of world society of abdominal compartment syndrome 3. Directions for relaparotomy from 2013 WSES guidelines for the management of intraabdominal infections and 4.suggestions for early surgical minimal intervention and post-operative care. The effectiveness of this protocol studied in 25 consecutively selected advanced peritonitis patients during 24 months. All the patients were resuscitated. The measures adopted to prevent abdominal compartment syndrome found to be useful to close the abdomen. Open abdomen method of treatment not required in these patients. Planned relaparotomy was done in one, and on-demand relaparotomy done in two patients. The mortality rate reduced to 16%.
A suitable management protocol is necessary depends on aetiological causes, time of presentation, economic considerations and available medical facilities to reduce the mortality rate in these patients.
Keywords: Advanced peritonitis, a Management protocol
INTRODUCTION Postsurgical patients in the intensive care unit (ICU) often confront a myriad of medical and new surgical complications. Among these, intra-abdominal infections remain the most formidable adversary, affecting an estimated 6% of all critically ill surgical patients. Organ dysfunction continues to be a major manifestation of these infections, resulting in a high mortality of 23% (1). Yet, the literature is relatively sparse in recommendations for diagnosis in management. In updating this chapter, a search of PUBMED for “Intraabdominal infection and ICU” disclosed only 37 articles published between 1989 and 2008, many of which were tangential or simply not relevant. Also, we have not included management of the “open abdomen” in our discussion, focusing instead on specific diseases.
Purpose. The use of routine microbiological monitoring in the intensive care unit (ICU) setting has been controversially discussed in the past. Therefore, the primary goal of this study was to evaluate the efficiency and value of both laboratory and microbiological monitoring as useful diagnostic tools for nosocomial infections, particularly in patients with severe sepsis. Materials and methods. Between 2000 and 2002, 60 consecutive patients with severe sepsis and tertiary peritonitis on a surgical ICU were retrospectively analysed for this study. All nosocomial infections that occurred during ongoing treatment as well as parameters that finally initiated screening for infections were registered. The time course of serum inflammatory parameters (C-reactive protein, leucocyte count, procalcitonin, interleukin-6) and core temperature (fever < =38.0°C) for 72 h before definite diagnosis of an infection as well as their predictive value were analysed. The results of a routine microbiological monitoring were evaluated with special regards to their potential for the isolation of causative pathogens and, thus, the early identification of nosocomial infection with subsequent initiation of adequate therapy. Results. Clinical and laboratory diagnosis of subsequent ICU-acquired infections in this particular patient population was complicated by recurrent acute inflammatory reactions. Overall, 205 definite infections (pneumonia, tracheobronchitis, catheter-related infections, peritonitis) were analysed regarding the diagnostic value of laboratory tests and microbiological monitoring. The sensitivity of serum inflammatory parameters varied broadly, from 35 to 57%. C-reactive protein was found to be the most predictive marker (57.1%). Successful screening for infectious focus was most frequently initiated by the results of microbiological investigations (45.9%) or by clinical signs and symptoms (23.4%). Additional routine microbiological monitoring (endotracheal aspirate, urine and blood cultures) allowed the early diagnosis of 134 of 205 infections (65.4%) and adequate antimicrobial treatment of 127 infections (62%) during the study period. Conclusions. Nosocomial infections and related complications occur frequently in patients with severe sepsis. These infections, as well as the necessity of recurrent surgical interventions, may complicate the course and have a significant negative impact on patient outcome. A routine microbiological monitoring for patients with severe sepsis or septic shock is a helpful additional tool for the early diagnosis and adequate treatment of subsequent ICU-acquired infections in the setting of a surgical ICU. Thus, mortality rates of these debilitated and critically ill patients can be effectively improved. © 2006, Informa UK Ltd All rights reserved: reproduction in whole or part not permitted. All rights reserved.
Introduction: Intra-abdominal infection is characterized by its high incidence and mortality. Mortality rates reported in the literature vary widely and there are no studies that show differences depending on the degree of sepsis present. This study presents only patients with severe sepsis and septic shock of abdominal origin and the impact on mortality by performing preoperative resuscitation using the Surviving Sepsis Campaign guidelines as the only variable that changes the mortality rate. Material and Methods: A retrospective, observational, analytical and cross-sectional study was conducted in a population of 146 patients with intra-abdominal infection categorized with severe sepsis and septic shock in Tampico General Hospital. Preoperative resuscitation was performed on all patients based on the Surviving Sepsis Campaign guidelines. This was classifi ed as a success or failure, and the impact on mortality was reviewed. Results: Of the 146 patients, 112 had severe sepsis and 34 septic shock. Resuscitation was considered successful in 105 patients. The overall mortality in the study was 20.5%, with 9.8% for severe sepsis and 55.8% for septic shock. In patients with successful resuscitation, overall mortality decreased to 9.5%, and in patients with severe sepsis it was 2.2% and with septic shock it was 47%, which was statistically signifi cant. (Pearson Chisquare 33, P=.001 and OR 38, 95% CI: 7-208). Conclusions: The results of the successful preoperative resuscitation in severe sepsis and septic shock in patients with intra-abdominal infection show a statistically significant impact on reducing mortality.
Introduction. Primary anastomosis is a feasible technique in the management of severe secondary peritonitis in critically ill patients; however, its use has been limited due to the risk of complications and death. Materials and methods. We selected patients with severe secondary peritonitis that required resection of an intestinal segment and managed with temporary intestinal ligature, open abdomen, elective repeat laparotomies, and ulterior deferred primary anastomosis. Primordial success was labeled in those patients that had primary anastomosis and no leakage or fistulae. Results. Twenty six patients were included in the study, with a mean APACHE II score of 15.3. There were 6 anastomoses in the small bowel, 5 in the large bowel, 4 of the ileum to the large bowel, and in 3 patients an anastomosis could not be performed. A mean of 4 scheduled relaparotomies were registered, starting 24 hours after the anastomosis. Primordial success was achieved in 20 patients (77%), 28-day survival was 88.3%; 23 patients left the hospital alive, and only 3 (11.5%) died in the ICU; these deaths were independent of the procedure. Discussion. Damage control surgery was feasible and secure in patients with severe secondary peritonitis, with a primary success rate of 77%; fistulae developed in 11.5%, and mortality was 11.5%.
Bei der diffusen Peritonitis handelt es sich nach wie vor um ein Krankheitsbild mit hoher Morbidität und Letalität. Durch die Entwicklung neuer operativer Konzepte, den Einsatz neuester antimikrobieller Therapien und ständige Fortschritte in der Intensivmedizin ist es zwar gelungen,die Letalität zu senken, die Behandlung stellt jedoch nach wie vor eine Herausforderung an den Chirurgen und die Intensivmediziner dar und fordert ein großes Maß an interdisziplinärer Zusammenarbeit.
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COMPARTMENT SYNDROME is a condition in which increased pressure in a confined anatomical space adversely affects the circulation and threatens the function and viability of the tissues therein. Although compartment syndrome is best known to occur within the fascial spaces of the extremities, it also may develop within the non-yielding envelopes of the orbital globe (as in glaucoma), the intracranial cavity, and the kidney (post ischemic oliguria) (1).
The concept that the abdominal cavity can also be considered as a single compartment and that any change in the volume of any of its contents will elevate intra-abdominal pressure is not new. However, the notion that elevated intra-abdominal pressure may impair organ and physiologic function by producing an abdominal compartment syndrome (ACS) has received relatively little attention. This is the first comprehensive presentation all aspects of the abdominal compartment syndrome.
Objective: To study the pattern of intraperitoneal cytokine release in secondary peritonitis and its correlation with plasma levels and prognosis.
Design: Non comparative descriptive case series,
Setting: Department of surgery in a university hospital
Patients: Seventeen consecutive patients undergoing planned relaparotomy for severe intra-abdominal infection (Acute Physiological and Chronic Health Evaluation [APACHE Il] score> 10; mean score, 17.5
Interventions: The following were measured at the first and last serial operations in the peritoneal exudate and plasma: endotoxin, tumor necrosis factor α (TNF-α), interleukin-I (IL-l), interleukin-6 (IL-6) ,elastase, and neopterin.
Main Outcome Measures: Survival and death.
Results: Six patients died. Peritoneal endotoxin levels were significantly higher than in the plasma and were significantly higher in the non survivors. Plasma TNFα, IL-6, elastase, and neopterin levels remained elevated in the non survivors prior to death. Levels of TNF-α, lL-6, elastase, and endotoxin were 19,993,239, and 7 times higher, respectively, in the peritoneal exudate than in plasma, all significant differences. Elastase and TNF-α levels decreased in survivors during the operative treatment but remained elevated in the non-survivors.
Conclusions: Secondary peritonitis is associated with a significant cytokine-mediated inflammatory response that is compartmentalized in the peritoneal cavity and indicates an adverse prognosis. Levels o cytokines in the exudate of peritonitis may be used to better stratify the severity of peritonitis and, in future, to guide local therapy.
Article de synthese. Etude des divers aspects de l'ecologie microbienne de l'intestin dans des modeles animaux. Developpement de la flore intestinale apres la naissance. Facteurs ecologiques associes a la colonisation de l'intestin par Clostridium difficile
• Maintain a high degree of suspicion: the primary goal is diagnosis prior to bowel infarction — a complication that carries a mortality of up to 90% [1, 2]. • Aggressive use of angiography to make the correct diagnosis and plan surgical intervention appropriately. • Restoration of bowel perfusion requires not only surgical intervention but also aggressive use of invasive monitoring to assure adequate resuscitation. • Following resection of devitalized bowel, make a plan for a second-look procedure based on the appearance of the bowel.
• In general, reoperation should be delayed for several months following resolution of all complications arising from the source control operation. It seems prudent to delay surgery for at least 6 months. • The sensitive nature of reoperation for prior complications requires a strong physician-patient relationship to minimize patient anxiety prior to the procedure. • In all reoperative cases, it is critically important for the operating surgeon to fully understand the nature of prior surgeries. • It is preferable to enter the peritoneal cavity through a “virgin area” of the abdominal wall.
The treatment of patients with necrotizing pancreatitis is a challenge, and the indications and proper timing of operative intervention for necrosectomy/debridement remain controversial. This experience shows that thorough debridement and drainage followed by 'closed' packing of the resulting cavity results in an acceptable mortality rate of 8%. Although further percutaneous drainage is still required in 22%, the reoperation rate is acceptably low at 17%. Morbidity is common following these procedures, and is certainly not absent with this approach. A pancreatic fistula, albeit managed conservatively in the majority of cases, was present in one-half of the patients, and an enteric fistula in 19%. The prolonged hospital stay and time required before returning to regular activities are particularly worrisome in this era of managed care and cost containment. Forty percent of the patients in this series had sterile necrosis, and it could be argued that the morbidity of surgery may have been avoided had conservative management continued. This series cannot answer this debate, although we and others have shown that the consequences of sterile necrosis can be as lethal as that of infected necrosis (1,9).
• This prospective, open, consecutive, nonrandomized trial examined management techniques and outcome in severe peritonitis. A total of 239 patients with surgical infection in the abdomen and an APACHE (acute physiology and chronic health evaluation) II score greater than 10 were studied. Seventy-seven patients (32%) died. Reoperation had a 42% mortality rate (35 of 83 patients died) compared with a 27% mortality rate (42 of 156 died ) in patients who did not undergo reoperation. Forty-six patients underwent one reoperation; 15, two reoperations; 10, three reoperations; five, four reoperations; and seven, five reoperations, with mortality rates of 43%, 40%, 30%, 40%, and 57%, respectively. There was no significant difference in mortality between patients treated with a "closed-abdomen technique" (31% mortality) and those treated with variations of the "open-abdomen" technique (44% mortality). Logistic regression analysis showed that a high APACHE II score, low serum albumin level, and high New York Heart Association cardiac function status were significantly and independently associated with death. Low serum albumin level, youth, and high APACHE II score were significantly and independently associated with reoperation.(Arch Surg. 1993;128:193-199)
Every day we excrete 100–200 g of feces. Given that 75% of the wet weight is composed of bacteria (Stephen and Cummings, 1980) and that each gram contains 1 × 1011 organisms belonging to up to 400 different species (Moore and Holdeman, 1974), it is clear that we are the outer casing of possibly one of the most highly evolved and complex microbial ecosystems of them all. Freter et al (1983a) have commented on the apparent paradox that 100 years of intensive research has not brought us close to an understanding of what controls the indigenous microbiota* of the gastrointestinal tract. This lack of progress does not seem so surprising if we consider the intestine as a continuous culture vessel containing at the one time hundreds of organisms in steady state conditions. The study of even two or three organisms in steady state in a culture vessel is difficult enough. And yet, here the culture vessel of the gut compounds the problem by being composed of living animal cells.
• The original criteria for percutaneous abscess drainage were limited to simple abscesses (well-defined, unilocular) with safe drainage routes. We expanded these entry criteria to include complex abscesses (loculated, ill-defined, or extensively dissecting abscesses), multiple abscesses, abscesses with enteric fistulas or whose drainage routes traversed normal organs, as well as complicated abscesses (appendiceal, splenic, interloop, and pelvic). Using these expanded criteria, cure was achieved nonoperatively in 92 (73.6%) of 125 abscesses with ten deaths (9%), and 11 complications (9%). Cure was achieved in 82% of simple abscesses, but only 45% of complex abscesses. There was no correlation between size, depth, drainage route, or etiology of the abscess (spontaneous v postoperative) with either cure or complications. We recommend a trial of percutaneous drainage in all simple abscesses and most complex abscesses with clinical response as the key determinant of the need for operative intervention.
A clinical syndrome of massive bleeding from acute multiple gastric ulcers associated with respiratory failure, hypotension, sepsis, and jaundice developed in eight of 150 consecutive patients admitted to the respiratory-surgical intensive care unit of the Beth Israel Hospital. These ulcers were almost exclusively located in the fundus of the stomach. Only one of these eight patients survived.
Hypothesis Planned relaparotomy (PRL) has been suggested to have detrimental effects on the systemic activation of inflammation mediators, thereby enhancing organ dysfunctions as assessed by clinical scores in secondary peritonitis. Design Prospective, nonrandomized control trial. Setting Intensive care units of an urban and a university teaching hospital. Patients Twenty-nine patients with secondary peritonitis. Interventions Of the 29 patients with comparable initial peritonitis conditions, 11 underwent PRL and 18 obtained primary abdominal closure. Blood samples were obtained preoperatively and at 2, 6, 8, 12, 18, 24, 30, 36, 42, and 48 hours after the primary operation, then every 12th hour until day 5 and once daily until day 8. Main Outcome Measures Quantification of circulating inflammation parameters (coagulation, acute-phase proteins, cytokine system, cell adhesion, opsonization) in correlation with Acute Physiology and Chronic Health Evaluation II, multiple organ failure, and Sepsis-Related Organ Failure Assessment scores. Results Preoperatively, the patient groups did not differ in mean age, cause of peritonitis, or clinical scores. On average, 5.1 (SEM, ± 0.7; range, 3-11) lavage treatments were performed in the PRL group, with 90% of the procedures executed during the first 6 days. The PRL treatment resulted in a significantly higher need of blood components and an increased inflammation mediator response, especially concerning coagulation factors, proinflammatory cytokines, adhesion molecules, and opsonic parameters. During PRL, clinical score systems showed higher values and a delayed decline compared with primary abdominal closure treatment. Incidence of multiorgan failure, mortality, and the mean intensive care unit hospitalization period were clearly more pronounced in the PRL group. Conclusion In our pilot study, additional lavage treatment of secondary peritonitis resulted in an enhancement of systemic inflammatory mediator response (in particular interleukin 8), which may contribute to a further impairment of organ function.
Secondary bacterial peritonitis arises as a consequence of injury to an intraabdominal viscus from intrinsic disease or extrinsic trauma. The resulting infection is typically polymicrobial, with aerobic Gram negatives such as Escherichia coli and anaerobes such as Bacteroides fragilis playing an important role in its evolution. The first priority in management is resuscitation and hemodynamic stabilization of the patient. Definitive therapy is primarily surgical, through the drainage of localized collections or abscesses, the debridement of necrotic tissue and other adjuvants, and the definitive management of loci of ongoing microbial contamination. Antibiotics provide adjunctive therapy; a variety of regimens have shown clinical efficacy. Prognosis is determined primarily by the severity of the resultant physiologic derangement and the adequacy of surgical therapy; treatment failure is reflected in progressive organ dysfunction.
• The microbiology of infection acquired in the intensive care unit (ICU) was studied prospectively in 205 consecutive patients admitted to a surgical intensive care unit. A multiple organ failure (MOF) score was calculated for each admission. Susceptibility to ICU-acquired infection increased with increasing MOF scores. While Escherichia coli, Bacteroides fragilis, and enterococci were the most common isolates from infections present at the time of ICU admission, Staphylococcus epidermidis, Candida, and Pseudomonas dominated infections occurring in patients with high MOF scores. Mortality correlated highly with infection due to S epidermidis or Candida and only poorly with infection due to Pseudomonas or E coli; significant foci of invasive infection were frequently absent at autopsy. Quantitative cultures of proximal gastrointestinal fluid in 16 of these patients showed Candida, S epidermidis, and Pseudomonas to be the most common isolates, and all but one patient colonized with these organisms had invasive infection with the same organism. The proximal gastrointestinal tract appears to be an important occult reservoir of the predominant pathogens in MOF.
(Arch Surg 1988;123:309-315)
Hypothesis
Abdominal computed tomographic (ACT) scans are useful in the evaluation of sepsis of unknown origin in patients with major trauma.Design
Prospective case series of consecutive patients.Setting
Intensive care unit of level I academic trauma center.Patients
Eighty-five critically injured patients admitted to the intensive care unit in 32 months (6% of all intensive care unit admissions) who developed sepsis of unknown origin.Interventions
One hundred sixty-one ACT scans.Main Outcome Measures
Sensitivity and specificity of the ACT scans, number of patients subjected to changes in treatment following an ACT scan.Results
Forty-nine patients (58%) had an intra-abdominal focus of infection identified on ACT scan. Penetrating trauma and emergent laparotomy were the only independent factors associated with abnormal findings on ACT scan. The sensitivity and specificity of the test were 97.5% and 61.5%, respectively. Overall, 59 patients (69%) benefited from treatment changes after an ACT scan.Conclusion
Abdominal computed tomographic scans reliably identify intra-abdominal foci of infection in patients with major trauma evaluated for sepsis of unknown origin.
• Generalized peritonitis was assessed in 176 patients, 67 (38%) of whom died. Cases were divided into causative groups: (1) appendicitis and perforated duodenal ulcer, (2) intraperitoneal origin other than appendix or duodenum, and (3) postoperative peritonitis. Mortalities were 10%, 50%, and 60%, respectively. Postoperative peritonitis was characterized by lack of influence of age on outcome, late operation, and more frequent organ failure. Delayed surgery carried a worse prognosis. Organ failure was a risk factor with 76% mortality, and was associated with late operation. Early surgery in organ failure improved survival. More sensitive indicators of early organ dysfunction might improve survival.
(Arch Surg 1983;118:285-290)
• We reviewed the charts of 2,567 patients from 11 prospective clinical trials of antibiotic therapy for surgical infection to identify reliable predictors of sepsis eradication. Particular attention was paid to temperature, blood cell counts, renal and hepatic function tests, arterial gases, and clotting factors, both at the termination of parenteral antibiotic administration as well as at patient discharge from the hospital. On the discontinuation of antibiotic therapy, sepsis recurred in 19% of the patients who had a normal rectal temperature, in 3% of the patients if the rectal temperature and WBC count were normal, but in no patient when both the temperature and WBC count were normal and the differential blood smear contained less than 73% granulocytes and less than 3% immature forms. Rates for recurrent sepsis, once antibiotic therapy was discontinued for more than 48 hours, were 8%, 2%, and 0%, respectively, for the same criteria at hospital discharge.
(Arch Surg 1985;120:17-20)
• This retrospective case-controlled study compares the morbidity and mortality of 27 percutaneously drained (PD) abscesses with 27 that were surgically drained (SD). Patients were matched for age, sex, diagnosis, and abscess etiology and location. There was no difference in severity of illness (acute physiology score [APS] = 8.3 vs 10.2), comparable morbidity (29.6% vs 40.7%), or mortality (11.0% vs 7.4%) between PD and SD groups. Duration of drainage was significantly longer in the PD group; however, this is explained in part by the 48% vs 18.5% difference in associated fistulae. Failures of the SD group had a higher mean APS (15) than both failures of the PD group (APS=9.3) and successes of the SD group (APS = 8.6). All three PD group deaths and half of the SD group deaths were related to ongoing sepsis. Surgical drainage of intra-abdominal abscess is as successful as PD. Percutaneous drainage is reasonable initial treatment for intra-abdominal abscess; however, early assessment of clinical status and frequent reassessment are mandatory to ensure that failures are dealt with early. We present a drainage algorithm.
(Arch Surg 1986;121:141-146)
Objective:
To assess the role of 12th rib resection in the treatment of postoperative, subphrenic abscesses.Design:
Consecutive case series.Setting:
University hospital, level I trauma center.Patients:
Operative logs for a 13-year period were reviewed for all patients undergoing 12th rib resection for drainage of a postoperative subphrenic abscess. Each individual medical record was reviewed for demographic data, primary diagnosis, computed tomographic scan findings, and clinical status (temperature, white blood cell count, and Acute, Physiologic, Age, and Chronic Health Evaluation II score) at the time of rib resection.Main Outcome Measures:
Operative results, microbiological data, complications, and outcomes.Results:
Twenty-six patients underwent 27 rib resections for a secondary left subphrenic (23) or a right subhepatic (4) abscess. All patients had undergone at least 1 prior laparotomy (average, 1.5; range, 1-4). Sixteen patients had traumatic injuries, and 7 had complicated pancreatitis. Twelve patients had undergone prior failed attempts at percutaneous drainage before rib resection. Fourteen patients underwent operative drainage without attempted percutaneous drainage, mainly for peripancreatic (7) or multiloculated (3) abscesses. There were 3 postoperative complications (3/27 [11%]): a gastrocutaneous fistula, a gastrocolic-cutaneous fistula requiring laparotomy and temporary colostomy, and fasciitis in the resection site. Four (15%) of the 26 patients died: 3 died of progressive multiple system organ failure, and 1 died of an unrelated injury. The remaining 20 (77%) of the patients were discharged from the hospital with healing wounds and no further episodes of intra-abdominal infection.Conclusions:
Twelfth rib resection is an effective alternative therapy for secondary subphrenic abscesses. The nature of the incision allows for open, dependent drainage; avoids subsequent laparotomy; and effectively controls intra-abdominal infections. Twelfth rib resection remains a useful tool in the treatment of subphrenic abscess and may be the preferred approach when other attempts at abscess drainage have failed.Arch Surg. 1997;132:1203-1206
Objective:
To define the role of planned relaparotomy (PR) in the treatment of intraperitoneal infection, compared with that of relaparotomy on demand (RD).Design:
Case-control study on the basis of a prospective multicenter cohort analytic study. Statistical evaluation was done by the McNemar test for qualitative data and the Wilcoxon matched-pairs signed rank test for qualitative data.Setting:
Eighteen hospitals of different care levels in Austria, Germany, and Switzerland.Patients:
Thirty-eight of 42 patients with intraabdominal infections who underwent PR were matched for APACHE II (Acute Physiology and Chronic Health Evaluation II) score, age, cause of infection, site of origin of peritonitis, and the ability of the surgeon to securely eliminate the source of infection with 38 patients taken from a cohort of 278 undergoing RD.Interventions:
Planned relaparotomy was defined as at least one relaparotomy decided on at the time of the first surgical intervention; RD, relaparotomy indicated by clinical findings.Main Outcome Measures:
Mortality and incidence of postoperative multiple organ failure and infectious complications.Results:
There was no significant difference in mortality between patients treated with PR (21%) or RD (13%). Postoperative multiple organ failure as defined by a Goris score of more than 5 was more frequent in the group of patients undergoing PR (50%), compared with the group undergoing RD (24%) (P=.01), as were infectious complications (68% vs 39% [P=.01]). Infectious complications were due to more frequent suture leaks (16% vs 0% [P=.05]), recurrent intra-abdominal sepsis (16% vs 0% [P=.05]), and septecemia (45% vs 18% [P=.05]) in the PR vs the RD groups. The incidence of other complications was not different in the two groups.Conclusions:
Until larger prospective studies are available, the indication for PR should be evaluated with caution.(Arch Surg. 1995;130:1193-1197)
PURPOSE: Our hypothesis was that in patients with perforated sigmoid colon diverticulitis and peritonitis (Hinchey Stage III and IV) a one-stage sigmoid colon resection is safe and cost effective when performed by an experienced colorectal surgeon. We evaluated outcome and cost of one-stagevs. two-stage sigmoid colon resection after diverticulitis perforation and peritonitis. METHODS: Patients undergoing emergency resection for perforated sigmoid colon diverticulitis and peritonitis (Hinchey Stage III and IV). Outcome, costs, and insurers reimbursement were compared between 13 patients undergoing sigmoid colon resection and primary anastomosis (Group A) and 42 patients undergoing sigmoid colon resection with Hartmann's procedure and secondary descendorectostomy (Group B). RESULTS: Group A patients were comparable to Group B patients in age, gender, preoperative risk and severity of peritonitis (Mannheim Peritonitis Index and C-reactive protein). Operating room time for sigmoid colon resection with primary anastomosis (3.3±1.2 hours) was identical to the time for sigmoid colon resection with colostomy (3.3±1 hour), and morbidity and mortality, intensive care unit, and in-hospital stay were not significantly different between the two groups. In Group B patients' intestinal continuity was restored 169±74 days after the primary resection in 32 of 42 patients only (78 percent). The second procedure took on average 1.4 hours longer than the first procedure. Patients in Group B received more antibiotics (2.2vs. 2) albeit for a shorter period of time (4.5vs. 5.7 days,P = not significant). Overall expenses for restoration of intestinal continuity were between 74 and 229 percent higher for Group B patients than for Group A patients. Reimbursement was 18,191±16,761 SFr (Group A) and 41,321±26,983 SFr (Group B) respectively. CONCLUSION: With meticulous surgical technique and extensive intraoperative lavage, perforated sigmoid colon diverticulitis with peritonitis can be treated by a one-stage sigmoid colon resection and anastomosis with a low mortality and morbidity. A one-stage procedure is considerably cheaper and patients are rehabilitated faster and to a higher percentage.
We retrospectively studied relations between age, pre-existing chronic disease, sepsis, organ system failure, and mortality in 487 patients from a medical ICU. Single organ system failure (SOSF) occurred in 136 (28%) and multiple (>=2) organ system failure (MOSF) in 187 (38%) patients. Cardiovascular and pulmonary failure predominated. Overall mortality was 27%. SOSF mortality was 16% and for MOSF 58%. Eighty-three percent of nonsurvivors had MOSF. Hence, MOSF is common and a major cause of death in critically ill medical patients. Advancing age and prior chronic disease may diminish physiologic reserve and predispose to sepsis and MOSF. Although sepsis is a major risk factor for MOSF, a nonspecific host response to critical illness may contribute to the syndrome in 35% of patients. Advancing age, chronic disease, and the number of failing organs, particularly failure of cardiovascular, pulmonary, renal, and neurologic systems, are major determinants of overall mortality, but sepsis is not an independent contributor.
(C) Williams & Wilkins 1990. All Rights Reserved.
Objective : Determine the significance of recovering yeasts from intraoperative specimens from the abdominal cavity and to evaluate the effect of a single intraoperative dose of fluconazole on clinical outcome in patients with intra-abdominal perforations.
Design : Prospective, randomized, double-blind study.
Setting : Multicenter study from 13 hospitals in Norway.
Patients : One hundred nine patients with intra-abdominal perforations.
Interventions : Patients were randomized to receive either a single 400-mg fluconazole dose or placebo during the operation.
Measurements and Main Results : An intra-abdominal specimen for microbiological culture was obtained at the time of the operation. The primary response variable in the study was death. Secondary response variables were three parameters indicating a complicated postoperative period: mechanical ventilation for ≥5 days, intensive care treatment for ≥10 days, and use of a central venous catheter for ≥10 days. Yeasts were recovered from a intraoperative intra-abdominal specimen from only 1 (3.5%) of 28 patients with perforated appendicitis and from 32 (39.5%) of 81 nonappendicitis patients. Excluding the appendicitis patients, the yeast recovery rate was high both for patients hospitalized at the time of the perforation (45%) and for nonhospitalized patients (32%). The overall mortality was 11% (12 patients). Single-dose intraoperative fluconazole prophylaxis did not reach a statistically significant effect on mortality (4 of 53 patients in the fluconazole group and 8 of 56 patients in the placebo group died [p = .059]). The only two explanatory variables significantly related to death were a intraoperative finding of yeast from an intra-abdominal specimen and the occurrence of a spontaneous perforation in a patient already hospitalized for nonsurgical cancer treatment. Detection of yeast was also a significant explanatory variable for a prolonged period of mechanical ventilation, intensive care treatment, and prolonged use of a central venous catheter.
Conclusions : Single-dose intraoperative fluconazole prophylaxis did not have a statistically significant effect on overall mortality (odds ratio = 0.21; 95% confidence interval, 0.04–1.06;p = .059) in patients with intra-abdominal perforation. The recovery rate of yeast from intraoperative specimens from the abdominal cavity was high (>30%) and was associated with death and a complicated postoperative course.
Spontaneous bacterial peritonitis (SBP) is a complication of end-stage liver disease with a reported mortality of 30-50%. In this study, we investigated the outcome of all patients admitted to Maryland hospitals with SBP from 1988 to 1998. Main outcomes considered included trends in survival rates over time, changes in the length of stay, total health care costs, and variables that predicted survival rates.
We used the Maryland Health Services Cost Review database of all patients admitted to Maryland hospitals with an International Classification of Diseases (Ninth Revision) code for both peritonitis and cirrhosis from 1988 to 1998.
A total of 348 patients were admitted with an in-hospital mortality of 32.6%; there was no significant change in mortality rate during this period. The survival rate was similar in the university and community hospitals. In the logistic regression analysis, age (p = 0.001) and intensive care unit stay (p = 0.0001) were found to significantly influence the survival rates; those patients who had an intensive care unit stay were 2.8 times more likely to die than those who did not have an intensive care unit stay, controlling for age. The average length of hospital stay remained unchanged (13.5 +/- 12.7 days) during the study period. Although the median hospital charge (excluding professional fees) remained unchanged, mean inflation-adjusted charges increased from $7,897 in 1988 to $25,902 in
The mortality rate associated with SBP has remained unchanged over an 11-yr period from 1988 to 1998. The mortality showed a strong correlation with age and intensive care unit stay. The median hospital stay and median charges remained unchanged during this period, but mean costs increased significantly because of increased use of resources by a few patients.
Enterococcus
,
Candida
,
Staphylococcus epidermidis
, and
Enterobacter
. Infectious foci were rarely amenable to percutaneous drainage and were found to be poorly localized at laparotomy. Recurrent, or tertiary, peritonitis is a common complication of intraabdominal infection in patients admitted to an ICU. It differs from uncomplicated secondary peritonitis in its microbial flora and lack of response to appropriate surgical and antibiotic therapy. Like nosocomial pneumonia in the critically ill patient, the syndrome appears to be more a reflection than a cause of adverse outcome.
Two experiments were performed to determine the effect of heparin on experimental fibrinopurulent peritonitis in dogs. Peritonitis was induced by the creation of a 10 cm long isolated loop of terminal ileum. In a first experiment comprising 24 dogs the necrotic loop was removed 24 hours later without cleaning or irrigating the peritoneal cavity. All dogs showed fibrino-purulent peritonitis at that time. No antibiotics were given. All dogs received 500 ml of Ringer's lactate during surgery and were allowed p.o. fluids on the first postoperative day. At the time of excision the dogs were blindly randomized into a control group and two treatment groups receiving heparin 100 u/kg i.p. or s.c. respectively. Of the eight animals in the control group, five died of peritonitis and two showed residual intraperitoneal sepsis at the time of sacrifice 14 days after the initial surgery. Thus, only one dog cleared his peritoneal infection spontaneously. Of the heparin treated dogs six out of eight in the i.p. treated and seven out of eight in the s.c. treated group cleared their peritonitis spontaneously within 14 days (p </= 0.05 and 0.02 respectively). In a second experiment peritonitis was induced in 24 dogs as described above, but the necrotic loop was not removed. The dogs were blindly randomized to daily low dose heparin (50 u/kg s.c. b.i.d.) or no therapy. Only two out of 12 dogs of the control group survived the observation period of 14 days compared with eight out of 12 of the heparin treated group (p </= 0.05). However, in all dogs in this experiment residual i.p. sepsis was found. We conclude that heparin has a therapeutic effect in experimental canine peritonitis by preventing the additional apposition of fibrin and, thus, rendering the bacteria more susceptible to cellular and noncellular clearing mechanisms.
Intra-abdominal sepsis was studied in Wistar rats by using four microbial species: Escherichia coli, enterococci, Bacteroides fragilis, and Fusobacterium varium. These organisms were implanted into the peritoneal cavity singly and in all possible dual combinations. Results were evaluated by mortality rates and the incidence of intra-abdominal abscesses on autopsy following sacrifice after 7 days. Mortality was restricted to recipients of E. coli, thus implicating coliforms in the acute lethality associated with this experimental model. Intra-abdominal abscesses were produced in 61 of 95 (94%) animals that received the combination of an anaerobe and a facultative organism. Abscesses failed to form with any single strain or with E. coli plus enterococci, and they were detected in one 1 of 19 animals receiving B. fragilis plus F. varium. These results suggest that intra-abdominal abscess formation is related to synergy between anaerobes and facultative bacteria.
Remote or local infection appears to be causally associated with major organ failure in some surgical patients. Experience with the patients described suggests that the converse relationship may be clinically useful: organ failure may indicate the presence of otherwise occult intra-abdominal infection in postoperative patients and trauma victims. Support of organ function without definitive correction of underlying infection is only pallative.
The continued high mortality in patients with generalized peritonitis, treated by conventional means, led the author, in 1963, to a study of the effects of radical surgical debridement in those patients in whom the source of contamination could be eliminated. Ninety two patients have been treated with the described regimen. They varied from 3 to 69 years of age, and a variety of contamination sources were encountered. All were critically ill and over 90% had mechanical intestinal obstruction. Although these operations were tedious and often prolonged (average operating time, three hours), all patients survived and postoperative complications were surprisingly minimal. It is believed that the success of this method results from stopping further contamination and restoring the peritoneum to a state that allows normal host defense mechanisms to clear any residual infection.
To study the effect of severe illness on the nature of peritonitis and intra-abdominal abscesses, the microbiology and clinical course of patients operated on over a 1-year period with culture-proven intra-abdominal infections whose preoperative Acute Physiology and Chronic Health Evaluation (APACHE) II scores were greater than or equal to 15 (predicted mortality at least 50%) were examined. Twenty-nine patients were enrolled, and overall mortality was 52 per cent, with increasing mortality correlating with higher APACHE II scores. The organism most commonly isolated from the peritoneum was Candida albicans, followed by Enterococcus species, Enterobacter species, and Staphylococcus epidermidis. An increase in the mean of the APACHE II scores on Days 3 and 7 compared to the preoperative score was associated with a 91 per cent mortality, while a decrease was associated with only a 22 per cent mortality. The authors conclude that the microbiology of intra-abdominal infections is inherently different in severely ill patients and that longitudinal clinical scoring may be more useful than a single scoring in predicting outcome. These data suggest that trials to investigate the broadening of standard perioperative antimicrobial coverage in the ill and use of longitudinal clinical scoring to direct aggressive reintervention may be warranted.
A wide range of imaging tools is available for the investigation of abdominal sepsis. Plain films and barium studies alone are generally regarded as inadequate and most patients will require ultrasound, CT or nuclear medicine studies to locate the source of sepsis. The choice of imaging modality depends on several factors, most important of which are the clinical condition of the patient and the presence or absence of localizing signs and symptoms. Ultrasound has the advantage of being portable and is therefore probably the best initial imaging method for the critically ill patient. It should also be the first investigation in patients with signs and symptoms localizing to the right upper quadrant, renal areas, subphrenic spaces or pelvis. Transvaginal ultrasound is particularly useful in examining the pelvis. CT is the imaging modality of choice for the pancreas and retroperitoneum and in patients who are poor candidates for ultrasound or in whom visualization on ultrasound is inadequate. In patients with PUO or evidence of sepsis without localizing signs or symptoms, nuclear medicine studies in the form of 67Ga citrate or labelled white cell scans are useful to localize the septic focus, although in most cases CT or ultrasound will subsequently be required for detailed anatomical definition. Imaging techniques have an increasingly important role to play in the treatment of sepsis, and guided aspiration and drainage may be performed with a high degree of accuracy under ultrasound or CT guidance, eliminating the need for surgical intervention in many individuals.
The records of 83 patients with intra-abdominal abscesses treated between 1986 and 1990 were reviewed to determine if there were significant differences in the outcome of patients treated by surgical drainage (n = 41) or percutaneous drainage (n = 42). The two groups were matched for age, abscess location, and etiology. Parametric statistical evaluations included the Student's t test as well as analysis of variance; nonparametric statistics used were chi-square and Wilcoxon rank sums. No significant difference was found in mortality (surgical 14% versus percutaneous 12%) or morbidity (surgical 26% versus percutaneous 29%). The duration of hospital stay was similar. Although there was no significant difference between the two groups in severity of illness as measured by APACHE II scores, these scores were significant in determining prognosis. APACHE II scores were significantly higher in non-survivors of both groups (23 versus 13) and also higher in those developing complications. A subgroup of patients with diverticular abscess was identified in whom percutaneous drainage enabled later resection with primary anastomosis without complication. This study indicates that percutaneous drainage of an intra-abdominal abscess is as efficacious as surgical drainage and that APACHE II scores are prognostic of both potential mortality and morbidity.
Deposition of fibrin within the peritoneal cavity is an integral host response to local infection. To directly assess the role of fibrin deposition in the pathogenesis of intraabdominal abscess formation, the ability to induce abscesses in fibrinogen-depleted mice was examined. We hypothesized that systemic defibrinogenation with ancrod would limit the availability of fibrinogen for deposition within the peritoneal cavity and would therefore impair intraabdominal abscess formation. A gelatin capsule containing 50% sterile feces plus Bacteroides fragilis 1 x 10(9) CFU was inserted IP into control or defibrinogenated mice. System defibrinogenation resulted in alteration of the character of abscess formation, as manifested by reduced abscess size and degree of purulence. Abscesses were significantly smaller (0.18 +/- 0.02 gm [n = 29] vs. 0.09 +/- 0.02 gm [n = 11], p less than 0.01) and less purulent (p less than 0.001) in the ancrod-treated mice than in control animals, despite equal numbers of bacteria in the abscesses recovered from both groups. The effect of ancrod was specific for defibrinogenation, because IP repletion with fibrinogen reversed the ancrod effect on abscess size. In addition to its local effects, systemic fibrinogen depletion resulted in a significant elevation in mortality following IP infection (1 of 30 control animals vs. 10 of 23 ancrod-treated animals, p less than 0.01). However, this was not due to an increase in the magnitude of the B. fragilis bacteremia. These studies demonstrate that fibrin deposition contributes to the pathogenesis of purulent abscess formation and that systemic depletion of fibrinogen may alter host susceptibility to the consequences of infection.
The enterococcus has been relegated to a position of unimportance in the pathogenesis of surgical infections. However the increasing prevalence and virulence of these bacteria prompt reconsideration of this view, particularly because the surgical patient has become increasingly vulnerable to infectious morbidity due to debility, immunosuppression, and therapy with increasingly potent antibiotics. The enterococcus is a versatile opportunistic nosocomial pathogen, causing such diverse infections as wound, intra-abdominal, and urinary tract infections; catheter-associated infection; suppurative thrombophlebitis; endocarditis; and pneumonia. Although surgical drainage remains the cornerstone of therapy for enterococcal infections involving a discrete focus, in the circumstances typified by the compromised surgical patient, specific antibacterial therapy directed against the enterococcus is warranted. Recent evidence indicates that parenteral antibiotic therapy for enterococcal bacteremia is mandatory and that appropriate therapy clearly reduces the number of deaths.
To prospectively assess the value of an algorithm in differentiating spontaneous from secondary bacterial peritonitis, we performed serial paracenteses in 43 episodes of ascitic fluid infection (28 spontaneous and 15 secondary) in 40 patients. The algorithm involved identification of (a) secondary peritonitis associated with gut perforation, based on previously proposed criteria in patients with neutrocytic ascites (ascitic fluid total protein greater than 1 g/dl, glucose less than 50 mg/dl, and lactate dehydrogenase greater than the upper limit of normal for serum) and (b) separation of spontaneous from secondary peritonitis (unassociated with perforation) based on the response of the ascitic fluid cell count to antibiotic therapy. The perforation criteria had 100% sensitivity in detecting episodes of actual gut perforation; their specificity, however, was low (45%). After 48 h of treatment the concentration of ascitic fluid neutrophils was below the baseline pretreatment value in all episodes of spontaneous peritonitis but in only two thirds of the patients with secondary peritonitis. This algorithm is useful in (a) identifying patients who have infected ascites associated with perforation of an intraabdominal viscus, and (b) differentiating spontaneous from nonperforation secondary peritonitis on the basis of the response of the ascitic fluid cell count to appropriate antibiotic therapy. The optimal time for repeat paracentesis in patients with infected ascites appears to be 48 h after initiation of treatment.
Over a 2-year period, all surgical patients from whom Candida was isolated from intra-abdominal specimens were evaluated. All but 1 of the 49 evaluable patients had either a spontaneous perforation (57%) or a surgical opening of the gastrointestinal tract (41%). Candida caused infection in 19 patients (39%), of whom 7 had an intra-abdominal abscess and 12 peritonitis. In the other 30 patients (61%), there were no signs of infection and specific surgical or medical treatment was not required. Candida was more likely to cause infection when isolated in patients having surgery for acute pancreatitis than in those with either gastrointestinal perforations or other surgical conditions. The development of a clinical infection was significantly associated with a high initial or increasing amount of Candida in the semiquantitative culture. Surgery alone failed in 16 of 19 patients (84%), of whom 7 died and 9 recovered after combined antifungal and surgical treatment. The overall mortality and the mortality related to infections were significantly higher in the patients with intraabdominal candidal infections than in those without such infections.
• Multiple system organ failure (MSOF) remains a principal cause of death after major operative procedures and/or severe trauma. We studied multiple parameters in 553 consecutive emergency surgical patients to determine the incidence of MSOF, the predisposing factors to MSOF, and the sequelae of MSOF. Thirty-eight patients had MSOF; mortality was 74% for these patients. Evaluation of multiple factors demonstrated that (1) MSOF is primarily due to infection, (2) the temporal sequence of organ failure is lung, liver, gastric mucosa, and kidney, and (3) MSOF is the most common fatal expression of uncontrolled infection.
(Arch Surg 115:136-140, 1980)
Local septic complications in acute pancreatitis need to be exactly characterized and defined in order to develop improved concepts for their prevention, early diagnosis, and therapy. While up to now all local septic complications have been termed abscesses, the present study for the first time delineates the morphologic, clinical, and laboratory criteria needed to distinguish between two separate clinical entities: the infected necrosis (IN) and the pancreatic abscess (PA). IN is defined as a diffuse bacterial inflammation of necrotic pancreatic and peripancreatic tissue, but without any significant pus collections. On the other hand, the morphologic substrate of PA is a localized collection of pus surrounded by a more or less distinct capsula. IN becomes clinically evident during the early phase of acute pancreatitis (AP). The patients with IN present both the signs of sepsis and the laboratory findings of AP. Thus in these patients the most fulminant course of AP is observed; 51.8% and 35.7% of them have pulmonary or renal insufficiency, respectively. The mortality of the patients with IN is high and amounts to 32.1%. Pancreatic abscess, on the other hand, does not develop before the fifth week after onset of symptoms and after subsidence of the acute phase of pancreatitis. In these patients laboratory signs of AP-like amylasemia, hypocalcemia, hyperglycemia, and rise of LDH are rarely observed. Corresponding to the lack of pathophysiologic effects of AP per se, pulmonary and renal insufficiencies occur in only 33.3% and 16.7%, respectively, and mortality in these patients is 22.2%. While an abscess may readily be identified by computed tomography, the differentiation between IN and non-IN can be very difficult.(ABSTRACT TRUNCATED AT 250 WORDS)
The microbiology of infection acquired in the intensive care unit (ICU) was studied prospectively in 205 consecutive patients admitted to a surgical intensive care unit. A multiple organ failure (MOF) score was calculated for each admission. Susceptibility to ICU-acquired infection increased with increasing MOF scores. While Escherichia coli, Bacteroides fragilis, and enterococci were the most common isolates from infections present at the time of ICU admission, Staphylococcus epidermidis, Candida, and Pseudomonas dominated infections occurring in patients with high MOF scores. Mortality correlated highly with infection due to S epidermidis or Candida and only poorly with infection due to Pseudomonas or E coli; significant foci of invasive infection were frequently absent at autopsy. Quantitative cultures of proximal gastrointestinal fluid in 16 of these patients showed Candida, S epidermidis, and Pseudomonas to be the most common isolates, and all but one patient colonized with these organisms had invasive infection with the same organism. The proximal gastrointestinal tract appears to be an important occult reservoir of the predominant pathogens in MOF.
Despite the advent of sophisticated diagnostic technology the diagnosis of the surgical abdomen in the Intensive Care Unit continues to pose a problem for the surgeon. A retrospective analysis was carried out to evaluate the utility of diagnostic peritoneal lavage to diagnose intra-abdominal surgical disease. Diagnostic peritoneal lavage was carried out in patients in whom the physical exam was deemed unreliable, such as in patients with cardiopulmonary instability or mental obtundation. Patients were included in the study if autopsy or laparotomy confirmation of the lavage data was available. Forty four patients met the inclusion criteria and formed the basis of this study. Of the twenty three patients with a positive lavage, three false-positive diagnostic peritoneal lavages were discovered, either at laparotomy or postmortem exam. Of the twenty one patients where diagnostic peritoneal lavage was negative, no false-negatives were discovered at autopsy or laparatomy. Therefore, this test is 100 per cent sensitive and 88 per cent specific. It is concluded that a negative diagnostic peritoneal lavage makes intra-abdominal surgical disease highly unlikely. However, a positive lavage may require further diagnostic work-up.
Fibrin deposition initiated by peritonitis is thought to be an important local defense mechanism because it sequesters and walls off bacterial spillage. However, fibrin has been shown to predispose to residual abscess formation in rat peritonitis model. To examine the potential mechanisms of this effect, fibrin was tested in vitro for its inhibitory effect on neutrophil function. At all concentrations tested (50-1000 mg/dl), fibrin significantly impaired the ability of neutrophils to kill Escherichia coli. This inhibition occurred in a dose dependent fashion with almost complete prevention of killing at the highest concentration tested. Further studies showed that pre-exposure to fibrin did not reduce the neutrophil's ability to degranulate, undergo a respiratory burst, or kill E. coli, indicating that fibrin did not cause irreversible damage to the normal microbicidal functions of the neutrophil. However, fibrin, at physiologic concentrations, significantly impaired phagocytosis of radiolabeled E. coli. The data support the concept that phagocytosis of bacteria is impaired by neutrophils enmeshed in fibrin. Thus, contaminated fibrin could act as a nidus for residual abscesses formation following peritonitis even if an adequate number of normal leukocytes were present.