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Risk factors associated with intraabdominal infections: a prospective multicenter study. Peritonitis Study Group
Abstract
A prospective observational multicenter study with 18 hospitals was performed to assess preoperative risk, therapeutic management and outcome of patients with peritonitis. Data collection was carried out according to standardized and recommended definitions. Included in the study were 355 patients with macroscopically confirmed peritonitis.
In the univariate analysis, the following factors influenced both the mortality and the incidence of postoperative complications: age, presence of certain concomitant disease, site of origin of peritonitis, type of admission and the ability of the surgeon to eliminate the source of infection. In addition, postoperative infective complications were related to the etiology of peritonitis and the exudate. In the multivariate analysis, APACHE II (P<0.001), successful operation (P<0.001), age (P<0.001), liver disease (P<0.03), malignant disease (P<0.04) and renal disease (P<0.05) turned out to be significant with respect to death. Escherichia coli was the predominant organism (51%), following by enterococci (30%) and bacteroides (25%). There was a significantly higher postoperative infection rate in patients with no adequate treatment of enterococci than patients with adequate treatment or no enterococci (P<0.05).
The study demonstrated the important role of the physiological reserve of the patient and of the surgeon, which is not adequately reflected in existing scoring systems. Further investigations are needed to study the impact of enterococci on the outcome.
... The latter was the first severity scoring system designed to assess and provide prognosis for individual postoperative mortality in patients with peritonitis, who can receive surgical treatment. Described by Wacha et al., [11], it was based on the results of 1253 patients with peritonitis treated between 1963 and 1979 in Germany and was developed by discriminative analysis of 17 possible risk factors, of which eight were significant for prognosis, obtaining the information during the first laparotomy, allowing an immediate and easy-to-apply classifications [4]. Multivariate analysis has shown that the most clinically relevant factors are preoperative organ failure and purulent or fecaloid peritonitis [12]; and it has also shown a high sensitivity and specificity applied in different surgical scenarios in different multicentric studies [9]. ...
... The maximum score is 47 points; results can be grouped in low and high mortality, being 26 the cutoff point (50% mortality with scores ≥26; and 1-3% mortality with scores <26), with a 95.9% sensitivity and 80% specificity, with a 98.9% positive predictive value and 50% negative predictive value [11,14]. Patients with a higher score will have a higher probability of complications, hospital-stay, intensive care requirement and, of course, higher morbidity and mortality [15]. ...
... Other authors have studied isolated variables and have observed that septic shock or concomitant diseases are predictors of postoperative mortality in colonic perforation. Different risk factors with predictive value for postoperative morbidity and mortality have been identified, and valid prognostic indices have been developed for surgical patients, although not specific to emergency procedures or colorectal disease [11]. ...
Introduction: In the last 30 years, scoring systems have been developed to determine patients’ illness severity or prognosis. In the present work, the role of the Mannheim Prognostic Index (MPI) to predict the risk of mortality, complications, prolonged hospital-stay, and the need for ICU was determined in all the patients who presented secondary peritonitis, and to validate the test as a useful and an easy tool to apply in the clinical practice of the surgeon and critical care physician. Materials and methods: An observational, retrospective, cross-sectional and analytical study was conducted. Results: The effectiveness of the MPI was compared to another widely used mortality prediction system such as Apache II; 279 patients from the Luis Vernaza were included. The prediction rate was 93.3% and 86.9%, respectively. Conclusions: Although Mannheim presents an excellent response as a predictor of mortality, its assessment is not infallible since other factors remain unconsidered; and these may cause a patient who was assessed as having a low risk of mortality to be deceased.
... One of the most pressing public health problems is inflammation of the abdominal organs because the number of patients, including those with severe forms of this disease, is constantly increasing. Inflammation in the parietal and visceral layers of the peritoneum is accompanied by severe general health problems in patients [1][2][3]. ...
This paper provides data regarding the ratios of the functional structures of lymph nodes after inflammation in the abdominal organs. Lymph systems, including lymph nodes, function as filters of tissues and tissue fluids and are places of origin and lymphocyte production for normal physiological functions. They display specific morphological and functional responses in reaction to endogenous and exogenous substances. The morphological pattern of the mesenteric lymph node in experimental rat groups reflects a decrease in its immune function due to the processes of inflammation in the abdominal cavity. These processes work together with the associated organs and their involvement in the abdominal lymph nodes, in which there are discharges of the structure of the paracortical zone under conditions of reduced lymphogenic processes, according to the decrease in the size of the paracortex and the ratios of lymphoid nodes with and without germinal centers. Histological and morphometric analyses show changes in the mesenteric lymph node. These analyses are characterized by changes in the cortical and medullary substances, while the proportion of the cortical structure decreases. We also noted an increase in the number of macrophages in the lymphoid nodes and cerebral sinus, as well as a decrease in the number of mature plasmocytes, the paracortex, and the pulp strands. These changes indicate immunosuppressive effects on the lymph node. Under the conditions of inflammation, the formation of a mixed immune response occurs.
... An operation can reverse the multiorgan failure of some patients with intra-abdominal sepsis after surgery and reduce their mortality rate [16]. Although the mechanism is not fully understood, early surgical exploration can reduce the mortality of patients with abdominal infection and the occurrence of complications [13,17]. ...
BACKGROUND
Intra-abdominal infections (IAIs) is the most common type of surgical infection, with high associated morbidity and mortality rates. In recent years, due to the use of antibiotics, various drug-resistant bacteria have emerged, making the treatment of abdominal infections more challenging. Early surgical exploration can reduce the mortality of patients with abdominal infection and the occurrence of complications. However, available evidence regarding the optimal timing of IAI surgery is still weak. In study, we compared the effects of operation time on patients with abdominal cavity infection and tried to confirm the best timing of surgery.
AIM
To assess the efficacy of early vs delayed surgical exploration in the treatment of IAI, in terms of overall mortality.
METHODS
A systematic literature search was performed using PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Ovid, and ScienceDirect. The systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses method. Based on the timing of the surgical operation, we divided the literature into two groups: Early surgery and delayed surgery. For the early and delayed surgery groups, the intervention was performed with and after 12 h of the initial surgical intervention, respectively. The main outcome measure was the mortality rate. The literature search was performed from May 5 to 20, 2021. We also searched the World Health Organization International Clinical Trials Registry Platform search portal and ClinicalTrials.gov on May 20, 2021, for ongoing trials. This study was registered with the International Prospective Register of Systematic Reviews.
RESULTS
We identified nine eligible trial comparisons. Early surgical exploration of patients with IAIs (performed within 12 h) has significantly reduced the mortality and complications of patients, improved the survival rate, and shortened the hospital stay.
CONCLUSION
Early surgical exploration within 12 h may be more effective for the treatment of IAIs relative to a delayed operation.
... In the 19th century, patients with intra-abdominal sepsis had an almost 90% mortality rate. In recent years, better and earlier surgical intervention and utilization of antibiotics have reduced that rate to about 30% [3][4][5][6][7][8]. ...
Patients with intra-abdominal sepsis suffer from significant mortality and morbidity. The main pillars of treatment for intra-abdominal infections are (1) source control and (2) early delivery of antibiotics. Antibiotic therapy should be started as soon as possible. However, the duration of antibiotics remains a matter of debate. Prolonged antibiotic delivery can lead to increased microbial resistance and the development of nosocomial infections. There has been much research on biomarkers and their ability to aid the decision on when to stop antibiotics. Some of these biomarkers include interleukins, C-reactive protein (CRP) and procalcitonin (PCT). PCT’s value as a biomarker has been a focus area of research in recent years. Most studies use either a cut-off value of 0.50 ng/mL or an >80% reduction in PCT levels to determine when to stop antibiotics. This paper performs a literature review and provides a synthesized up-to-date global overview on the value of PCT in managing intra-abdominal infections.
... Hence it is essential to know when an anaerobic infection is vital in order to use appropriate microbiologic methods to identify the bacteria and to select the correct treatment. 8 In this regard, this study was aimed to describe and analyse the distribution of various obligate anaerobes causing varied anaerobic intra abdominal infections, and also to document any antimicrobial resistance among the obligate anaerobes. ...
Obligate anaerobes, which are part of normal intestinal flora are now gaining pathogenic potential by becoming more virulent and causing moderate to severe abdominal infections. Moreover, there is delay in initiation of appropriate antimicrobial therapy. The study aimed to describe and analyse 23 years data on anaerobic intra – abdominal infections in regards to the distribution and antimicrobial susceptibility patterns of the obligate anaerobes which were isolated from various intra – abdominal infections. The demographic and microbiological data was retrieved from the microbiology departmental registers. Total number of cases/specimen were 1124. Bacteroides fragilis group (238) (56%) and Peptostreptococcus sp (109) (25%) amounted to the majority of the isolates. Rare anaerobes like Clostridium sporogenes, Propionibacterium sp, Clostridium bifermentans and Fusobacterium varium were also isolated. Majority of mixed anaerobic infections were contributed by Bacteroides fragilis group and Peptostreptococcus sp (99) out of 102 mixed anaerobic infections). Chronic alcoholism was the most common predisposing condition (p value <0.05). Among the antimicrobials which were used by the clinicians for treating the infection, only Metronidazole was tested for its susceptibility pattern. One isolate was resistant to metronidazole (Diameter of inhibition zone was 6 mm). As they are fastidious they usually go unnoticed. Hence, this descriptive study intends to bring light on the large number of various obligate anaerobes and the potential diseases that they can cause and also the need for their antibiotic susceptibility testing to look for antimicrobial resistance among the isolates.
... In general, it can be assumed that the number of pathogens involved in intra-abdominal infections is underestimated, typically 5 to 10 bacterial species are detected per intra-abdominal sample taken. The most frequently isolated are Gram-negative Enterobacteriaceae such as Escherichia coli and Klebsiella pneumoniae as well as Gram-positive enterococci (Enterococcus faecalis, Enterococcus faecium) and Bacteroides fragilis (23). ...
... In general, it can be assumed that the number of pathogens involved in intra-abdominal infections is underestimated, typically 5 to 10 bacterial species are detected per intra-abdominal sample taken. The most frequently isolated are Gram-negative Enterobacteriaceae such as Escherichia coli and Klebsiella pneumoniae as well as Gram-positive enterococci (Enterococcus faecalis, Enterococcus faecium) and Bacteroides fragilis (23). ...
Purpose: Despite the development of surgical methods, infections continue to be serious postoperative complications. Probiotics have been shown to be effective in reducing the prevalence of infections. We explored the effectiveness of probiotics in reducing the prevalence of infections in subjects undergoing surgery for hip fractures. Methods: Fifty-one patients admitted for surgical treatment of hip fractures were divided randomly into two groups: Synbiotic 2000 Forte and placebo. The occurrence of infection was closely observed upon hospital admission until the fifth postoperative day using, among other parameters, the C-reactive protein (CRP) level. Additionally, the patients’ tolerance to Synbiotic 2000 Forte was established using subjective (self-reported problems) and objective means. Results: Infection was confirmed in 4 patients in each group. Urinary tract infection was noted in 7 subjects and a local wound infection in 1 patient. No differences were found in CRP levels upon hospital admission and the fifth postoperative day. Tolerance to Synbiotic 2000 Forte was lower in patients undergoing placebo treatment. Conclusion: Synbiotic 2000 Forte did not reduce the number of postoperative infections. Further studies are needed to confirm these findings.
Purpose:
Evaluation of the efficacy of use of probiotics as prophylaxis for postoperative wound infection in under-five children following gastrointestinal surgery.
Materials and methods:
This randomized control trial was conducted over a period of 2 years in the pediatric surgery units of a tertiary level hospital in Dhaka, Bangladesh. A total of 60 patients undergoing gastrointestinal surgery under the age of 5 years were included in the study and randomly assigned to two groups - probiotics group (n = 30) and nonprobiotics group (n = 30). Patients in the probiotics group received probiotics in the preoperative (3 days) and postoperative period (7 days) along with traditional gut preparation (antibiotics and mechanical bowel wash). Patients in the nonprobiotic group got only antibiotics and traditional gut preparation. Outcome variables were surgical site infection, fever, c-reactive protein (CRP), total white blood cell (WBC) count, and neutrophil count.
Results:
Postoperative wound infection was less in the probiotic group (n = 2) compared to the nonprobiotic group (n = 3), but the difference was not statistically significant (P = 0.640). Postoperative CRP level was significantly lower in the probiotics group (P = 0.020). There was more decline in total count of WBCs in postoperative period in the probiotic group. No statistical difference was seen between the groups in postoperative pyrexia, the total count of WBC, and neutrophil count.
Conclusion:
Use of probiotics along with traditional gut preparation as prophylaxis for postoperative infection in children showed no added benefit in comparison to the use of traditional gut preparation only.
Der Einsatz von Antibiotika zur Behandlung bakterieller Infektionen ist auch in der Chirurgie unverzichtbar. Resistenzentwicklung und mangelnde Neuentwicklungen gefährden diese wichtige Medikamentengruppe. Ein rationaler Einsatz, der nur erfolgen kann, wenn das nötige Wissen um Wirkungsspektrum, Wirkmechanismen, pharmakokinetische Grundlagen und sinnvolle Einsatzgebiete vorhanden ist, ist der einzige erfolgversprechende Weg, um noch möglichst lange mit den vorhandenen Ressourcen therapeutischen Erfolg zu erzielen Diese Kapitel informiert über die wichtigsten Grundregeln einer rationalen Antibiotikatherapie, über eine rationale perioperative Antibiotika-Prophylaxe und bietet eine komprimierte Übersicht über alle relevanten Antibiotika- und Antimykotika-Klassen und ihre wesentlichen Eigenschaften.
Patients presenting with sepsis are complexly ill with multiple risk factors for short-term mortality. In order to fully represent this complexity, an accurate comprehensive individual patient risk mortality based on reliable risk factors available at the time of treatment can be constructed from large, contemporary, clinically accurate databases. The individual patient risk assessments produced by this approach can be used within clinical evaluations to ensure that baseline risks for mortality were equally distributed among treatment groups and to investigate whether there is a relationship between baseline risk and efficacy of new therapeutic compounds. If clinical evaluations performed in this manner use common definitions and data collection procedures? then the results of such assessments can futher refine and revise the risk predictions and describe the relative benefit of new compounds or combinations of such compounds for individual patients.
In the years 1970-1988, 245 perforated gastroduodenal ulcer patients were operated on at our clinic. Up to 1985, the collection of data was carried out retrospectively; since then, this has been done prospectively. After a univariate analysis of the possible extent of influence on the postoperative development, a prognostic index was drawn up with the help of a discriminant analysis. Preoperative clinical shock and medical illnesses were taken into account in this. The rate of error of this prognostic index of perforated peptic ulcers in prospectively recorded patients was less than 5%. Two more prognostic indices were validated in these patients: the Mannheim peritonitis index (MPI) and one further special riskscore for perforated ulcers. In comparison with the indices established by us, all the scoring systems in the quality parameters showed very good results which agree well. The efficiency of the MPI could be proved using this group of patients. Our prognostic index of perforated peptic ulcer seems to be beter suited to certain problems (e.g. therapy decisions).
Early prognostic evaluation of abdominal sepsis is desirable to select high-risk patients for more aggressive therapeutic procedures and to provide objective classification of the severity of disease. The reliability of the Mannheim peritonitis index was assessed and its predictive power for different populations examined in a study of 2003 patients from seven centres in three European countries. The prevalence of risk factors varied considerably between the groups. For a threshold index score of 26, the sensitivity was 86 (range 54–98) per cent, specificity 74 (range 58–97) per cent and accuracy 83 (range 70–94) per cent in predicting death. For patients with a score less than 21 the mean mortality rate was 2.3 (range 0–11) per cent, for score 21–29 22.5 (range 10.6–50) per cent and for score greater than 29 59.1 (range 41–87) per cent. The mean index score and mean mortality rate correlated in the different groups, reflecting a homogeneous standard of therapy for peritonitis. The Mannheim peritonitis index provides an easy and reliable means of risk evaluation and classification for patients with peritoneal inflammation.
To construct a score that would accurately predict outcome for patients with perforated peptic ulcers.
Retrospective study.
University Hospital.
173 patients who were operated on for perforated peptic duodenal ulcers over a 14 year period.
Results of multivariate discriminant function analysis of derived set of clinical variables known to be associated with high mortality, and comparison with the Mannheim Peritonitis Index.
Serious coexisting medical illness, acute renal failure, white cell count of more than 20 x 10(9)/l, and male sex were the most significant factors influencing mortality. The Hacettepe score for perforated peptic ulcer was established using these four variables. The sensitivity was 83%, the specificity 94%, and the overall predictive accuracy 93%. The corresponding figures for the Mannheim Peritonitis Index were 75%, 96%, and 94% respectively.
The Hacettepe score is useful in predicting whether a patient will survive after perforation of a peptic duodenal ulcer.
To evaluate the effects of reorganizing physician resources in a medical intensive care unit (MICU), we studied the impact of these changes in patients with septic shock. Patients were compared during two consecutive 12-month periods: (1) an interval in which faculty without critical care medicine (CCM) training supervised the MICU (before CCM, n = 100) and (2) following staffing with physicians formally trained in CCM (after CCM, n = 112). Acute Physiology and Chronic Health Evaluation scores were utilized to compare severity of illness and were similar for each group (29 +/- 11 before CCM vs 28 +/- 10 after CCM). However, mortality was significantly lower during the post-CCM interval (74% vs 57%, respectively). There was no significant difference in the frequency of use of mechanical ventilation (83% vs 87%), although pulmonary artery catheters (48% vs 64%) and arterial catheters (24% vs 73%) were employed more frequently after CCM. The number of subspecialty consultations and MICU and hospital length of stay were similar for both intervals. We conclude that the implementation of dedicated staffing by CCM physicians in a university hospital MICU was associated with a favorable impact on patients with septic shock.
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.
To determine admission characteristics associated with the outcome of septicemia in critically ill patients and more specifically assess the prognostic value of pre-existing co-morbidities.
5 year-retrospective cohort study.
Surgical Intensive Care Unit (ICU-20 beds) in a 1600 bed-tertiary care center.
Among 5457 patients admitted to the ICU between 1984 and 1988, 176 (3.2%) met prospectively-defined criteria for blood culture-proven septicemia (8.77 per 1000 patient-days). Overall septicemic patients had a 5-fold increased risk of death compared to non-septicemic patients (relative risk 5.03, 95% confidence intervals 4.17-6.07, p < 0.0001), and this estimate persisted after stratification according to age, sex, primary diagnosis and conditions of admission to the ICU (emergency/elective).
Prognostic factors recorded on admission to ICU that were associated with mortality from septicemia among 173 patients were older age, higher admission Apache II score, gastrointestinal surgery, ultimately and rapidly fatal diseases and the number of co-morbidities in addition to the principal diagnosis (active smoking, alcohol abuse, non-cured malignancy, diabetes mellitus, splenectomy, recent antibiotic therapy, major surgery, or major cardiac event). In the multivariate analysis with logistic regression procedures, Apache II and co-morbidities were identified as the two independent predictors of mortality.
Pre-existing co-morbidities assessed at the admission to the ICU significantly improved the prediction of mortality from septicemia compared to Apache II score alone.