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Postoperative enterococcal infection after treatment of complicated intra-abdominal sepsis
Abstract
The prevalence of enterococcal isolation and factors associated with postoperative enterococcal infection remain ill defined.
A prospective longitudinal observational study was conducted of consecutive patients with a first episode of intra-abdominal infection and a positive microbiological culture who did or did not develop a postoperative septic complication involving enterococci. The prevalence of initial enterococcal isolation was determined for each focus of infection. Postoperative enterococcal infections were related to whether appropriate (piperacillin--tazobactam), suboptimal (carbapenems) or inappropriate (cefotaxime plus metronidazole) antienterococcal therapy had been administered empirically.
Enterococci were isolated in 42 (21 per cent) of the 200 patients investigated. The isolation rates were 11 per cent for community-acquired peritonitis, 50 per cent for postoperative peritonitis and 23 per cent for intra-abdominal abscesses of both origins. No enterococci were isolated from 49 patients with perforated appendicitis. Independent factors for postoperative enterococcal infection were type of intra-abdominal infection (P = 0.006), Acute Physiology And Chronic Health Evaluation (APACHE) II score greater than 12 (P = 0.04) and inappropriate empirical antibiotic cover (P = 0.05). Postoperative enterococcal infections were associated with a high mortality rate (21 versus 4 per cent; P < 0.0007).
Enterococci are frequently isolated from intra-abdominal infections of non-appendiceal origin and are often involved in postoperative infectious complications, particularly peritonitis. Empirical antibiotic therapy covering Enterococcus faecalis should be contemplated in some circumstances.
... Enterococci are found in 20%-30% of ascitic fluid cultures from patients with intra-abdominal infections [3]; they are the most common gram-positive cocci in nosocomial infections [4]. Moreover, intra-abdominal infections, in which enterococci are isolated from ascitic fluid, have a poor prognosis and high mortality rates [5,6]. However, it is unclear whether enterococcal infections worsen patient prognosis or whether patients with poor prognosis are more likely to develop enterococcal infections. ...
... Consequently, there are no definitive guidelines regarding which patients should receive empiric therapy with antimicrobial agents targeting enterococci before culture results are known. Additionally, there is no consensus on whether treatment with anti-enterococcal drugs can improve patient outcomes [5,[7][8][9][10]. Theunissen et al. found that the presence of enterococci was independently associated with increased mortality in both community-acquired and hospital-acquired intra-abdominal infections in immunocompromised patients [6]. ...
... Conversely, a study focusing on critically ill patients admitted to the intensive care unit with severe peritonitis, in which enterococci were detected, showed that a lack of appropriate treatment was associated with increased 30-day mortality [9]. Additionally, given the high likelihood of detecting enterococci in postoperative intraabdominal infections, studies have reported higher mortality rates when appropriate antienterococcal medications were not administered [5]. A meta-analysis including 23 randomized controlled trials and 13 observational studies [17] showed no improvement in mortality with empiric use of anti-enterococcal agents. ...
The clinical significance of enterococci in intra-abdominal infections, particularly those caused by multiple organisms, remains unclear. There are no definitive guidelines regarding the use of empiric therapy with antimicrobial agents targeting enterococci. In this study, we evaluated the impact of the initial antimicrobial therapy administration of anti-enterococcal agents on the treatment of intra-abdominal infections in patients with cancer in whom enterococci were isolated from ascitic fluid cultures. This retrospective study was conducted at Shizuoka Cancer Center between January 1, 2014, and December 31, 2020, on all adult patients with cancer with enterococci in their ascitic fluid cultures. The primary outcome was all-cause mortality, and the secondary outcomes were composite outcomes consisting of three components (mortality, recurrence, and treatment failure) and the risk factors associated with all-cause mortality and composite outcomes. In total, 103 patients were included: 61 received treatment covering enterococci, and 42 did not. The mortality rates did not differ significantly between the treated and untreated groups (treated: 8/61 [13.1%]; untreated: 5/42 [11.9%]; p = 1.00). Additionally, no significant difference was observed between the groups in terms of composite outcomes (treated group: 11/61 [18.0%]; untreated group: 9/42 [21.4%]; p = 0.80). Multivariate analysis showed that performance status (PS2–4; p < 0.0001) was an independent risk factor for mortality. The composite outcome was also significantly higher for PS2–4 (p = 0.007). Anti-enterococcal treatment was not associated with mortality or the composite outcome. In patients with cancer and intra-abdominal infections caused by enterococci, anti-enterococcal therapy was not associated with prognosis, whereas PS2 or higher was associated with prognosis. The results of this study suggest that the initial routine administration of anti-enterococcal agents for intra-abdominal infections may not be essential for all patients with cancer. To substantiate these findings, validation by a prospective randomized trial is warranted.
... SSIs are a major cause of postoperative morbidity and death in the U.S. health system. Not only do they affect the rehabilitation process, but they also increase hospital stay length and cost [3][4][5], drastically escalating expenses, causing higher rates of hospital readmission [6], and jeopardizing health outcomes [2]. The rate of hospital-acquired SSIs is markedly higher in developing countries, partially due to the performance of surgical procedures without proper postoperative management [7]. ...
... Although many studies have discussed enterococcal infections, their pathogenicity, and associated risk factors in hospital settings, few studies have focused on enterococcal infection in surgical sites in postoperative patients (Table 1). Subjects with enterococcal SSIs have a higher incidence of multiple infections, and the majority develop at least one polymicrobial infection at the surgical site [3,4,25]. In addition, postoperative enterococcal infections have been strongly associated with prior antibiotic exposure, such as exposure to cephalosporin and ampicillin, mostly administered as prophylaxis [25,26]. ...
... Enterococci are significant human pathogens which increasingly becoming resistant to multiple antimicrobials that patients receive after undergoing surgeries [23]. SSIs account for 15% of all nosocomial infections, which has led to an unexpected rise in expenses, use of more resources, and increased morbidity and mortality of patients [3][4][5]. ...
Enterococci are organisms that can be found in the normal intestinal and skin microbiota and show remarkable ability to acquire antibiotic resistance. This is an enormous challenge for surgeons when faced with surgical site infections caused by multidrug-resistant (MDR) Enterococci. Due to an increase in the prevalence of MDR Enterococcus within the last few decades, there has been a major decrease in therapeutic options, because the majority of E. faecium isolates are now resistant to ampicillin and vancomycin and exhibit high-level resistance to aminoglycosides, traditionally three of the most useful anti-enterococcal antibiotics. There is limited data regarding the magnitude and pattern of multidrug resistance among the enterococcal genus causing surgical site infections in hospitalized patients. The scope of the review is to summarize the most recent findings in the emergence of postoperative MDR Enterococci and discuss recent mechanisms of resistance and the best treatment options available.
... Compared with patients without enterococcal infection, ICU patients with enterococcal infection had a higher risk of failure of initial clinical therapy (49.6% vs. 24.2%; p < 0.001) and longer hospital stays (33 days [19, 48] vs. 18 days [12,29]; p < 0.001). Enterococcal infection was associated with increased 28-day mortality, in-hospital mortality, and ICU mortality. ...
... Enterococcal infection rates tended to vary between specific types of IAI patients. Prior subgroup analyses showed rates of approximately 50.0% in post-operative IAI patients [9,12]. In our study, the post-operative IAI enterococcal infection rate was 45.0% (54/120), which is concordant with the results of other studies. ...
... With an increasing number of reported enterococcal infections [25], scholars and clinicians have begun to pay more attention to the high-risk profile of enterococci [9][10][11]. Post-operative IAI, chronic comorbidities, APACHE II score, male gender, source of infection, and hypoproteinemia were considered to be risk factors for enterococcal infection [9][10][11][12]. Inconsistent with previous studies, we found that post-operative abdominal infection, intestinal source of infection, MPI score, and prior antibiotic use were risk factors for enterococcal infection. ...
Background:
To investigate the risk factors for enterococcal intra-abdominal infections (EIAIs) and the association between EIAIs and outcomes in intensive care unit (ICU) patients.
Methods:
We reviewed retrospectively the records of patients with intra-abdominal infections admitted to the Department of Critical Care Medicine at Nanfang Hospital, Southern Medical University, China, from January 2011 to December 2018. Patients with intra-abdominal infections were divided into enterococcal and non-enterococcal groups based on whether enterococci were isolated from intra-abdominal specimens.
Results:
A total of 431 patients with intra-abdominal infections were included, of whom 119 were infected with enterococci and 312 were infected with non-enterococci. Enterococci were isolated in 27.6% of patients, accounting for 24.5% (129/527) of all clinical bacterial isolates. Post-operative abdominal infection (adjusted odds ratio [OR], 2.361; p = 0.004), intestinal infection (adjusted OR, 2.703; p < 0.001), Mannheim Peritonitis Index score (MPI; adjusted OR, 1.052; p = 0.015), and use of antibiotic agents within the previous 90 days (adjusted OR, 1.880; p = 0.025) were associated with an increased risk of EIAIs. Compared with patients without enterococcal infection, ICU patients with enterococcal infection had a higher risk of failure of initial clinical therapy (49.6% vs. 24.2%; p < 0.001) and longer hospital stays (33 days [19, 48] vs. 18 days [12, 29]; p < 0.001). Enterococcal infection was associated with increased 28-day mortality, in-hospital mortality, and ICU mortality. However, no difference was found in length of ICU stay between the two groups. Additionally, there was no difference in ICU mortality, hospital mortality, or 28-day mortality in patients infected with enterococcus who did or did not receive empirical anti-enterococcal therapy.
Conclusion:
Post-operative abdominal infection, intestinal infection, MPI score, and use of antibiotic agents within the previous 90 days were independent risk factors for enterococcal infection. Enterococcal infection was associated with reduced short-term survival in ICU patients.
... It has been clearly demonstrated that Enteroccoci are associated with proinflammatory responses, greater clinical disease burden, and shock [9][10][11]. So far, all authors agree with an increase in morbidity (septic shock, higher APACHE 2, and Sequential Organ Failure Assessment (SOFA) scores, higher postoperative infection scores, longer duration of mechanical ventilation and vasopressors, more relaparotomies), but the impact of Enterococcus on mortality is unclear [12][13][14][15][16]. Some studies found that the presence of Enterococci on peritoneal samples is a predictive factor for death [17][18][19] whereas others did not [20,21]. ...
... This study included only non-severe community-acquired IAI (median APACHE scores 10 and 9); the number of IAI growing with Enterococcus was very low (6 over 110 peritonitis) [28]. However, in a population of 200 postoperative IAI among which 42 were growing with Enterococcus, Sitges-Serra et al. found that mortality was higher when IAT did not cover these Enterococcus (21% vs 4%, p < 0.001) [14]. In Enterococcus bacteremia, early use of anti-Enterococcus antimicrobial therapy within 48 h is a protective factor against death [29]. ...
... However, we did not find more redo laparotomies or percutaneous drainages or infectious complications at day 30 when IAT was inappropriate. Other studies showed that an inappropriate IAT against all microbials found on the peritoneal sample was associated with a higher morbidity both in community-acquired and nosocomial IAI in terms of length of stay, wound infection, redo laparotomies, and postoperative complications [14,26,30,31,33,34]. An inadequate IAT against Enterococcus spp. ...
Introduction:
Enterococcus species are associated with an increased morbidity in intraabdominal infections (IAI). However, their impact on mortality remains uncertain. Moreover, the influence on outcome of the appropriate or inappropriate status of initial antimicrobial therapy (IAT) is subjected to debate, except in septic shock. The aim of our study was to evaluate whether an IAT that did not cover Enterococcus spp. was associated with 30-day mortality in ICU patients presenting with IAI growing with Enterococcus spp.
Material and methods:
Retrospective analysis of French database OutcomeRea from 1997 to 2016. We included all patients with IAI with a peritoneal sample growing with Enterococcus. Primary endpoint was 30-day mortality.
Results:
Of the 1017 patients with IAI, 76 (8%) patients were included. Thirty-day mortality in patients with inadequate IAT against Enterococcus was higher (7/18 (39%) vs 10/58 (17%), p = 0.05); however, the incidence of postoperative complications was similar. Presence of Enterococcus spp. other than E. faecalis alone was associated with a significantly higher mortality, even greater when IAT was inadequate. Main risk factors for having an Enterococcus other than E. faecalis alone were as follows: SAPS score on day 0, ICU-acquired IAI, and antimicrobial therapy within 3 months prior to IAI especially with third-generation cephalosporins. Univariate analysis found a higher hazard ratio of death with an Enterococcus other than E. faecalis alone that had an inadequate IAT (HR = 4.4 [1.3-15.3], p = 0.019) versus an adequate IAT (HR = 3.1 [1.0-10.0], p = 0.053). However, after adjusting for confounders (i.e., SAPS II and septic shock at IAI diagnosis, ICU-acquired peritonitis, and adequacy of IAT for other germs), the impact of the adequacy of IAT was no longer significant in multivariate analysis. Septic shock at diagnosis and ICU-acquired IAI were prognostic factors.
Conclusion:
An IAT which does not cover Enterococcus is associated with an increased 30-day mortality in ICU patients presenting with an IAI growing with Enterococcus, especially when it is not an E. faecalis alone. It seems reasonable to use an IAT active against Enterococcus in severe postoperative ICU-acquired IAI, especially when a third-generation cephalosporin has been used within 3 months.
... In the current analysis, Enterococcus was identified in 29% and fungal infection in 11% of all patients, respectively. Other studies demonstrated an overall incidence of Enterococcal infection of 21-30% in patients with secondary peritonitis but only in 11% of patients presenting with a community-acquired peritonitis [22,23]. Cercenado et al. showed a strong association between the identification of Enterococcus and postoperative secondary peritonitis. ...
... Therein, identification of Enterococcus in patients with secondary peritonitis was significantly associated with increased mortality and complication rate. Thus, identification of Enterococcus should be considered as a marker of a severe disease [23]. When empiric antibiotic treatment was not appropriately chosen, 40% of the patients developed postoperative enterococcal infections in the latter study [23]. ...
... Thus, identification of Enterococcus should be considered as a marker of a severe disease [23]. When empiric antibiotic treatment was not appropriately chosen, 40% of the patients developed postoperative enterococcal infections in the latter study [23]. ...
Purpose:
Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery.
Methods:
Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48 h later. Therein, decision for definite reconstruction (anastomosis or Hartmann's procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed.
Results:
Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p = 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p = 0.001), and increased operation time (105 vs. 84 min., p = 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p < 0.001). Complication rate (44 vs. 24%, p = 0.092), mortality (12 vs. 0%, p = 0.061), overall number of surgeries (3.4 vs. 2.4, p = 0.017), enterostomy rate (76 vs. 36%, p = 0.001), and length of hospital stay (25 vs. 18.8 days, p = 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p = 0.005) and with fungal infection (100 vs. 49%, p = 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p < 0.001), enterostomy rate (81 vs. 48%, p = 0.017), and anastomotic leakage (29 vs. 6%, p = 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p = 0.014).
Conclusion:
Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.
... Post-operative IAIs result frequently in the isolation of Enterococcus in contrast to infections presenting from the community, and the isolation of this organism may portend treatment failure and death [3,[7][8][9]. In particular, a post hoc analysis of a randomized trial comparing ciprofloxacin plus metronidazole versus imipenem-cilastatin, found that isolation of Enterococcus from surgical cultures was an independent predictor of treatment failure [8]. ...
... The incidence of enterococcal isolation increases in post-operative and health-care-associated infections [8,11]. The occurrence of a post-operative infection predicts independently the isolation of Enterococcus along with increased age and APACHE II score, whereas appendiceal infections were a negative predictor for isolation of Enterococcus [7,8,12]. In the present study, the average age was the same between groups and similar to the Enterococcus not present group in Burnett et al. [8]. ...
... Other underlying differences in treatment outcome definitions and patient characteristics between previous studies and ours may explain the discrepant results. In addition to treatment failures, several studies linked the isolation of Enterococcus from IAI cultures to increased mortality [7,[14][15][16], whereas others demonstrated no association with mortality [3,13]. Our study showed zero deaths in the Enterococcus group. ...
Background:
Enterococci are isolated frequently as pathogens in patients with intra-abdominal infections (IAIs) and may predict poor clinical outcomes. It remains controversial whether enterococci warrant an altered treatment approach with regard to antimicrobial treatment.
Patients and methods:
The study population was derived from the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial database. Through post hoc analysis subjects were stratified into two groups based on isolation of Enterococcus. Fifty subjects of the cohort (n = 518) had Enterococcus isolated. Uni-variable and multi-variable analyses were conducted to determine whether isolation of Enterococcus constituted an independent predictor of the pre-defined STOP-IT composite outcome (surgical site infection, recurrent IAI, or death) and the individual components of the composite outcome.
Results:
From the cohort of 50 subjects, we identified 52 isolates of Enterococcus spp. with a predominance of Enterococcus faecalis (40%) followed by other Enterococcus spp. (37%) and Enterococcus faecium (17%). Baseline demographic characteristics were statistically similar between the two groups. Antibiotic utilization distribution remained balanced between the Enterococcus and no Enterococcus groups with the majority receiving piperacillin-tazobactam (62% and 54%, respectively). The groups had comparable infection characteristics including setting of acquisition (>50% community acquired) and origin of infection (predominantly colon or rectum). Individual and composite clinical outcomes were not different statistically between the Enterococcus and no Enterococcus groups: surgical site infection (10% vs. 7.5%; p = 0.53), recurrent IAI (20% vs. 14.1%; p = 0.26), death (2% vs. 1%; p = 0.40), and composite of all three (30% vs. 20.9%; p = 0.14], respectively. Multi-variable analysis revealed that isolation of Enterococcus did not predict independently the incidence of the composite outcome (odds ratio [OR] 1.53 [95% confidence interval {CI} = 0.78-3.01]; p = 0.22; c-statistic = 0.65; goodness of fit, p = 0.71).
Conclusions:
Enterococcus was not a more common pathogen in health-care-associated IAIs and was not an independent risk factor for the composite outcome. The isolation of Enterococcus from IAIs may not warrant an alternative treatment approach but larger studies are needed to validate these findings.
... Risk factors for polymicrobial infection include extremes of age, being immunocompromised, having pre-existing health conditions, experiencing prolonged hospital stays (especially in ICUs), or undergoing surgical intervention. 9,14,15,189,190 More often than not, the etiology of these infections and the virulence mechanisms involved are largely unknown and although clinical reports may associate polymicrobial infections with poor outcomes, studies by Lagnaf et al. and Garc ıa-Granja et al. dispute this claim. 9,15,19,191 Early Enterococcal polymicrobial infection studies found that co-infecting mice with P. aeruginosa and E. faecalis in the model of ascending UTI aggravates pyelonephritis and persistence of P. aeruginosa in the kidneys despite b-lactam antibiotic treatment during co-infection. ...
... 85 In the hospital setting, both pre-colonization by VRE and surgery are risk factors for VRE colonization and infection in critical care patients. 14,189,190 Polymicrobial peritonitis is one of the common infections originating from a VRE colonized GI tract; that may or may not lead to poorer prognosis. 189,[196][197][198][199][200][201][202][203] Interestingly, mice colonized with VR E. faecium for 14 d in the GI tract followed by intestinal perforation (CLP; cecal ligation and puncture), suffered leakage of intestinal contents into the peritoneal cavity, but were able to accelerate bacterial clearance at 48 hours post-CLP compared with those not pre-colonized by VR E. faecium. ...
... 14,189,190 Polymicrobial peritonitis is one of the common infections originating from a VRE colonized GI tract; that may or may not lead to poorer prognosis. 189,[196][197][198][199][200][201][202][203] Interestingly, mice colonized with VR E. faecium for 14 d in the GI tract followed by intestinal perforation (CLP; cecal ligation and puncture), suffered leakage of intestinal contents into the peritoneal cavity, but were able to accelerate bacterial clearance at 48 hours post-CLP compared with those not pre-colonized by VR E. faecium. 204 This was accompanied by diminished peritoneal and plasma inflammatory response (TNF-a, IL-6 and MCP-1), and lower neutrophil-attracting and -activating chemokines (KC, MIP-2 and LIX) at 48 hours post-CLP in VR E. faecium colonized mice. ...
Enterococcus faecalis and Enterococcus faecium are common inhabitants of the human gastrointestinal tract, as well as frequent opportunistic pathogens. Enterococci cause a range of infections including, most frequently, infections of the urinary tract, catheterized urinary tract, bloodstream, wounds and surgical sites, and heart valves in endocarditis. Enterococcal infections are often biofilm-associated, polymicrobial in nature, and resistant to antibiotics of last resort. Understanding Enterococcal mechanisms of colonization and pathogenesis are important for identifying new ways to manage and intervene with these infections. We review vertebrate and invertebrate model systems applied to study the most common E. faecalis and E. faecium infections, with emphasis on recent findings examining Enterococcal-host interactions using these models. We discuss strengths and shortcomings of each model, propose future animal models not yet applied to study mono- and polymicrobial infections involving E. faecalis and E. faecium, and comment on the significance of anti-virulence strategies derived from a fundamental understanding of host-pathogen interactions in model systems.
... Patients infected with resistant or opportunistic microorganisms have been identified as being at increased risk for an adverse outcome [24,39,42,43,45,49,58,62,68]. There is a broad body of evidence that patients with HA-IAI, including patients with post-operative infections, are at increased risk for infection with resistant or opportunistic pathogens [15,17,[22][23][24]26,32,33,62,77,[85][86][87][88][89][90]. Patients who are not hospitalized, however, may nonetheless be at risk for IAI because of these micro-organisms. ...
... The criteria for identifying patients with HA-IAI were discussed in Section 1 and are listed in Table 7. Epidemiologic studies have identified a number of risk factors identifying patients with HA-IAI at risk for harboring resistant or opportunistic pathogens [15,17,19,[22][23][24]26,32,33,62,77,79,[85][86][87][88][89][90]110,340,417,418]. The task force believes that Enterococcus spp., MRSA, resistant gram-negative bacilli, and Candida spp. ...
... We suggest that broader-spectrum agents or regimens described for use in higher-risk patients with CA-IAI be used for the initial empiric antimicrobial therapy of patients Enterococci are common opportunistic micro-organisms isolated from patients with HA-IAI, although their pathogenic role in IAI is still a matter of some debate. Isolation of enterococci has been associated with a higher risk for an adverse outcome in many, but not all studies [24,27,49,58,86,88,89,119,403,408]. Patients in whom HA-IAI develops after an abdominal operation appear to be at particular risk for infection from Enterococcus spp. ...
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.
... The patients most likely to be detected with Enterococcus spp. were those with healthcareassociated infections or postoperative infections among complicated intra-abdominal infections, severe immunosuppression, recurrent infections, and long-term antibiotic use [41]. Patients detected with Enterococcus spp. ...
... had a worse prognosis than those without Enterococcus spp. [41,42]. Intra-abdominal infections caused by MRSA are rare, but the elderly, patients with significant underlying medical conditions, recent hospitalization or surgery, antibiotic therapy, or colonization of MRSA are considered high-risk groups for MRSA infections [6]. ...
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.
... and fungi, which are both associated with poor outcomes regardless of the type of peritonitis [25]. Enterococcus is associated with high death rates in peritonitis, even with adequate treatment, and an inadequate inflammatory response has been hypothesized [26,27]. It is also more frequently associated with severely ill, immunocompromised patients and with those treated with third-generation cephalosporins [28,29]. ...
... The initial severity of peritonitis and the presence of Candida spp. in cultures are also major risk factors for development of TP [30]. The higher prevalence of Candida spp. is linked with factors that are present in our population such as stomach-duodenum perforations, TPN, urgent operation, and long treatment periods with broad-spectrum antibiotic agents [7,26]. ...
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.
... In the past amoxicillin/clavulanic acid may have been a preferred choice for antimicrobial prophylaxis in abdominal surgery, because of its superior coverage of enterococci, as well as for reasons of availability and cost-effectiveness compared to other antibiotic regimes [30,31]. However, enterococcal infections are encountered less frequently after appendicitis than after biliary tract or colonic surgery [32]. Against this background, amoxicillin/clavulanic acid and cefuroxime plus metronidazole may be considered equivalent in their efficacy to prevent SSI in patients with uncomplicated appendicitis based on their expected antimicrobial spectrum. ...
Objective:
We aimed to evaluate the association between post-appendectomy SSI rates and the two most commonly used regimens for perioperative antimicrobial prophylaxis in Swiss children.
Methods:
We conducted a retrospective cohort study, analysing data from the Swiss national SSI surveillance database with a study period from 2014 to 2018. All hospitals undertaking paediatric appendectomies in Switzerland participate in the surveillance. We compared the cumulative incidence and odds of post-appendectomy SSI within 30 days of surgery in children ≤ 16 years of age undergoing appendectomy for uncomplicated appendicitis and receiving perioperative antimicrobial prophylaxis with cefuroxime plus metronidazole or with amoxicillin/clavulanic acid using multivariable adjusted logistic regression and propensity-score matching.
Results:
A total of 6207 cases were recorded in the study time frame. Overall SSI cumulative incidence was 1.9% (n = 119). 4256 children (54.9% male, median (IQR) age 12 [10, 14] years) received either cefuroxime plus metronidazole (n = 2348, 53.8% male) or amoxicillin/clavulanic acid (n = 1491, 57.0% male). SSI cumulative incidence was 1.1% (25/2348) among children receiving cefuroxime plus metronidazole and 2.8% (42/1491, p < 0.001) when receiving amoxicillin/clavulanic acid. The administration of cefuroxime plus metronidazole was associated with statistically significantly lower SSI odds compared to amoxicillin/clavulanic acid (aOR 0.35, 95%CI [0.20, 0.61], p < 0.001), and this was confirmed upon propensity-score matching.
Conclusion:
We found lower odds of post-appendectomy SSI in children receiving cefuroxime plus metronidazole compared to amoxicillin/clavulanic acid. Treating amoxicillin/clavulanic acid as the baseline, only 55 children need to receive cefuroxime plus metronidazole perioperative prophylaxis to avert one SSI. Existing guidelines recommending amoxicillin/clavulanic acid may need to be revised. Trial registration ISRCTN47727811, registered retrospectively.
... In previous studies enterococci were found in 19 to 44% of cases (13)(14)(15). According to certain authors, isolation of enterococci from peritoneal fluid is associated with a high mortality rate, particularly when virulence factors are expressed (20)(21)(22). However in the study conducted by Seguin et al. ( 14), the presence of enterococci was associated with a higher rate of intraperitoneal abscess and did not affect the mortality rate. ...
Introduction Postoperative peronitis (POP) is a serious complication, difficult to control especially with the emergence of multidrug resistant bacteria. The aim of this work was to study the epidemiological characteristics and the bacteriological profile of POP. Material and methods This is a retrospective study over a period of 6 years, from 01/01/2014 to 31/12/2019. Results Thirty-nine cases were collected, 31 of which have a positive culture of peritoneal swab. POP were characterized by a male predominance (sex-ratio: 1.61). Patients over 60 years old were mainly affected (64.7%). The main antecedents observed were abdominal surgery (89.7%) and neoplastic disease (77%). The most frequent etiology of postoperative peritonitis was anastomotic leakage (38.5%). The culture was multi-microbial in 48.4% of cases. Sixty-nine strains have been isolated. Seventy one per cent were aerobic bacteria, 21.7% were anaerobic and 7.3% were yeasts. The distribution of germs varied according to the stage of the initial intervention. Enterobacteriaceae were more prevalent in the supramesocolic stage (62.5%). In the sub-meso-colic stage, anaerobes and enterobacteriaceae accounted respectively for 28.9% and 31.1% of isolated microorganism. Multidrug resistant bacteria (n=19) were isolated in 61.3% of cases. Conclusion Considering the high rate of multi-resistant bacteria, the prevention and management of POP is a major challenge. Constant analysis of microbiological data remains essential.
... 3.3.3 Recommandations dans les péritonites nosocomiales etpostopératoires :[137,140,144,[147][148][149][152][153][154][155][156][157][158][159][160] -Dans ce type de péritonite, l'écologie bactérienne est modifiée selon chaque établissement, ce qui impose une adaptation selon les caractéristiques locales.-il faut évoquer un risque élevé d'isoler une bactérie multi-résistante dans les circonstances suivantes : Antibiothérapie dans les 3 mois qui précèdent l'hospitalisation Et/ou > 2 jours précédant le premier épisode infectieux Et/ou délai > 5 jours entre la première chirurgie et une reprise chirurgicale -Les schémas conseillés sont les suivants : La piperacilline/tazobactam (4,5 g×4 j−1) + amikacine (20mgkg−1 en une à deux injections par jour) -Si le patient présente deux critères parmi les six énoncés ci-dessous, il est à risque de bacilles multi-résistants (BMR) : Traitement antérieur par céphalosporine de 3éme génération ou fluoroquinolone (dont monodose) dans les 3 mois Portage d'une entérobactérie porteuse d'une bêta-lactamase à spectre élargie, ou Pseudomonas aeruginosa résistant à la ceftazidime, sur un prélèvement de moins de 3 mois, quel que soit le site Hospitalisation à l'étranger dans les 12 mois précédents Patient vivant en établissement d'hébergement pour personnes âgées dépendantes (EHPAD) médicalisé ou soins de longue durée ET porteur d'une sonde à demeure et/ou d'une gastrotomie Echec de traitement par une antibiothérapie à large spectre par céphalosporine de 3éme génération ou fluoroquinolone ou pipéracilline-tazobactam Récidive précoce (< 15 jours) d'une infection traitée par pipéracillinetazobactam pendant au moins 3 jours). ...
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.
... A total of 13 observational studies investigated whether severe CA-IAI and HA-IAI required empiric therapy against enterococci [230,[257][258][259][260][261][262][263][264][265][266][267][268]. The risk factors for enterococcal infection were revealed using meta-analysis. ...
The Chinese guidelines for IAI presented here were developed by a panel that included experts from the fields of surgery, critical care, microbiology, infection control, pharmacology, and evidence-based medicine. All questions were structured in population, intervention, comparison, and outcomes format, and evidence profiles were generated. Recommendations were generated following the principles of the Grading of Recommendations Assessment, Development, and Evaluation system or Best Practice Statement (BPS), when applicable. The final guidelines include 45 graded recommendations and 17 BPSs, including the classification of disease severity, diagnosis, source control, antimicrobial therapy, microbiologic evaluation, nutritional therapy, other supportive therapies, diagnosis and management of specific IAIs, and recognition and management of source control failure. Recommendations on fluid resuscitation and organ support therapy could not be formulated and thus were not included. Accordingly, additional high-quality clinical studies should be performed in the future to address the clinicians’ concerns.
... The question is if, at all, under what conditions E. faecium has to be included in designing strategic antibiotic regimens. Post-operative enterococcal infections are associated with increased mortality rates [37]. In our study population, an increased mortality rate was observed in antibiotically pretreated patients with intraabdominal E. faecium. ...
Background:
Complicated diverticulitis of the sigmoid colon typically is treated by resection after initial antibiotic treatment. Third-generation cephalosporins are the drugs of choice but are not effective against enterococci and can induce colonic colonization by Enterococcus faecium within hours. Infections caused by enterococci, especially E. faecium, are difficult to treat but should be considered in the strategic treatment planning of hospital-acquired peritonitis (e.g., anastomotic leakage), especially in immunocompromised patients.
Methods:
To determine whether the duration of pre-operative ceftriaxone treatment in complicated diverticulitis increases the incidence of intra-abdominal E. faecium detection, we analyzed all patients operated on for diverticulitis of the sigmoid colon in our department between 2008 and 2016.
Results:
Analyzing 516 resections performed for complicated diverticulitis, we found that E. faecium generally was detected intra-abdominally more often in the group that underwent longer pre-operative ceftriaxone treatment (≥ 4 days). During primary resection, E. faecium was detected in 2.7%, 11.1%, and 37.0% cases in the group undergoing immediate operation, 1-3 days of antibiotic treatment, and ≥4 days of antibiotic treatment, respectively. Enterococcus faecium was detected in 0, 25.0%, and 70.6% of surgical revisions and 28.6%, 14.3%, and 56.0%, respectively, of incisional surgical site infections with identified pathogens. A multivariable analysis discovered anastomotic leakage and antibiotic treatment lasting ≥4 days to be independent risk factors for intra-abdominal isolation of E. faecium.
Conclusion:
A ceftriaxone treatment ≥4 days led to a higher incidence of intra-abdominal E. faecium. Our data further suggested that empiric coverage of E. faecium in the treatment of hospital-acquired peritonitis could be beneficial after a long duration of ceftriaxone treatment.
... All bacteria including resistant GPC in PP have to be treated [20,21], but some specific issues are still debated [22]. The timing of initiation of glycopeptides has never been specifically addressed. ...
Purpose
In postoperative peritonitis, Gram stain examination (GSE) of peritoneal fluid has been proposed as a guide for the prescription of glycopeptides and antifungal therapy in empirical antibiotherapy. No data support this approach for Gram-positive cocci. We aimed to evaluate the performance of GSE in predicting the results of the culture of peritoneal fluid.
Methods
In this retrospective single-center study, concordance between GSE and culture of peritoneal fluid was assessed for different types of microorganisms. Factors associated with concordance of the two tests were evaluated in the subpopulation of Gram-positive cocci peritonitis.
Results
Among the 152 episodes, the GSE was negative in 57 cases. The negative predictive value and the positive predictive value were 41% and 87% for Gram-positive cocci (GPC), 31% and 86% for Gram-negative bacilli, and 78% and 94% for fungi. GSE is not a reliable guide for the choice of empirical antibiotherapy and cannot reliably rule out the presence of GPC at culture. If we aim to achieve a high rate of adequacy, the systematic use of glycopeptide in the empirical antibiotherapy may be considered.
Conclusion
GSE shows poor performance to predict the results of culture of peritoneal fluid in postoperative peritonitis. Avoiding covering resistant GPC cannot be based on the result of GSE.
... [24] Thus, postoperative patients are unusually vulnerable to E faecalis infection, which worsens disease severity and clinical outcome. [25,26] PI and HPVG are rare but potentially lethal conditions mostly associated with several acute abdominal conditions such as inflammatory bowel disease, infections, graft-versushost disease, diverticulitis, bowel obstruction, and ischemic enterocolitis. [27][28][29] Although the mechanism is not fully understood, many researchers hold to a mechanical theory, in which PI and HPVG stem from flatus escaping through a damaged intestinal mucosa into the submucosal stroma and vessels and, from there, into the portal venous system. ...
Rationale:
Pneumatosis intestinalis (PI) and hepatic portal venous gas (HPVG) are rare but potentially lethal conditions in which gas pathologically accumulates in the portal vein and intestinal wall, respectively. Proposed mechanisms include flatus escaping through an injured intestinal mucosa into the submucosa and thence into the portal venous system, or bacterial translocation (BT) of gas-forming enteric microorganisms from the gut into and through the intestinal wall to other organs. However, there has been no clear histopathological evidence to support these hypotheses.
Patient concerns:
A 61-year-old man underwent sigmoidectomy for colonic adenocarcinoma. Postoperatively, he developed paralytic ileus and then had a sudden cardiopulmonary arrest.
Diagnoses:
PI and HPVG were found at autopsy, presumably caused by the postoperative paralytic ileus and associated with BT of gas-forming organisms.
Interventions:
Cardiopulmonary resuscitation was unsuccessful.
Outcomes:
Postmortem imaging indicated the presence of massive PI and HPVG. At autopsy, there was marked intestinal emphysema with diffuse ischemic mucosal necrosis and severe pneumatosis in the stomach and intestine and marked gaseous dilation of the intrahepatic portal veins. Postmortem bacterial cultures revealed enteric bacteria in the peripheral blood and liver tissue.
Lessons:
Postoperative ileus leading to intestinal mucosal damage may be associated with BT of gas-forming enteric bacteria and the rapid onset of PI and HPVG with a lethal outcome.
... Isolation of Enterococcus is more common among patients with health care-associated intra-abdominal infection, particularly those with postoperative infections, and its isolation is a risk factor for treatment failure and death [116,117]. Thus, in patients with health care-associated intra-abdominal infection, including those with postoperative infection, a reasonable option would be to include coverage of Enterococcus in the empiric regimen until definitive culture results are available. Ampicillin and vancomycin are agents that have activity against this organism and could be added to a regimen lacking antienterococcal activity. ...
BACKGROUND
Antimicrobial resistance and inappropriate antibiotic regimen hamper a favorable outcome in intra-abdominal infections. Clinicians rely on the minimum inhibitory concentration (MIC) value to choose from the susceptible antimicrobials. However, the MIC values cannot be directly compared between the different antibiotics because their breakpoints are different. For that reason, efficacy ratio (ER), a ratio of susceptible MIC breakpoint and MIC of isolate, can be used to choose the most appropriate antimicrobial.
MATERIALS AND METHODS
A prospective, observational study conducted during 2015 and 2016 included 356 Escherichia coli and 158 Klebsiella spp. isolates obtained from the intra-abdominal specimens. MIC was determined by microbroth dilution method, and ER of each antibiotic was calculated for all the isolates.
RESULTS
For both E. coli and Klebsiella spp., ertapenem, amikacin, and piperacillin/tazobactam had the best activities among their respective antibiotic classes.
DISCUSSION
This is the first study calculating ER for deciding empiric treatment choices. ER also has a potential additional value in choosing the use of susceptible drugs as monotherapy or combination therapy. A shift in ERs over a period of time tracks rising MIC values and predicts antimicrobial resistance development.
CONCLUSION
Estimation of ER could be a meaningful addition for the interpretation of an antimicrobial susceptibility report, thus helping the physician to choose the best among susceptible antimicrobials for patient management.
... Some evidence also exists that enterococcal infections are an important cause of postoperative abdominal infections in people. 37 Given the emergence of vancomycin resistance in people and the data presented in our study, it may be prudent to discourage vancomycin treatment for enterococcal infections when cultured as a coinfection. In addition, the susceptibility data reviewed here do not support empirical use of vancomycin for non-enterococcal infections, but it could be considered after full susceptibility data are available on a case-by-case basis. ...
Background
Vancomycin is commonly used to treat resistant bacterial infections in people. Reported adverse effects of vancomycin in people include acute kidney injury (AKI), neutropenia, and systemic allergic reaction. Given the increased incidence of vancomycin‐resistant bacterial infections in people, support is growing for restriction of vancomycin.
Objectives
To evaluate the use of intravenous (IV) vancomycin in a university teaching hospital and to describe potential adverse effects.
Animals
Twenty‐nine dogs and 7 cats.
Methods
Medical records of dogs and cats treated with IV vancomycin at the Foster Hospital for Small Animals between January 2003 and October 2017 were reviewed. Information recorded included signalment, infection source, vancomycin dosing, potential adverse effects, and outcome.
Results
Vancomycin was used to treat infections from a range of sources with a variety of dosing intervals. The most common bacterial isolates susceptible to vancomycin included Enterococcus sp. (11/36, 30.6%), methicillin‐resistant Staphylococcus aureus (8/36, 22.2%), and methicillin‐resistant Staphylococcus pseudintermedius (2/36, 5.6%). AKI occurred in 6 of 36 patients (16.7%) during vancomycin treatment but could not definitively be attributed to vancomycin treatment in any patients because of illness severity, additional nephrotoxic treatments, or both. Neutropenia or allergic reaction was not documented in any animal. In 2 of 36 patients (5.6%), susceptibility data documented an infection that was only susceptible to vancomycin. Most patients survived to discharge (25/36, 69.4%).
Conclusions and Clinical Importance
Adverse effects attributable to vancomycin were infrequent in dogs and cats. In most cases, there were potential alternative effective antimicrobials or lack of susceptibility data to support vancomycin treatment.
... Plusieurs études tendent à montrer l'absence de pathogénie, y compris des études récentes[2,71]. D'autres auteurs, à l'inverse, démontrent le rôle pathogène de ce cocci gram positif[14,39,46,72,73].L'enterocoque étant naturellement résistant aux céphalosporines et cet antibiotique étant proposées par la SFAR dans 3 des schémas thérapeutiques, le taux de résistance dans notre série est donc immanquablement majoré. Notre étude ne montre pas de taux de complication plus importante en cas de première antibiothérapie inefficace (largement expliqué par la résistance de l'entérocoque aux C3G), laissant supposer un rôle peu pathogène de l'Entérocoque. ...
La péritonite aiguë communautaire, pathologie grave, se traite par la chirurgie avec l'adjonction d'une antibiothérapie initialement probabiliste. Les recommandations françaises de 2000 n'ont pas été réactualisées. Simultanément, les bactéries résistantes sont en pleine croissance. L'objectif de notre étude était d'évaluer la mobi-mortalité quand l'antibiothérapie empirique était inefficace. Matériel et méthodes : Étude rétrospective monocentrique au CHU de Rouen, de janvier 2010 à octobre 2012, nous avions évalué 99 patients atteints d'une péritonite aiguë communautaire, réanimatoire ou non. Un groupe "ATBproba +" (n = 33) et un groupe "ATBproba -" (n = 66) ont été comparés. Le travail analysait statistiquement l'impact sur la morbi-mortalité. Secondairement, les profils de sensibilité des protocoles d'antibiothérapies recommandées par le consensus français étaient recherchés. Résultats : En analyse globale, le taux de mortalité n'était pas différent entre les 33 patients ayant reçu une antibiothérapie initiale efficace et les 66 patients dont l'antibiothérapie empirique était résistante (12,1% vs 16,7%, p = 0,77). De même, le taux de guérison n'était pas significativement différent (69,7% vs 54,5%, p = 0,19). Les protocoles d'antibiothérapie initiale gardaient une sensibilité acceptable vis-à-vis de l'écologie bactérienne digestive. Conclusion : Dans notre population, la morbi-mortalité n'est pas impactée par l'efficacité de l'antibiothérapie initiale. Les recommandations SFAR 2000 restent d'actualité.
... Deux études cliniques récentes apportent des arguments supplémentaires venant appuyer la thèse expérimentale développée précédemment. [50,51] Etude de Burnett et al [50] Cet essai prospectif, randomisé, multicentrique, en double aveugle d'une équipe américaine avait pour but de rechercher le rôle des entérocoques dans les infections intra-abdominales. L'essai a porté sur un total de 330 patients présentant une péritonite secondaire traitée soit par imipénème, soit par l'association ciprofloxacine / métronidazole. ...
Parmi les péritonites, les péritonites post-opératoires occupent une placeparticulière par leur fréquence importante (95% des péritonites nosocomiales),par le fait que ce sont des complications trompeuses et souvent mésestiméeset surtout par leur pronostic très sévère (entre 30 et 70% de mortalité). Cettecomplication pose pour les praticiens un double problème: la reconnaissancede la complication et la mise en place d'un traitement étiologique completd'emblée. En effet , les péritonites post-opératoires présentent par rapport auxautres péritonites, la particularité supplémentaire d'avoir une écologiebactérienne très difficile. Ceci explique en partie la lourde mortalité observéeet pourquoi dans cette catégorie de péritonites , encore plus que dans lesautres, il est donc particulièrement important de prescrire le traitement le plusadéquat possible dès le diagnostic établi. Cependant, si la prise en chargedes péritonites communautaires est bien codifiée , il existe en effet plusieursconférences de consensus sur ce sujet, il n'existe que très peu d'écrit dans lalittérature médicale concernant les péritonites post-opératoires en particulier.Ainsi, les cliniciens confrontés à cette complication sont donc contraints, pourprendre une décision de traitement, d'extrapoler les résultats obtenus à partird'études cliniques incluant des patients hospitalisés pour des péritonitesmoins sévères. L'objectif de ce travail est donc de rassembler des étudespouvant permettre aux cliniciens d'orienter leur décision.
... Resistant flora may include the non-fermenting gramnegative Pseudomonas aeruginosa, very dangerous either in the abdominal cavity, [261] or in hepatobiliary surgery [262][263][264][265] and Acinetobacter spp, ESBL-producing K. pneumonia, E. coli and vancomycin-resistant enterococci (VRE) [266,267]. ...
The original article [1] contained an error whereby a co-author, Boris Sakakushev had their name spelt incorrectly. The original article has now been updated to display Dr. Sakakushev's name correctly.
... Resistant flora may include the non-fermenting gramnegative Pseudomonas aeruginosa, very dangerous either in the abdominal cavity, [261] or in hepatobiliary surgery [262][263][264][265] and Acinetobacter spp, ESBL-producing K. pneumonia, E. coli and vancomycin-resistant enterococci (VRE) [266,267]. ...
Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide.
The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important.
In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs.
The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.
... Although Enterococci were also present in community-acquired infections, they were more prevalent in HA-IAIs (22.3% in HA-IAIs versus 13.9% in CA-IAIs). Some studies have demonstrated poor outcomes among patients with documented enterococcal infections [185][186][187][188], particularly in those with post-operative IAIs where Enterococci coverage should always be considered. Empirical coverage of Enterococci is not generally recommended for patients with CA-IAIs. ...
This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.
... Die Behandlungsbedürftigkeit im Rahmen polymikrobieller Infektionen, z. B. einer sekundären Peritonitis, insbesondere als kalkulierte Therapie, ist noch nichtabschließend geklärt.Die Kausalität des Enterokokkennachweises einschließlich von VRE hinsichtlich Morbidität und Letalität konnte nicht eindeutig belegt werden [5,29]. Lediglich nach Lebertransplantation war die Kolonisation mit VRE mit einem erhöhten Infektionsrisiko verbunden [37]. ...
Background:
The role of enterococci in the context of peritonitis and surgical site infections (SSI) has not yet been definitively clarified but enterococci are being detected more frequently. Numerous resistances reduce the available antibiotic options.
Objective:
This article gives an overview of the pathogenic importance of enterococci and of current recommendations for therapy and prophylaxis. On the basis of our own data we discuss the relevance of enterococci for SSI.
Material and methods:
All colorectal resections carried out between January 2008 and September 2016 were retrospectively documented. Revision surgery, SSI and intra-abdominally or subcutaneously detected pathogens were recorded.
Results:
A total of 2713 interventions were evaluated with 28.3% having primary peritonitis. In 587 patients (21.6%) SSI followed, and pathogen determination was possible in 431 cases (73.4%). Enterococci were frequently found in re-operations (58.4%) and SSI (46.1%), with E. faecalis and E. faecium in approximately equal proportions. If intra-abdominal enterococci were detectable in patients with primary peritonitis, it was more common to develop SSI and enterococci were more frequently detected subcutaneously. Enterococci in SSI were found to be significantly more frequent in left hemicolectomies as well as in pre-existing renal insufficiency.
Conclusion:
It can be inferred that enterococci are not adequately covered by commonly used perioperative antibiotic therapy or preoperative prophylaxis, which increases the risk for SSI by enterococci. This could be favored by selection of these pathogens due to the use of antibiotics without enterococcal efficacy (e. g. cephalosporins). The consideration in the choice of perioperative antibiotic prophylaxis by the additional administration of ampicillin or vancomycin could be advantageous.
... Among Gram-positive bacteria, enterococci play a significant role in IAI. Some studies have demonstrated poor outcomes among patients with documented enterococcal infections, particularly in those with postoperative IAI [124][125][126][127] where enterococci coverage should be always considered. ...
Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients.
The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance.
The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria.
An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.
El peritoneo: descripción de un nuevo síndrome es el resultado de múltiples cuestionamientos surgidos durante la formación como médicos y cirujanos de los autores, referente a la función del peritoneo en el sentido orgánico específicamente en su aplicación práctica, sin perder de vista el beneficio para los pacientes y de sus familiares.
Riassunto
La peritonite secondaria è un’infiammazione acuta del peritoneo conseguente alla perforazione del tratto digerente o alla diffusione di un’infezione intraddominale. Viene fatta una distinzione tra infezioni comunitarie e infezioni associate al trattamento, principalmente postoperatorio. I germi coinvolti sono quelli della flora digestiva, principalmente enterobatteri e anaerobi nelle infezioni comunitarie, ma anche cocchi Gram-positivi, lieviti e bacilli Gram-negativi non fermentanti nelle infezioni associate al trattamento. È spesso complicata da shock settico. Si tratta di un’urgenza diagnostica e terapeutica. Ogni ora persa peggiora la prognosi. La diagnosi è il più delle volte clinica, supportata dallaTC, e può essere difficile da stabilire durante un’infezione postoperatoria. Il trattamento è chirurgico e medico. Il trattamento eziologico si basa su tecniche chirurgiche o interventistiche per identificare ed escludere la causa dell’infezione, prelevare campioni microbiologici, eseguire una toilette peritoneale e prevenire la recidiva. Il trattamento medico supporta le conseguenze dell’infezione mediante rianimazione perioperatoria e trattamento antibiotico probabilistico poi diretto contro i germi isolati nei campioni perioperatori. La terapia antibiotica che non tiene conto di tutti i germi isolati e la gestione tardiva sono fattori di fallimento del trattamento, di persistenza dell’infezione e di morte. La peritonite rimane gravata da un’elevata mortalità, in particolare quando si manifesta in un soggetto anziano con patologie sottostanti, operato tardivamente, soprattutto quando si tratta di un’infezione postoperatoria.
Resumen
La peritonitis secundaria corresponde a una inflamación aguda del peritoneo como consecuencia de una perforación del tubo digestivo o de la extensión de una infección intraabdominal. Se distinguen dos tipos de infecciones: las comunitarias y las asociadas a los cuidados, en su mayoría postoperatorios. Los gérmenes implicados son los de la flora digestiva, principalmente enterobacterias y anaerobios en las infecciones comunitarias, pero también cocos grampositivos, levaduras y bacilos gramnegativos no fermentadores en las infecciones asociadas a cuidados. A menudo se complica con un shock séptico. Se trata de una urgencia diagnóstica y terapéutica, ya que cada hora perdida ensombrece el pronóstico. El diagnóstico suele ser clínico, se confirma mediante tomografía computarizada (TC) pero puede ser difícil de establecer cuando se trata de una infección postoperatoria. El tratamiento es quirúrgico y médico. El tratamiento etiológico está basado en la cirugía o en técnicas intervencionistas para identificar y eliminar la causa de la infección, recoger muestras microbiológicas, realizar una toilette peritoneal y prevenir la recidiva. El tratamiento médico se ocupa de las consecuencias de la infección mediante la reanimación perioperatoria y el tratamiento antibiótico, que primero es probabilista y después específico contra los gérmenes aislados en las muestras perioperatorias. Una antibioticoterapia que no cubra todos los gérmenes aislados y un tratamiento tardío son factores para el fracaso terapéutico, la persistencia de la infección y la muerte. La peritonitis sigue teniendo una elevada mortalidad, sobre todo cuando aparece en el anciano, portador de enfermedades subyacentes, operado tarde, sobre todo cuando se trata de una infección postoperatoria.
Objective. Studying of rate and structure of peritonitis of various genesis.
Materials and methods. During 2020 yr in the Department of Surgery of Brovary Multidisciplinary Clinical Hospital 265/1316 (20.1%) patients, including 124 (47,8%) women and 141 (53,2%) men, suffering peritonitis, were operated.
Results. Appendicitis have constituted a most frequent cause of local and diffuse peritonitis – in 71.5 and 92.3% patients, accordingly. Spread peritonitis in 55.2% patients was caused by perforative gastric or duodenal ulcer. Total peritonitis was present in 35.7% of cases and caused by abdominal trauma mainly. Treatment of spread forms of peritonitis (prevalent, diffuse and a total one) was conducted in 121 (45.7%) patients, suffering this disease.
Conclusion. It is mandatory to take into account the peritonitis spread, cause, stage and character of exudate while planning preoperative preparation, surgery and the postoperative treatment volume in patients with this disease.
Intra-abdominal infections can be classified into uncomplicated or complicated (peritonitis). Peritonitis is divided into primary, secondary, and tertiary. Tertiary peritonitis is the less common but the most severe among peritonitis stratifications, being defined as a recurrent intra-abdominal infection that occurs 48 h after a well-succeeded control of a secondary peritonitis. This disease has a complex pathogenesis that is closely related to the capacity of the peritoneal cavity to activate immunological processes. Patients who progress to persistent peritonitis are at an increased risk of developing several infectious complications such as sepsis and multiple organ failure syndrome. Moreover, tertiary peritonitis remains an important cause of hospital death mainly among patients with associated risk factors. The microbiological profile of organisms causing tertiary peritonitis is often different from that observed in other types of peritonitis. In addition, there is a high prevalence of multidrug-resistant pathogens causing this condition, and an appropriate and successful clinical management depends on an early diagnosis, which can be made easier with the use of clinical scores presenting a good prediction value during the intensive care unit admission. Complementarily, immediate therapy should be performed to control the infectious focus and to prevent new recurrences. In this sense, the treatment is based on initial antimicrobial therapy and well-performed peritoneal drainage.
Microbiology is integrated in general surgical practice, and a knowledge of basic microbiology is essential for appropriate and safe surgical practice. The field of microbiology is extremely wide and detailed knowledge of microbiological tests is not mandatory for a surgeon. Nonetheless, a surgeon should ensure that sampling technique, specimen storage before transportation, and specimen transportation are managed properly. When the preanalytical specimen management is not performed correctly, the microbiological results will be influenced, and interpretation could be misleading. The results of microbial examination may be utilized for two purposes: (1) diagnosis and therapy of infection in individual patient and (2) support to the healthcare-associated infections control in the hospital. The surgeon is responsible for correct indication of microbiological examination. The results of microbiological testing may have great importance for the choice of therapeutic strategy for every individual patient, in particular in the adaptation of targeted antimicrobial therapy. The surgeon should be aware of current recommendation for microbial screening of surgical patients. The proper interpretation of microbiological results is one of the most challenging duties of clinical microbiology laboratory - thus, a collaboration between the microbiologist and the surgeon is an essential requirement.
Background
Sepsis requiring admission to intensive care (ICU) is a rare complication of elective surgery, but is associated with high morbidity and mortality. The aim of this study was to describe the incidence and outcome of sepsis following elective surgery.
Methods
This was a retrospective, observational study where all admissions to Icelandic ICUs during calendar years 2006, 2008, 2010, 2012, 2014 and 2016 were screened, identifing patients with sepsis following elective surgery (ACCP/SCCM criteria). The number of elective operations performed at the largest center (Landspitali) during the study years were collected. Descriptive statistics were used to assess the incidence and outcome of patients with sepsis after elective surgery.
Results
During the study years, 88 patients were admitted to Icelandic ICUs with sepsis following elective surgery. Of those, 80 were operated at Landspitali, where the incidence of sepsis was 0.19% per elective procedure, highest following pancreaticoduodenectomies (14%, CI 6‐25) and esophagectomies (13%, CI 4‐27), but the greatest number of patients (30% (26/88)) developed sepsis after a colorectal procedure. The most common infection sources were the abdomen (65% (57/88)) and lungs/mediastinum (22% (19/88)), frequently polymicrobial (58% (36/62) of patients with cultures). The incidence of insufficient empirical antibiotics was high (50% (30/60)). The median ICU and hospital length‐of‐stay were 5.5 and 26 days and the 28‐day and 1‐year mortality rates were 16% (14/88) and 41% (36/87), respectively.
Conclusions
Incidence of sepsis following elective surgery is low in Iceland but mortality is high. Initial antimicrobial therapy needs careful consideration in these hospital‐acquired, often polymicrobial infections.
Introduction: infections caused by Vancomycin-resistant Enterococcus (VRE) have higher mortality in critically ill patients, associated with increase in this pattern of
resistance, especially in the Americas, which is why adequate empirical antimicrobial therapy is essential to improve outcomes
Objective: to determine the risk factors associated with the development of infection by VRE in septic patients in the Intensive Care Unit (ICU) of San José Hospital
in Bogotá, Colombia.
Methods: Case-control study in septic patients admitted to the ICU during 2016 and 2017. The cases were defined as patients with VRE infection and the controls
were patients with infection by another germ.
Results: 32 patients with EVR isolation and 96 controls were included. The risk factors associated with infection by EVR were: parenteral nutrition (OR 15.7 IC 4.2-
71.4), peritoneal lavage (OR 8.9 IC 3.2-24.8), polymicrobial culture (OR 19,9 IC 6.0-83.4). Mortality was 56.2% in cases and 33.3% in controls.
Conclusions:. The risk factors found most frequently were: multiple peritoneal lavage, parenteral nutrition and polymicrobial cultures. We found a significant correlation in the use of adequate empirical antibiotic and the reduction in mortality
Background
The association between bacterial infection and clinically relevant postoperative pancreatic fistula (CR‐POPF) after pancreatoduodenectomy (PD) has not been fully elucidated.
Methods
Microbiological data for intraoperative bile culture (BC) and drain culture on postoperative day 4 (DC) were collected. The study population was classified into the following 3 groups: P1 (positive BC and DC), P2 (positive BC and negative DC), and N (negative BC). A total of 209 patients (P1: 38, P2: 72, and N: 99) who underwent PD between May 2013 and May 2018 met the inclusion criteria of the study.
Results
The rate of CR‐POPF was significantly higher in the P1 group (34.2%) than in the P2 (12.5%; P = 0.007) and N groups (14.1%; P = 0.008). Between P1 and P2 groups, a significant difference was observed in the proportion of Enterococcus faecalis grown in BC (42.1% versus 4.2%; P <0.001). Multivariable logistic regression analysis showed that the presence of E. faecalis in bile was independently associated with CR‐POPF.
Conclusions
The detection of both bile and postoperative abdominal fluid infections can be more accurate in predicting CR‐POPF. Furthermore, the presence of E. faecalis in bile may serve as a novel surrogate marker for CR‐POPF.
Background:
Delayed treatment of seriously infected patients results in increased mortality. However, antimicrobial therapy for the initial 24 to 48 hours is mostly empirically provided, without evidence regarding the causative pathogen. Whether empiric anti-enterococcal therapy should be administered to treat intra-abdominal infection (IAI) before obtaining culture results remains unknown. We performed a meta-analysis to explore the effects of empiric enterococci covered antibiotic therapy in IAI and the risk factors for enterococcal infection in IAI.
Methods:
We searched multiple databases systematically and included 23 randomized controlled trials (RCTs) and 13 observational studies. The quality of included studies was assessed, and the reporting bias was evaluated. Meta-analysis was performed using random effects or fixed effects models according to the heterogeneity. The risk ratio (RR), odds ratio (OR), and 95% confidence interval (CI) were calculated.
Results:
Enterococci-covered antibiotic regimens provided no improvement in treatment success compared with control regimens (RR, 0.99; 95% CI, 0.97-1.00; p = 0.15), with similar mortality and adverse effects in both arms. Basic characteristic analysis revealed that most of the enrolled patients with IAI in RCTs were young, lower risk community-acquired intra-abdominal infection (CA-IAI) patients with a relatively low APACHE II score. Interestingly, risk factor screening revealed that malignancy, corticosteroid use, operation, any antibiotic treatment, admission to intensive care unit (ICU), and indwelling urinary catheter could predispose the patients with IAI to a substantially higher risk of enterococcal infection. "Hospital acquired" itself was a risk factor (OR, 2.81; 95% CI, 2.34-3.39; p < 0.001).
Conclusion:
It is unnecessary to use additional agents empirically to specifically provide anti-enterococcal coverage for the management of CA-IAI in lower risk patients without evidence of causative pathogen, and risk factors can increase the risk of enterococcal infection. Thus, there is a rationale for providing empiric anti-enterococcal coverage for severely ill patients with CA-IAI with high risk factors and patients with hospital-acquired intra-abdominal infection (HA-IAI).
The purpose of this study was to evaluate the clinical significance of fungi and multidrug-resistant organisms (MDROs) isolated from patients with intra-abdominal infections (IAIs). This multicenter study included consecutive patients admitted for microbiologically proven IAIs at six university-affiliated hospitals in South Korea between 2016 and 2018.
A total of 1571 patients were enrolled. Multivariable logistic regression analysis revealed that the isolation of MDROs, isolation of Candida spp., underlying renal diseases, Charlson comorbidity score ≥ 3, septic shock, failure to receive a required surgery or invasive intervention, secondary bacteremia due to IAIs, and lower body mass index were found to be independent predictors for 28-day mortality. However, the isolation of Enterococcus spp. was not identified as a significant risk factor. MDROs and Candida spp. were found in 42 (2.7%) and 395 (25.1%), patients respectively. The isolation of MDROs or Candida spp. was a surrogate marker of 28-day mortality.
Objective:
Introduction: Intra-abdominal infections are a common cause of morbidity and mortality worldwide. Early clinical diagnosis and appropriate antimicrobial therapy are the cornerstones in the management of all infections. The aim: Aim of our work was to obtain the first national estimates of the current prevalence of intra-abdominal infections and resistance of their causative agents to antibiotics in Ukrainian hospitals.
Patients and methods:
Materials and methods: In total of 1986 patients with microbiologically proven IAI were included in the study. The identification and antimicrobial susceptibility to antibiotics of cultures were determined, using automated microbiology analyzer and Kirby - Bauer antibiotic testing.
Results:
Results: Among 1986 patients, 1404 (70.7%) community-acquired and 582 (29.3%) nosocomial infections were observed. Death during hospitalization was reported in 4.1% community-acquired cases and 7.7% nosocomial cases. The distribution of the microorganisms differed according to the nosocomial or community origin of the infection but not according to their location. In nosocomial patients were observed with increased proportions of Enterococcus faecalis and Pseudomonas aeruginosa. The carbapenems and amikacin were the most consistently active against Enterobacteriaceae. Against P. aeruginosa, amikacin, imipenem, ceftazidime and ciprofloxacin were the most active agents in community-acquired infections, while imipenem, cefepime and amikacin were the most active agents in nosocomial cases.
Conclusion:
Conclusions: The significant risk factors defined should be addressed preoperatively to decrease the risk for nosocomial infections. Antibiotics application tactics should be determined in accordance with the local data of resistance to them in each surgical hospital.
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.
Enterococci spp. cause serious infections in ICU environment, associated with high mortality. The importance of know the risk factors for VRE , are the patients with septic shock to admission of icu and surgical abdominal with request parenteral nutrition for set up the empirical management appropriated.
Purpose: To clarify the relationship between prophylactic antibiotics and perineal wound infection by examining the causative bacteria and risk factors for perineal wound infection following abdominoperineal resection (APR) for rectal and anal canal cancer. Methods: We examined causative bacteria in 43 patients given a diagnosis of perineal wound infection among 173 patients who underwent APR between October 2002 and November 2013. The prophylactic antibiotic given during this period was cefmetazole (CMZ), which was converted to ampicillin/sulbactam (ABPC/SBT) from November 2013. Next, we analyzed risk factors for perineal wound infection in 203 patients treated between October 2002 and April 2015 through univariate and multivariate analyses. Results: The most common causative bacteria in perineal wound infections were Staphylococcus species in 72.1% of cases, followed by Enterococcus species, which are not susceptible to CMZ, in 34.9%. The incidence of perineal wound infection caused by the type of prophylactic antibiotic was found in 43 patients (24.9%) in the CMZ group and 3 patients (10.0%; P=0.097) in the ABPC/SBT group, indicating a lower tendency in the latter group. The results of multivariate analysis identified age (≥70 years), diabetes (present), and prophylactic antibiotics (CMZ group) as independent risk factors for perineal wound infection. Conclusions: Our findings suggest that the prophylactic antibiotics ABPC/SBT suppress the onset of retroperitoneal space infection to a greater degree than CMZ following APR.
Study objective:
It is unknown if beta-lactam monotherapy is sufficient for complicated intra-abdominal infections or if broader coverage is required, such as with vancomycin. This study sought to determine the clinical outcomes of piperacillin/tazobactam monotherapy compared to combination therapy with vancomycin and piperacillin/tazobactam for complicated intra-abdominal infections among patients within a surgical intensive care unit.
Design:
Retrospective cohort study.
Setting:
Three surgical intensive care units at a tertiary academic medical center.
Patients:
417 patients with a secondary peritonitis identified by International Classification of Diseases 9 codes who received either piperacillin/tazobactam monotherapy (228 patients) or piperacillin/tazobactam and vancomycin combination therapy (189 patients).
Measurements and main results:
The primary outcome was day 28 clinical cure; secondary outcomes included day 7 clinical cure, length of stay (LOS), and mortality. There were no statistically significant differences between the monotherapy and combination therapy groups with respect to day 28 clinical cure (33.9% vs. 25.5%, p=0.064), day 7 clinical cure (23.6% vs. 17.6%, p=0.14), or 28 day mortality (7% vs. 7.9%, p=0.72). LOS in the ICU was significantly shorter in the monotherapy group (6 days) compared with the combination group (7 days; p=0.04); however, hospital LOS was not significantly different.
Conclusions:
No difference was observed in clinical cure rates at day 7 or day 28 between those who received PIP/TAZ monotherapy compared to PIP/TAZ and vancomycin combination therapy. This article is protected by copyright. All rights reserved.
Background:
Management of complicated intra-abdominal infections (cIAIs) includes broad-spectrum antimicrobial coverage and commonly includes vancomycin for the empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA). Ideally, culture-guided de-escalation follows to promote robust antimicrobial stewardship. This study assessed the impact and necessity of vancomycin in cIAI treatment regimens.
Patients and methods:
A post hoc analysis of the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial was performed. Patients receiving piperacillin-tazobactam (P/T) and/or a carbapenem were included with categorization based on use of vancomycin. Univariate and multivariable analyses evaluated effects of including vancomycin on individual and the composite of undesirable outcomes (recurrent IAI, surgical site infection [SSI], or death).
Results:
The study cohort included 344 patients with 110 (32%) patients receiving vancomycin. Isolation of MRSA occurred in only eight (2.3%) patients. Vancomycin use was associated with a similar composite outcome, 29.1%, vs. no vancomycin, 22.2% (p = 0.17). Patients receiving vancomycin had (mean [standard deviation]) higher Acute Physiology and Chronic Health Evaluation II scores (13.1 [6.6] vs. 9.4 [5.7], p < 0.0001), extended length of stay (12.6 [10.2] vs. 8.6 [8.0] d, p < 0.001), and prolonged antibiotic courses (9.1 [8.0] vs. 7.1 [4.9] d, p = 0.02). After risk adjustment in a multivariate model, no significant difference existed for the measured outcomes.
Conclusions:
This post hoc analysis reveals that addition of vancomycin occurred in nearly one third of patients and more often in sicker patients. Despite this selection bias, no appreciable differences in undesired outcomes were demonstrated, suggesting limited utility for adding vancomycin to cIAI treatment regimens.
This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases.When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
In cases of community-acquired peritonitis, the adequacy of empirical antibiotic treatment has been shown to attenuate mortality
and morbidity.The impact of empirical antibiotics on the outcome of postoperative peritonitis has never been evaluated. This
study included 100 consecutively studied patients with postoperative peritonitis. The adequacy of empirical treatment was
determined by means of culture and susceptibility data obtained at the time of reoperation, and the effect of such treatment
on outcome was evaluated. One hundred resistant pathogens were isolated from 70 patients, of whom 45% died; by comparison,
mortality among those from whom susceptible organisms were isolated was 16% (P < .05). Inadequate empirical treatment was administered to 54 patients and was associatedwith poorer outcome(P ⩽ .05). The outcomeof postoperative peritonitis is affected by the choice and adequacy of the initial empirical antibiotic
therapy. Late changes in antibiotic therapy based on culture results did not affect outcome when the initial regimen was inadequate.
A prospective four-year study on the infection rate of clean operative wounds is presented. From January 1982 to June 1985, a nurse epidemiologist and a medical team assessed 4,468 operative procedures, from the day of surgery to the patients' discharge from the hospital. The infection rate was 3.2%. A higher incidence of wound infection was detected in patients requiring emergency operations (5.1%), in drained wounds (5.4%), and in patients with conditions thought to predispose to infection, such as advanced cancer, hepatic cirrhosis, diabetes, nephrotic syndrome, previous splenectomy, and treatment with immunosuppressive drugs (7.8%). Age over 65 did not influence infection rates. There were up to tenfold differences in infection indices between surgeons performing the same clean procedures. The continued monitoring of clean wound infection rates allowed the early detection and control of infection outbreaks. Providing periodic information on infection rates to the different surgical services was associated with decreasing infection rates over time.
A total of 192 men and 139 women aged 15 to 89 years with diagnosed intra- abdominal infection were randomised in a 2:1 ratio to treatment with either intravenous piperacillin/tazobactam (3 g/375 mg every six hours) or clindamycin (600 mg every six hours) plus gentamicin (2.5 mg to 5.0 mg/kg every eight to 12 hours) in a multicentre trial. Of 147 evaluable patients with microbiologically confirmed infections, 104 were treated with piperacillin/tazobactam and 43 with clindamycin plus gentamicin. The diagnoses of perforated appendicitis (n = 79), other peritonitis (n = 32), cholecystitis/cholangitis (n = 18), intraabdominal abscess (n = 14), and diverticulitis (n = 3), were distributed proportionately between the two therapeutic groups. Ninety one of 104 patients (88%) in the piperacillin/tazobactam group and 33 of 43 patients (77%) in the clindamycin plus gentamicin group were considered cured or improved (p = 0.13). In the piperacillin/tazobactam group, 80 of 88 (91%) Bacteroides fragilis group organisms and 68 of 74 (92%) E coli isolates were eradicated; in the clindamycin plus gentamicin group, 21 of 25 (84%) Bacteroides fragilis group isolates and 23 of 30 (76%) E coli isolates were eradicated. Eleven evaluable patients in the piperacillin/tazobactam group had β-lactamase-producing organisms that were resistant to piperacillin but susceptible to piperacillin/tazobactam; in 10 of these patients (91%) bacteria were eradicated. We conclude that piperacillin/tazobactam is an effective antimicrobial drug for monotherapy of intra-abdominal infections with efficacy similar to or better than standard aminoglycoside/anti-anaerobe combinations.
• Several antibiotics have been marketed for therapeutic use in intra-abdominal infection. Often, these agents do not provide a sufficient spectrum activity against both facultative and obligate anaerobic gram-negative organisms, or have certain toxic effects that would not otherwise support their use. Guidelines have been developed for selection of antibiotic therapy for intra-abdominal infections and are presented as a statement of the Surgical Infection Society endorsed by the Executive Council. These guidelines are restricted to infections derived from the gastrointestinal tract and deal with those microorganisms commonly seen in such infections. The recommendations are based on in vitro activity against enteric bacteria, experience in animal models, and documented efficacy in clinical trials. Other concerns regarding pharmacokinetics, mechanisms of action, microbial resistance, and safety were also used in the formation of these guidelines. For community-acquired infections of mild to moderate severity, single-agent therapy with cefoxitin, cefotetan, or cefmetazole or ticarcillin—clavulanic acid is recommended. For more severe infections, single-agent therapy with carbapenems (imipenem/cilastatin) or combination therapy with either a third-generation cephalosporin, a monobactam (aztreonam), or an aminoglycoside plus clindamycin or metronidazole is recommended. Regimens with little or no activity against facultative gram-negative rods or anaerobic gram-negative rods are not considered acceptable.
(Arch Surg. 1992;127:83-89)
Objective:
To evaluate the safety and efficacy of cefepime hydrochloride plus metronidazole vs the combination of imipenem and cilastatin sodium in the treatment of complicated intra-abdominal infections in adult patients.Design:
Prospective, randomized, double-blind multicenter study.Setting:
University-affiliated hospitals in the United States and Canada.Patients:
Three hundred twenty-three patients with complicated intra-abdominal infections in whom an operative procedure or percutaneous drainage was required for diagnosis and management.Intervention:
Cefepime, 2 g, was administered intravenously every 12 hours (n=164) in addition to metronidazole, 500 mg (or 7.5 mg/kg) intravenously every 6 hours. Imipenen—cilastatin sodium, 500 mg, was administered intravenously every 6 hours (n= 159). Surgical infection management was determined by the patients' surgeons.Main Outcome Assessments:
Clinical cure, defined as elimination of all signs and symptoms relevant to the original infection; and treatment failure, defined as persistence, increase or worsening of signs and symptoms resulting in an antibiotic change, requirement of an additional surgical procedure to cure the infection, or a wound infection with fever.Results:
Of the initial isolates, 84% were susceptible to cefepime and 92% were susceptible to imipenemcilastatin. Among the 217 protocol-valid patients, those treated with cefepime+metronidizole were deemed clinical cures (88%) more frequently than were imipenemcilastatin—treated patients (76%) (P=.02). Using multivariate analysis to adjust for identified clinical risk factors for an adverse outcome (severity of presenting illness, isolation of enterococcus, type of infection, and duration of prestudy hospitalization), there was a trend (P=.06) toward a higher cure rate favoring cefepime+metronidazole. Pathogens were eradicated in significantly (P=.01) more patients treated with combined cefepime and metronidazole (89%) than with imipenem-cilastatin (76%).Conclusion:
The combination of cefepime plus metronidazole is safe and effective therapy for patients with severe intra-abdominal infections.Arch Surg. 1997;132:1294-1302
A double-blind trial was conducted in 385 patients with suspected bacterial intra-abdominal injections to compare the efficacy and safety of ampicillin-sulbactam with cefoxitin. Patients were randomized to receive either 3 g ampicillin-sulbactam (2 g ampicillin-1 g sulbactam), or 2 g cefoxitin, every 6 hours. To be evaluable, patients had to demonstrate positive culture evidence of peritoneal infection at the time of operation. A total of 197 patients were evaluable for clinical efficacy. The two treatment groups were comparable in demographic features and in the presence of risk factors for infection. Clinical success (absence of infection and of adverse drug reaction) was observed in 86% of patients in the ampicillin-sulbactam group and 78% in the cefoxitin group. Eradication of infection occurred in 88% of the ampicillin-sulbactam group and 79% of the cefoxitin group. There were no differences in the nature or frequency of side effects observed in the two groups. Ampicillin-sulbactam demonstrated no difference in safety or efficacy when compared with cefoxitin in the treatment of serious intra-abdominal infections of bacterial origin.
The enterococcus has become an important nosocomial pathogen, reported by the National Nosocomial Infections Surveillance System as the third most common pathogen associated with blood-stream infections and the second most commonly isolated pathogen overall. It is now more frequently recognized as a cause of superinfection in the surgical patient, as the possible result of the frequent use of ineffective antimicrobials for prophylaxis and treatment. Both of these findings are due, in part, to the intrinsic antimicrobial resistance of the enterococci. Of greater concern is the ready ability of this organism to acquire resistance traits. During the past 5 years, the appearance and rapid dissemination of strains with high-level resistance to vancomycin, ampicillin, gentamicin, and streptomycin have been reported; in some cases, no effective antimicrobial therapy was available to patients infected with these strains. Enterococci, in addition to their intrinsic and acquired tolerance to beta-lactams, have acquired the ability to inactivate penicillin and ampicillin via beta-lactamase production. Prompt recognition of such multiresistant enterococci, the implementation of effective infection control precautions, and rational use of antimicrobials may limit or even prevent the spread of such strains in the hospital setting.
The frequency of isolation of enterococci from surgical patients has increased significantly during the past decade, although
the role of these organisms as pathogens in mixed infections remains a mystery. Bacteremia and other infections in which enterococci
are the only pathogens frequently result in high morbidity and mortality among patients unless specific antimicrobial therapy
is initiated promptly. Debate continues concerning the necessity for treatment with such agents when this organism is isolated
as a component of a polymicrobial infecting flora. Our recent data indicate that enterococci are rarely isolated in postoperative
infections after penetrating abdominal trauma if no gastrointestinal perforation has occurred. However, they were found in
56% of postoperative infections of patients with gastrointestinal perforation. In contrast, enterococci were isolated in only
9% of cultures of specimens from patients with secondary suppurative peritonitis. The occurrence of superinfection after therapy
with a cephalosporin appears to be an important factor in this finding. Future studies are necessary to evaluate the efficacy
of antibiotic treatment of enterococcal infections and to assess the need for prophylaxis against enterococci.
Several antibiotics have been marketed for therapeutic use in intra-abdominal infection. Often, these agents do not provide a sufficient spectrum activity against both facultative and obligate anaerobic gram-negative organisms, or have certain toxic effects that would not otherwise support their use. Guidelines have been developed for selection of antibiotic therapy for intra-abdominal infections and are presented as a statement of the Surgical Infection Society endorsed by the Executive Council. These guidelines are restricted to infections derived from the gastrointestinal tract and deal with those microorganisms commonly seen in such infections. The recommendations are based on in vitro activity against enteric bacteria, experience in animal models, and documented efficacy in clinical trials. Other concerns regarding pharmacokinetics, mechanisms of action, microbial resistance, and safety were also used in the formation of these guidelines. For community-acquired infections of mild to moderate severity, single-agent therapy with cefoxitin, cefotetan, or cefmetazole or ticarcillin-clavulanic acid is recommended. For more severe infections, single-agent therapy with carbapenems (imipenem/cilastatin) or combination therapy with either a third-generation cephalosporin, a monobactam (aztreonam), or an aminoglycoside plus clindamycin or metronidazole is recommended. Regimens with little or no activity against facultative gram-negative rods or anaerobic gram-negative rods are not considered acceptable.
The charts of 480 patients with secondary bacterial peritonitis were reviewed. The antibiotics used were compared with the culture and sensitivity data obtained at surgery, and the outcomes of patients were evaluated. Patients treated with a single broad-spectrum antibiotic had a better outcome than patients treated with multiple drug treatment. Inadequate empiric antibiotic treatment was associated with poorer outcome than any other type of treatment. The outcome of this inadequate treatment group could not be improved by any antibiotic response to culture and sensitivity information after operation. Those patients treated with antibiotic coverage for anticipated organisms and having no cultures taken did as well as patients having cultures taken. Surgeons typically ignore culture data after operation, and only 8.8% of patients in this study had an appropriate change in antibiotic treatment after operation. A benefit from obtaining operative cultures could not be identified.
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.
• Surgical infection remains a leading cause of hospital morbidity and mortality. We compared the efficacy and toxicity of imipenem—cilastatin sodium in 32 patients with that of clindamycin phosphate and gentamicin sulfate in 25 patients. In the imipenem-cilastatin group, 87.5% had a favorable outcome, with a 12.5% failure rate and 13 adverse reactions. In the clindamycin-gentamicin group, 80% had a favorable outcome, with a 20% failure rate and ten adverse reactions. Two significant superinfections with Pseudomonas and Candida were noted in patients treated with impenem-cilastatin. Each group had one case of Clostridium difficile—associated colitis. Cost analysis showed no differences between treatment arms, except in the appendicitis subgroup. For serious surgical infections, single-agent therapy with imipenem-cilastatin appears to be as efficacious as combination therapy with clindamycin and gentamicin.
(Arch Surg 1988;123:322-326)
In a randomized study the clinical and bacteriologic effectiveness of imipenem was compared with the classical combination of netilmicin with clindamycin in patients who had surgery for an intraperitoneal infection, localized or generalized, with positive bacteriologic findings of the specimen taken at surgery. Excluded were all patients who received other antibiotics before surgery, or who died within 3 days after antibiotic therapy was started. Imipenem was given at a dose of 500 mg t.i.d., clindamycin 600 mg t.i.d., and netilmicin according to serum levels. The diagnoses ranged from postoperative peritonitis, gallbladder empyema, perforated gastroduodenal ulcer, small bowel perforation with and without obstruction, and perforated appendicitis to perforation of the colon. The bacteriologic work-up included examination of the primary specimen (aerobic and anaerobic), the urine, feces, and serologic testing for Candida albicans once or twice a week and after the course of antibiotic therapy. In addition, pH measurements of abscesses and drainage fluids were performed. Ninety-three patients entered the study. Forty-seven patients were treated with imipenem (test group), and 46 patients were treated with the combination therapy (control group). The two groups did not show significant differences in age, sex, diagnostic groups, risk factors, primary bacteriology, and duration of therapy (mean: 6.7 days). Thirty-eight patients (80.9%) treated with imipenem were cured, six patients (12.8%) were improved, and there were three (6.4%) failures. The respective numbers for the control group were 31 (67.4%), 10 (21.7%), and 5 (10.9%). The mean duration of hospitalization was 19 days for the test group and 24.5 days for the control group. There were four wound infections in the test group and 11 wound infections in the control group. Imipenem is at least as effective in the adjuvant therapy of intra-abdominal infections as the combination of netilmicin with clindamycin.
A prospective four-year study on the infection rate of clean operative wounds is presented. From January 1982 to June 1985, a nurse epidemiologist and a medical team assessed 4,468 operative procedures, from the day of surgery to the patients' discharge from the hospital. The infection rate was 3.2%. A higher incidence of wound infection was detected in patients requiring emergency operations (5.1%), in drained wounds (5.4%), and in patients with conditions thought to predispose to infection, such as advanced cancer, hepatic cirrhosis, diabetes, nephrotic syndrome, previous splenectomy, and treatment with immunosuppressive drugs (7.8%). Age over 65 did not influence infection rates. There were up to tenfold differences in infection indices between surgeons performing the same clean procedures. The continued monitoring of clean wound infection rates allowed the early detection and control of infection outbreaks. Providing periodic information on infection rates to the different surgical services was associated with decreasing infection rates over time.
The pathogenicity of the enterococcus remains controversial despite recognition of this organism in inflammatory exudates. A review of 114 patients with 123 bacteremic events with enterococcus from all hospital services was undertaken. A total of 46% were in the perioperative period. The clinical indications for blood culture varied, but only 19 patients had septic shock at the time. Employing three or more associated diseases as a definition, 71 patients were considered chronically ill. The primary sources of bacteremia were commonly urinary tract (22), soft tissue (17), and intra-abdominal (12). An impressive total of 48 patients had no discernible primary focus of infection. Except for the urinary tract, infections tended to be polymicrobial; 51 patients had associated synchronous or metachronous polymicrobial bacteremias. Antibiotic therapy appropriate for enterococcus did not favorably influence outcome. By chi-square analysis, patients with urinary tract and soft tissue infections had significantly better survival rates than the group as a whole, while patients with intra-abdominal sepsis, polymicrobial bacteremia, or an unknown focus of infection did statistically worse. Enterococcal bacteremia results in a high mortality (54%); its frequent identification with other facultative and anaerobic organisms may indicate that it has a synergistic role; the frequency of unexplained bacteremias stimulates speculation that primary bacteremia from the gastrointestinal tract may be a plausible explanation.
A simple system for grading the severity of sepsis has been developed by scoring the attributes of sepsis under four headings: local effects of infection, pyrexia, secondary effects of sepsis and laboratory data. The information needed should be readily available at district general hospital level. The system produces a number which indicates the severity of sepsis and which varies with the patient's condition. This system could be useful in comparing patients with sepsis and studies on such patients in different centres.
The role of enterococcus in intraabdominal infection is controversial. This study examines the contribution of enterococcus to adverse outcome in a large intraabdominal infection trial.
A randomized prospective double-blind trial was performed to compare two different antimicrobial regimens in combination with surgical or percutaneous drainage in the treatment of complicated intraabdominal infections. A total of 330 valid patients was enrolled from 22 centers in North America.
In 330 valid patients, 71 had enterococcus isolated from the initial drainage of an intraabdominal focus of infection. This finding was associated with a significantly higher treatment failure rate than that of patients without enterococcus (28% versus 14%, p < 0.01). In addition, only Acute Physiology and Chronic Health Evaluation II score and presence of enterococcus were significant independent predictors of treatment failure when stepwise logistic regression was performed (p < 0.01 and < 0.03). Risk factors for the presence of enterococcus include age, Acute Physiology and Chronic Health Evaluation II, preinfection hospital length of stay, postoperative infections, and anatomic source of infection. There was no difference between the clinical trial treatment regimens with regard to overall failure, failure associated with enterococcus, or frequency of enterococcal isolation.
This study is the first to report enterococcus as a predictor of treatment failure in complicated intraabdominal infections. This trial also identifies several significant risk factors for the presence of enterococcus in such infections.
Although single antimicrobials with broad-spectrum aerobic and anaerobic coverage are effective in patients with appendicitis, many general surgeons continue to use multiple agents. A prospective, double-blind, randomized trial was designed to detect any clinical correlate of in vitro susceptibility advantage of multiple antimicrobials as adjunctive therapy for 114 patients undergoing operation for complicated appendicitis. There was clinical resolution of intraabdominal infections with no occurrence of postoperative infectious complications in 90% (36 of 40) of the cefotetan group and 86% (31 of 36) of the clindamycin/amikacin group (p = 0.11). The number of patients who had changes in antibiotic therapy due to postoperative complications was higher in the clindamycin/amikacin group: five (12.5%), compared to one (2.8%) in the cefotetan group (p = 0.07). Although Bacteroides fragilis group organisms resistant to cefotetan were identified, none was responsible for the postoperative infections. Adverse drug events in 28% of the cefotetan group and 26% of the clindamycin/amikacin group consisted primarily of transient elevations of liver function tests. Monotherapy with a second-generation, broad-spectrum cephalosporin, such as cefotetan, given twice a day is an economical and effective adjunctive regimen in patients with complicated appendicitis for which operation is the definitive treatment. Aminoglycosides and other, more potent antimicrobials should be reserved for resistant organisms or nosocomial infections.
A randomized prospective trial was undertaken in adult patients with serious intra-abdominal infections to determine whether a new combination of antibiotic therapy could prove as efficacious as the combination that has been widely used in practice in the recent decade (clindamycin and gentamicin). Three hundred thirty-one patients were randomized in a 2:1 ratio, with the larger number of patients being treated parenterally with piperacillin and tazobactam. The results showed that both the clinical and microbiologic performance of the piperacillin/tazobactam combination was better than that of clindamycin and gentamicin. This clinical equivalence permits overall cost savings without compromising the existing quality of antimicrobial therapy for intra-abdominal infection.
Perioperative antibiotics decrease surgical wound infection (SWI) in trauma patients requiring abdominal exploration. This investigation evaluated 24 hours of cefoxitin or ampicillin/sulbactam used for early therapy in such patients. Patients were randomly assigned to one of two treatment groups. The primary endpoint evaluated was SWI, which was defined as purulent drainage or active wound treatment. Five hundred ninety-two patients were evaluated: 283 received ampicillin/sulbactam and 309 received cefoxitin. The incidence of wound infection among the ampicillin/sulbactam patients was 2% and among cefoxitin patients it was 7% (p < 0.004). The cefoxitin patients with colon injuries were analyzed (p < 0.007). The major difference between the two groups was an increased incidence of enterococcal infections in the cefoxitin-treated patients. A single broad-spectrum antibiotic given for 24 hour perioperatively effectively controls SWI. Use of ampicillin/sulbactam results in a significantly lower SWI rate than use of cefoxitin, which may be a result of improved enterococcal and Bacteroides coverage.
Objective:
In a randomized, double-blind, multicenter trial, ciprofloxacin/metronidazole was compared with imipenem/cilastatin for treatment of complicated intra-abdominal infections. A secondary objective was to demonstrate the ability to switch responding patients from intravenous (IV) to oral (PO) therapy.
Summary background data:
Intra-abdominal infections result in substantial morbidity, mortality, and cost. Antimicrobial therapy often includes a 7- to 10-day intravenous course. The use of oral antimicrobials is a recent advance due to the availability of agents with good tissue pharmacokinetics and potent aerobic gram-negative activity.
Methods:
Patients were randomized to either ciprofloxacin plus metronidazole intravenously (CIP/MTZ IV) or imipenem intravenously (IMI IV) throughout their treatment course, or ciprofloxacin plus metronidazole intravenously and treatment with oral ciprofloxacin plus metronidazole when oral feeding was resumed (CIP/MTZ IV/PO).
Results:
Among 671 patients who constituted the intent-to-treat population, overall success rates were as follows: 82% for the group treated with CIP/MTZ IV; 84% for the CIP/MTZ IV/PO group; and 82% for the IMI IV group. For 330 valid patients, treatment success occurred in 84% of patients treated with CIP/MTZ IV, 86% of those treated with CIP/MTZ IV/PO, and 81% of the patients treated with IMI IV. Analysis of microbiology in the 30 patients undergoing intervention after treatment failure suggested that persistence of gram-negative organisms was more common in the IMI IV-treated patients who subsequently failed. Of 46 CIP/MTZ IV/PO patients (active oral arm), treatment success occurred in 96%, compared with 89% for those treated with CIP/MTZ IV and 89% for those receiving IMI IV. Patients who received intravenous/oral therapy were treated, overall, for an average of 8.6 +/- 3.6 days, with an average of 4.0 +/- 3.0 days of oral treatment.
Conclusions:
These results demonstrate statistical equivalence between CIP/MTZ IV and IMI IV in both the intent-to-treat and valid populations. Conversion to oral therapy with CIP/MTZ appears as effective as continued intravenous therapy in patients able to tolerate oral feedings.
To test the hypothesis that comprehensive broad-spectrum empirical antimicrobial therapy is superior to limited-spectrum empirical antimicrobial therapy in intra-abdominal infections.
Prospective, randomized, double-blinded study.
University-affiliated hospitals in Canada.
Two hundred thirteen patients with intra-abdominal infections and planned operative or percutaneous drainage.
Limited-spectrum empirical antimicrobial therapy consisted of cefoxitin sodium, 2 g, intravenously, every 6 hours (n = 109). Comprehensive broad-spectrum empirical antimicrobial therapy consisted of a combination of imipenem and cilastatin sodium, 500 mg, intravenously, every 6 hours (n = 104).
Failure to cure the intra-abdominal infection (persistence of infection or death).
Of initial isolates, 98% were sensitive to imipenem plus cilastin sodium compared with 72% for cefoxitin. No difference was found in the failure rate between treatment groups. Among various reasons for failure (including technical), 12 of 80 patients in the limited-spectrum empirical antimicrobial therapy group had resistant organisms at a second intervention compared with 1 of 74 in the comprehensive broad-spectrum empirical antimicrobial therapy group (P < .003, chi 2). One death in the limited-spectrum empirical antimicrobial therapy group was due to autopsy-proved disseminated Pseudomonas aeruginosa (blood, peritoneum, lung, and pleural fluid) that was resistant to cefoxitin, and the other was associated with peritonitis due to cefoxitin-resistant Enterobacter cloacae. One death in the comprehensive broad-spectrum empirical antimicrobial therapy group was associated with peritonitis from Clostridium perfringens that was sensitive to imipenem plus cilastin sodium, and the other was associated with peritonitis from Pseudomonas aeruginosa that was resistant to imipenem plus cilastin sodium.
Treatment failure of intra-abdominal infection may be due, in part, to the presence of resistant pathogens at the site of infection. Therefore, routine culture of these sites seems worthwhile and empirical therapy should be as comprehensive as possible and should cover all potential pathogens.
To evaluate the safety and efficacy of cefepime hydrochloride plus metronidazole vs the combination of imipenem and cilastatin sodium in the treatment of complicated intra-abdominal infections in adult patients.
Prospective, randomized, double-blind multicenter study.
University-affiliated hospitals in the United States and Canada.
Three hundred twenty-three patients with complicated intra-abdominal infections in whom an operative procedure or percutaneous drainage was required for diagnosis and management.
Cefepime, 2 g, was administered intravenously every 12 hours (n= 164) in addition to metronidazole, 500 mg (or 7.5 mg/kg) intravenously every 6 hours. Imipenen-cilastatin sodium, 500 mg, was administered intravenously every 6 hours (n= 159). Surgical infection management was determined by the patients' surgeons. MAIN OUTCOME ASSESSMENTS: Clinical cure, defined as elimination of all signs and symptoms relevant to the original infection; and treatment failure, defined as persistence, increase or worsening of signs and symptoms resulting in an antibiotic change, requirement of an additional surgical procedure to cure the infection, or a wound infection with fever.
Of the initial isolates, 84% were susceptible to cefepime and 92% were susceptible to imipenem-cilastatin. Among the 217 protocol-valid patients, those treated with cefepime+metronidizole were deemed clinical cures (88%) more frequently than were imipenem-cilastatin-treated patients (76%) (P=.02). Using multivariate analysis to adjust for identified clinical risk factors for an adverse outcome (severity of presenting illness, isolation of enterococcus, type of infection, and duration of prestudy hospitalization), there was a trend (P=.06) toward a higher cure rate favoring cefepime+metronidazole. Pathogens were eradicated in significantly (P=.01) more patients treated with combined cefepime and metronidazole (89%) than with imipenem-cilastatin (76%).
The combination of cefepime plus metronidazole is safe and effective therapy for patients with severe intra-abdominal infections.
The empiric antibiotic treatment of intraabdominal infections is in constant evolution. Monotherapy appears to be a desirable goal because of the simplicity of its administration, lack of toxic effects and wide spectrum.
A multicentre, prospective, randomized, open study was carried out to compare two antibiotic regimens in the treatment of intraabdominal infections in patients undergoing surgery. Ninety-eight consecutive patients were randomly allocated into two groups. One group (GM, n = 51) received meropenem (1 g/8 h) and the other (GCM, n = 47) a combination of cefotaxime (2 g/8 h) plus metronidazol (0.5 g/8 h). Clinical and bacteriological responses were assessed at the end of treatment and at 2-4 weeks.
The severity of patients as assessed by the APACHE II score was similar in both groups (GM: 7.2 and GCM: 8.1). Three patients in each group could not be evaluated due to premature interruption of treatment or deviation from the protocol. The mean duration of treatment was 7.4 days in GM and 7.9 days in GCM. A satisfactory clinical response was obtained in 95% of patients in both groups. 31 patients (61%) in GM and 26 patients (55%) in GCM were bacteriologically evaluable. Bacteriological erradication was achieved in 94% of patients in GM and in 92% of patients in GCM.
Meropenem is a good alternative for single antibiotic therapy in intraabdominal infections of moderate severity.
This multicentre, open-label, randomised trial compared meropenem (0.5 g/8 h) and imipenem/cilastatin (at the commonly used dosage of 0.5 g/6 h) in monotherapy in patients with moderately severe intra-abdominal infections (IAIs). In total, 161 patients were randomised (82 meropenem, 79 imipenem/cilastatin). The mean APACHE II scores in the two groups were 5.8 and 6.4, respectively. At the end of therapy, 65/71 (91.6%) evaluable meropenem recipients were clinically cured or improved, compared to 60/64 (93.8%) imipenem/cilastatin recipients. This difference and that in an intention-to-treat analysis (82.1 vs 86.1%, respectively), were not statistically significant. Both drugs were generally well tolerated. Thus, meropenem 0.5 g/8 h is as clinically effective and well tolerated as imipenem/cilastatin 0.5 g/6 h in moderately severe IAIs.
To assess the effect of piperacillin/tazobactam compared with cefuroxime/metronidazole in the treatment of patients with intra-abdominal infections.
Randomised open study.
16 Swedish and 6 Norwegian hospitals.
269 patients with intra-abdominal infections were randomised and treated with at least one dose of each study drug. 205 patients, 105 treated with piperacillin/tazobactam and 100 with cefuroxime, were clinically evaluable for follow up (had been given the full course of treatment).
Patients were given piperacillin 4g/tazobactam 0.5 g every 8 hours or cefuroxime 1.5 g every 8 hours plus metronidazole 1.5 g every 24 hours. Each patient was to be treated for a minimum of 3 days and not more than 10 days.
Clinical evaluation of infection at the end of and 4-6 weeks after treatment. Evaluation of safety and tolerance to the drugs and bacteriological susceptibility to the treatment drugs.
In the intention to treat analysis treatment was equally successful for piperacillin/ tazobactam (103/140, 74%) and the cefuroxime/metronidazole groups (90/129, 70%) (p = 0.6). Corresponding figures for the clinically evaluable group were 102/105 (97%) and 94/100 (94%) for piperacillin/tazobactam and cefuroxime/metronidazole groups, respectively, at the end of treatment. At late follow up, 92/105 (88%) and 83/100 (83%) in the two groups, respectively, remained free of infection. The side effects of the treatment were mild and evenly distributed between the two groups. Most pathogens were susceptible to the drugs in both treatment groups.
Both piperacillin/tazobactam and cefuroxime/metronidazole are well suited to the treatment of patients with intra-abdominal infections, and we found no significant difference between the two. The drugs were safe and well tolerated in the regimens used.
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