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Tertiary Peritonitis: Clinical Features of a Complex Nosocomial Infection
Abstract
Enterococcus
,
Candida
,
Staphylococcus epidermidis
, and
Enterobacter
. Infectious foci were rarely amenable to percutaneous drainage and were found to be poorly localized at laparotomy. Recurrent, or tertiary, peritonitis is a common complication of intraabdominal infection in patients admitted to an ICU. It differs from uncomplicated secondary peritonitis in its microbial flora and lack of response to appropriate surgical and antibiotic therapy. Like nosocomial pneumonia in the critically ill patient, the syndrome appears to be more a reflection than a cause of adverse outcome.
... Clinically, it is most often suspected in cases of prolonged systemic inflammatory response syndrome and shock following effective management of the inciting pathology causing secondary peritonitis [1,7,8]. In Pennsylvania, patients who suffered from tertiary peritonitis were comorbid, malnourished, and metabolically deranged [9]. ...
... Both methods aid in the detection and drainage of abdominal fluid collections [10]. The effective treatment of tertiary peritonitis is multifaceted, although it has been described as representing the limit of surgical treatment of severe secondary peritonitis [7,8]. ...
... It was found that overall length of stay in ICU admission was 21 ± 14.9, frequency of TP of 27.3% at surgery and males were 80%. The clinical sequelae of tertiary peritonitis are grave and often deadly, with a mortality rate quoted at 30% to 64% in some populations [7,8]. ...
Background: Tertiary Peritonitis (TP) is defined as a severe recurrent or persistent intra-abdominal infection after adequate surgical source control of Secondary Peritonitis (SP). The aim of this study was to clarify the value of routinely used diagnostic parameters and early outcome after re-laparotomy in patients with tertiary peritonitis.
... It has been associated with an observed shift from gram negative and enteric bacteria to nosocomial microbes such as enterobacter, enterococcus, Acetinobacter, Citrobacter, Pseudomonas, and fungal species (9). The clinical sequelae of tertiary peritonitis are grave and often deadly, with a mortality rate quoted as 30%-64% in some populations (10,11). Clinically, it is most often suspected in cases of prolonged SIrS response and shock following effective management of the inciting pathology causing secondary peritonitis. ...
... The effective treatment of tertiary peritonitis is multifaceted, although it has been described as representing the limit of surgical treatment of severe secondary peritonitis (11,12). Patients suffering from tertiary peritonitis are often comorbid, malnourished, and metabolically deranged. ...
... Physiologic support often entails intensive care unit admission, administration of broad-spectrum antibiotics, and ensuring source control. However, pathogens cultured from the peritoneal cavity may be more of a symptom than a cause of critical illness (11). Cross-sectional imaging should confirm the absence of intra-abdominal abscess, anastomotic leakage, or failure of primary repairs that can be dealt with surgically. ...
Secondary peritonitis and intra-abdominal sepsis are a global health problem. The life-threatening systemic insult that results from intra-abdominal sepsis has been extensively studied and remains somewhat poorly understood. While local surgical therapy for perforation of the abdominal viscera is an age-old therapy, systemic therapies to control the subsequent systemic inflammatory response are scarce. Advancements in critical care have led to improved outcomes in secondary peritonitis. The understanding of the effect of secondary peritonitis on the human microbiome is an evolving field and has yielded potential therapeutic targets. This review of secondary peritonitis discusses the history, classification, pathophysiology, diagnosis, treatment, and future directions of the management of secondary peritonitis. Ongoing clinical studies in the treatment of secondary peritonitis and the open abdomen are discussed.
... About 30% of patients with IAI admitted in ICU die due to their illness (Evans et al. 2001;Bohnen et al. 1983). When IAI occurs as a post-operative complication or recurs during ICU admission, mortality is even higher (Nathens et al. 1998). ...
... The causative organisms of tertiary peritonitis are different from those causing secondary peritonitis and are generally unresponsive to antibiotics and source control measures. These include coagulase negative Staphylococcus, Pseudomonas, Candida and enterococcus (Nathens et al. 1998). ...
Renal infections have a spectrum of presentations, varying from minimal symptoms or asymptomatic to frank sepsis and septic shock. Urinary tract infections (UTI) are among the most common human infections and add substantial morbidity and financial burden on society. The common pathologies include acute and chronic bacterial pyelonephritis, emphysematous pyelonephritis, xanthogranulomatous pyelonephritis, renal abscess, pyonephrosis, and genitourinary tuberculosis involving the kidney. Advances in the understanding of the microbiology and the pathophysiology of UTI have improved the management of renal infections, with introduction of more effective antibiotics and better and judicious usage of drugs and combinations of endoscopic, percutaneous, or surgical interventions. In this chapter, the authors review the common pathologies and their management.
... Peritonitis is a prevalent inflammatory disease characterized by clinical manifestations such as diarrhea, abdominal pain, abdominal infection, and multiple organ failure, with a mortality rate exceeding 60% [6,7]. Despite the incomplete elucidation of the pathogenic mechanisms underlying this disease, extensive reported research suggests a close association between peritonitis and macrophages [8,9]. ...
IRAK4 is a critical mediator in NF-κB-regulated inflammatory signaling and has emerged as a promising therapeutic target for the treatment of autoimmune diseases; however, none of its inhibitors have received FDA approval. In this study, we identified a novel small-molecule IRAK4 kinase inhibitor, DW18134, with an IC50 value of 11.2 nM. DW18134 dose-dependently inhibited the phosphorylation of IRAK4 and IKK in primary peritoneal macrophages and RAW264.7 cells, inhibiting the secretion of TNF-α and IL-6 in both cell lines. The in vivo study demonstrated the efficacy of DW18134, significantly attenuating behavioral scores in an LPS-induced peritonitis model. Mechanistically, DW18134 reduced serum TNF-α and IL-6 levels and attenuated inflammatory tissue injury. By directly blocking IRAK4 activation, DW18134 diminished liver macrophage infiltration and the expression of related inflammatory cytokines in peritonitis mice. Additionally, in the DSS-induced colitis model, DW18134 significantly reduced the disease activity index (DAI) and normalized food and water intake and body weight. Furthermore, DW18134 restored intestinal damage and reduced inflammatory cytokine expression in mice by blocking the IRAK4 signaling pathway. Notably, DW18134 protected DSS-threatened intestinal barrier function by upregulating tight junction gene expression. In conclusion, our findings reported a novel IRAK4 inhibitor, DW18134, as a promising candidate for treating inflammatory diseases, including peritonitis and IBD.
... Candida yeasts, such as Candida albicans, are invasive species that can be deadly in immunocompromised patients. 1 With the limited number and activities of antifungal therapies, it is crucial to discover more antifungal drugs that can successfully treat Candida infections. 2,3 The investigation of fungal secondary metabolites (SMs) has progressed rapidly with the recent development of molecular genetic tools. ...
Filamentous fungi are an essential source of bioactive mycotoxins. Recent efforts have focused on developing antifungal agents that are effective against invasive yeasts, such as Candida spp. By screening fungal strains isolated from regions surrounding the Chernobyl nuclear power plant disaster for antifungal activity against Candida albicans, we found that Aspergillus melleus IMV 01140 produced compounds that inhibited the growth of the yeast. The active compound produced by A. melleus was isolated and found to be neoaspergillic acid, a compound that is closely related to aspergillic acid. While aspergillic acid and its derivatives have been characterized and were found to have antibacterial and antifungal properties, neoaspergillic acid has been much less studied. Even though neoaspergillic acid and related compounds were found to have antibacterial and antitumoral effects, further investigation into this group of compounds is limited by challenges associated with large-scale production, isolation, and purification. The production of neoaspergillic acid has been shown to require co-cultivation methods or special growth conditions. In this work, neoaspergillic acid and related compounds were found to be produced by A. melleus under laboratory growth conditions. The biosynthetic gene cluster of neoaspergillic acid was predicted using the aspergillic acid gene cluster as a model. The biosynthetic pathway for neoaspergillic acid was then confirmed by establishing an in vitro CRISPR-ribonucleoprotein system to individually delete genes within the cluster. A negative transcriptional factor, mcrA, was also eliminated to further improve the production of neoaspergillic acid and the related compounds for future studies.
... Tertiary peritonitis (TP) represents persistent inflammation and colonization as well as intermittent infection in an immune compromised host that develops after what was believed to be a successful attempt at primary source control [5,15,16]. This subset of the larger CCI patient population is characterized by non-resolving organ failure that involves multiple systems, but perhaps most importantly, host humoral and cell-mediated defense ( Fig. 1) [17]. ...
Peritonitis, as a major consequence of hollow visceral perforation, anastomotic disruption, ischemic necrosis, or other injuries of the gastrointestinal tract, often drives acute care in the emergency department, operating room, and the ICU. Chronic critical illness (CCI) represents a devastating challenge in modern surgical critical care where successful interventions have fostered a growing cohort of patients with prolonged dependence on mechanical ventilation and other organ supportive therapies who would previously have succumbed much earlier in the acute phase of critical illness. An important subset of CCI patients are those who have survived an emergency abdominal operation, but who subsequently require prolonged open abdomen management complicated by persistent peritoneal space infection or colonization, fistula formation, and gastrointestinal (GI) tract dysfunction; these patients are described as having tertiary peritonitis (TP).The organ dysfunction cascade in TP terminates in death in between 30 and 64% of patients. This narrative review describes key—but not all—elements in a framework for the coordinate multiprofessional team-based management of a patient with tertiary peritonitis to mitigate this risk of death and promote recovery. Given the prolonged critical illness course of this unique patient population, early and recurrent Palliative Care Medicine consultation helps establish goals of care, support adjustment to changes in life circumstance, and enable patient and family centered care.
... Most cases remain asymptomatic, but others will have symptoms or complications. The goals of treating uncomplicated symptomatic diverticular disease are to prevent their onset and to reduce the frequency and intensity of symptoms 12,13,27,[42][43][44][45][46] . In uncomplicated diverticulitis, outpatient management is considered the optimal approach for most patients, and oral antibiotics remain the mainstay of treatment. ...
Intra-abdominal infections are frequent at all levels of health care, therefore, it is necessary to maintain a high level of clinical suspicion, performing the fastest and most cost-effective measures to confirm the diagnosis and offer a precise and targeted multidisciplinary therapy, this being the only way to have an impact on the morbidity of this infection, reducing mortality and minimizing the complications and costs of health care. Intra-abdominal infections are linked to the appearance and selection of resistant mutants in both bacteria and fungi, becoming currently a major public health problem. Increasing bacterial resistance when associated with a greater possibility of difficulties in antimicrobial treatment increases mortality. This evidence-based consensus brings together the recommendations for the diagnosis and treatment of intra-abdominal infections in the pediatric and adult population. With strict monitoring of bacterial resistance and stimulating the control of the risk factors that have the greatest impact on the appearance of this phenomenon, this consensus is intended to be a practical guide that is easy to implement, and with periodic updates it will favor and facilitate multidisciplinary and the adequacy of the therapeutic management of intra-abdominal infections. © 2021 Asociacion Colombiana de Infectologia. All rights reserved.
... The authors found a significantly higher rate of postoperative intra-abdominal abscess in patients who underwent LPL than in those who underwent surgical resection. Since the aim of surgery was to treat the sepsis, and if this technique was associated with more postoperative abscesses, then this technique should be considered ineffective [124]. ...
IntroductionPeritonitis is still an important health problem associated with high morbidity and mortality. A multidisciplinary approach to the management of patients with peritonitis may be an important factor to reduce the risks for patients and improve efficiency, outcome, and the cost of care.Methods
Expert panel discussion on Peritonitis was held in Bucharest on May 2017, during the 17th ECTES Congress, involving surgeons, infectious disease specialists, radiologists and intensivists with the goal of defining recommendations for the optimal management of peritonitis.Conclusion
This document is an updated presentation of management of peritonitis and represents the summary of the final recommendations approved by a panel of experts.
... Various organisms reported are Enterococcus, Candida, Staphylococcus and enterobacter. 363,366 Evidence Statement ...
How to cite this article: Khilnani GC, Zirpe K, Hadda V, Mehta Y, Madan K, Kulkarni A, Mohan A, Dixit S, Guleria R, Bhattacharya P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian Journal of Critical Care Medicine 2019;23 (Suppl 1):1-63.
... Although the mortality of secondary peritonitis has improved with the use of advanced life support, antimicrobial agents and aggressive surgical techniques, treatment of tertiary peritonitis is not as well studied, and mortality of this condition remains high. 2 Planned relaparotomies may reduce bacterial load but progressive organ dysfunction lends itself to the high mortality rate despite seemingly adequate source control. Review of the current literature on tertiary peritonitis reveals a paucity of data on the consensus regarding appropriate treatment but includes planned relaparotomy and open management. ...
The open abdomen (OA) is a challenging surgical scenario necessitating meticulous management to mitigate complications and improve outcomes. This chapter provides a concise overview of contemporary strategies for OA management, encompassing indications, techniques, and complications. Emphasis is placed on evolving approaches such as negative pressure wound therapy, dynamic closure systems, and progressive closure techniques. Additionally, the author highlights the importance of multidisciplinary collaboration and adherence to evidence-based practices in optimizing outcomes for patients with an open abdomen.
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.
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.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
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.
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.
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.
Peritonitis is a major killer in practice of clinical surgery. Over the past few decades, the mortality of severe secondary peritonitis (SP) has markedly reduced as a result of increased knowledge of the underlying pathophysiology, aggressive surgical techniques, broad-spectrum antimicrobial agents, and advanced life-support facilities. However, the surgeon not uncommonly encounters a clinical situation in which the abdominal infection persists and multiple organ failure develops despite optimal treatment. This syndrome, so-called tertiary peritonitis (TP), is a severe recurrent or persistent intra-abdominal infection after adequate surgical control of secondary peritonitis and is associated with high mortality. There is significant difference between the microbial flora in tertiary peritonitis and secondary peritonitis and TP comprises of mostly opportunistic and nosocomial facultative pathogenic bacteria and fungi. The development of multidrug resistance has also been observed in microbes causing TP due to use of broad-spectrum antibiotic therapy.
Das Peritoneum umkleidet als mesotheliale Zellschicht die Abdominalhöhle (Peritoneum parietale) und die peritonealen Bauch- und Beckenorgane (Peritoneum viszerale). Durch Sekretion seröser Flüssigkeit stellt das Peritoneum die Beweglichkeit der Bauchorgane sicher. Es ermöglicht zudem als bidirektionale Membran den Transport und die Absorption von Wasser, Elektrolyten, Eiweißen, Zellen, Blut, Luft und Medikamenten.
How to cite this article: Khilnani GC, Zirpe K Evidence Statement Time-dependent antibiotics require drug concentrations greater than the minimum inhibitory concentration (MIC) for a certain period between doses, which usually ranges from 40 to 50% of the inter-dose interval for their best action. Continuous infusions are preferred over extended infusions for beta-lactam antibiotics and are associated with clinical benefits like a decrease in hospital stay, cost of therapy and mortality. For vancomycin, continuous infusion is associated with reduced toxicity and cost of therapy but no mortality benefit. Evidence Statement Streptococcus pneumoniae, gram-negative bacilli (including klebsiella, Haemophilus influenzae), atypical organisms (Mycoplasma pneumoniae) and viruses (including influenza) are common causes of community-acquired pneumonia (CAP) in intensive care unit (ICU). Staphylococcus aureus, Legionella, and Mycobacterium tuberculosis are less common causes of CAP in ICU. Pseudomonas aeruginosa is an important pathogen causing CAP in patients with structural lung disease. Methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant gram-negative organisms are relatively infrequent causes of CAP in India and are associated with risk factors such as structural lung disease and previous antimicrobial intake. Anaerobic organisms may cause CAP or co-infection in patients with risk factors for aspiration like elderly, altered sensorium, dysphagia, head, and neck malignancy. S. pneumoniae remains sensitive to beta-lactams and macrolides. Haemophilus influenzae has good sensitivity to beta-lactam with beta-lactamase inhibitors and fluoroquinolones. Recent studies show an increasing prevalence of extended spectrum β-lactamase (ESBL) producing Enterobacteriaceae.
Surgical infections cover a broad spectrum of infections involving various organ systems and are caused by various organisms. The common feature of all surgical infections is that they may require surgical treatment, a process called “source control”. These infections are essentially caused by violation of an epithelial barrier by surgery, trauma or any endogenous pathology like ischaemia, obstruction, etc. Thus, the term “surgical infection” encompasses all pathologies, from a minor wound infection to fatal infections like necrotizing fasciitis or bowel gangrene. Depending on the type of infection, the “source control” can be as simple as just removal of a suture to drain an infected wound, to extensive debridement or organ resection.
reziume: naSromis mizans warmoadgens saqarTveloSi aiv/SidsiT pacientebSi B da C hepatitis virusebiT koinfeqciis SemTxvevebisa da Tanmxlebi oraluri gamovlinebebis Seswavla. 2014 wels registrirebuli axal aiv infeqciaTa ganawileba stadiebis mixedviT aseTi iyo: • 15 (2,69%±6,02%) gamovlinda daavadebis mwvave fazaSi. • 76 (13,48%±2,53%) gamovlinda daavadebis asimptomuri stadiaze da pacientTa momarTvianobis mizezi iyo epidCveneba, orsuloba an riskis Semcveli qcevebi; • 176 (31,21%±1,49%) iyo simptomuri araSidsis stadiaze; • 293 (51,95%±0,96%) gamovlinda Sidsis stadiaze. • 4 (0,71%±11,83%) ganisazRvra rogorc daudgeneli. 2014 wels gamovlenil aiv infeqciaTa Soris ukve ganviTarebul Sidsis stadiaTa raodenoba maRalia. es adasturebs imas, rom qveyanaSi sakmaod maRalia aiv infeqciis SemTxvevebis gviani diagnostika. sul, 564 aiv inficirebul pacientTa Soris gamovlenili Tanmxlebi oraluri manifestaciebi aReniSna 293 (52,32%±0,95%) pacients. maTi gadanawileba daavadebis stadiebis mixedviT aseTia: • mwvave aiv infeqciis stadiaze aRiniSna sul 2 (13,33%±2,55%) gamovlineba; • asimptomuri aiv infeqciis dros - 1 (1,32%±8,65%) SemTxveva; • simptomuri araSidsis stadiaze - 65 (36,93%±1,31%); • Siidsis stadiaze - 225 (76,79%±0,55%). piris Rrus lorwovanze gamovlenili sxvadasxva daavadebaTa statistika ki aseTi iyo: • kandidozebiT gamowveuli SemTxvevaTa wili iyo 67.1%(±0,7%); • herpesvirusuli dazianebebiT - 37.2%(±1,3%); • gingivo-stomatitebi - 6,4%(±3,8%): • verukozuli leikoplakia - 6.2%(±3,9%) • kapoSis sarkoma – 0.18%(±23,55%); • ara-hojkinis limfoma - 0.3%(±18,23%). Sesabamisad, mniSvnelovania davaskvnaT, rom saqarTvelosTvis kvlav aqtualuria aiv/Sidsis drouli gamovlenis sakiTxi. aucilebelia jandacvis sistemis pirveladi da meoreuli rgolis dawesebulebebis, maT Soris stomatologiuri klinikebis, aiv infeqciis Sesaxeb informaciuli uzrunvelyofa, rac Cvens qveyanaSi gaaumjobesebs aiv/SidsiT pacientebis droul gamovlenas da garkveulwilad Seamcirebs mzard epidemias.
Community-acquired pneumonia (CAP) causes significant morbidity and mortality worldwide. In developed countries, most episodes occur in the elderly with one or more chronic underlying disease. Children are more commonly affected in the developing world. Mortality from CAP averages 14% and has not decreased significantly since the early 1950s despite advances in antibiotic and intensive care therapy. Making the clinical diagnosis of pneumonia is usually not difficult; deciding which patients should be admitted to the hospital and selecting appropriate therapy, however, can be challenging. Diagnosis and treatment Pneumonia is suspected when one or more of the following is present: cough, purulent sputum, dyspnea, pleuritic pain, fever, chest auscultation findings consistent with pneumonia, leukocytosis, or a new pulmonary infiltrate on imaging. Once the diagnosis is suspected, the physician must decide whether hospitalization is necessary and if intensive care unit (ICU) admission is appropriate.
DEFINITION Myocarditis is a rare, potentially deadly, and often underdiagnosed cause of heart failure that primarily affects children and young adults. Historically, the diagnosis of myocarditis was confirmed by analysis of endomyocardial biopsy specimens. The Dallas criteria, proposed in 1986, define myocarditis as an inflammatory cellular infiltrate of the myocardium with or without myocyte necrosis and/or degeneration of adjacent myocytes. These criteria have been criticized due to inter-reader variability in interpretation, low sensitivity due to sampling error, discrepancy with other markers of viral infection and immune activation in the myocardium and lack of prognostic value. Immunohistochemical stains that detect cellular surface antigens such as anti-CD3, anti-CD4, and anti-CD28 (T lymphocytes), anti-CD8 (macrophages), and Class I and II anti-human leukocyte antigens may have greater sensitivity than the Dallas criteria and may have prognostic value. In patients with previously unexplained heart failure, the presence of viral genomes may indicate active infectious lymphocytic myocarditis. The most common viruses screened in patients with suspected myocarditis are parvovirus B19 (PVB19), adenovirus, enterovirus, cytomegalovirus, Epstein–Barr virus, herpes simplex virus 1 and 2, human herpesvirus 6 (HHV-6), and hepatitis C virus. Fulminant myocarditis is described as acute onset of severe heart failure due to viral myocarditis. Cardiac sarcoidosis is a rare form of inflammatory myocarditis distinguished histologically by non-necrotizing interstitial granulomas. Idiopathic giant cell myocarditis (GCM) is another rare form of inflammatory myocarditis that is characterized histologically by multinucleated giant cells, myocyte necrosis, and a lymphocytic inflammatory infiltrate.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
Focal infections of the kidney can be divided into intrarenal and perirenal pathology (Table 67.1). The classification of intrarenal abscess encompasses renal cortical abscess and renal corticomedullary abscess; the latter includes acute focal bacterial nephritis, acute multifocal bacterial nephritis, and xanthogranulomatous pyelonephritis. Perirenal abscesses are found in the perinephric fascia external to the capsule of the kidney, generally occurring from extension of an intrarenal abscess. Papillary necrosis is a clinicopathologic syndrome that develops during the course of a variety of syndromes, including pyelonephritis, affecting the renal medullary vasculature, leading to ischemic necrosis of the renal medulla. Renal cortical abscess A renal cortical abscess results from hematogenous spread of bacteria from a primary focus of infection outside the kidney, often the skin. The most common causative agent is Staphylococcus aureus (90%). Predisposing conditions include entities associated with an increased risk for staphylococcal bacteremia, such as hemodialysis, diabetes mellitus, and injection drug use. The primary focus of infection may not be apparent in up to one-third of cases. Ascending infection is an infrequent cause of renal cortical abscess formation. Ten percent of renal cortical abscesses rupture through the renal capsule, forming a perinephric abscess.
Dengue is caused by any of four closely related viruses, or serotypes (dengue 1–4). Dengue viruses are small single-stranded RNA viruses, and belong to the genus Flavivirus, family Flaviviridae. Dengue is transmitted between people by the mosquitoes Aedes aegypti and Aedes albopictus, which are found throughout the world. In the last 50 years, there has been a dramatic increase in the global incidence of dengue virus infections with an estimated 50 million infections occurring annually in at least 100 countries in Asia, the Pacific, the Americas, Africa, and the Caribbean. Dengue virus infections may cause symptomatic infections or asymptomatic seroconversion. Symptomatic dengue infection has a wide range of clinical presentations which includes severe and nonsevere manifestations. While most patients recover following a self-limiting nonsevere clinical course, a small proportion progress to severe disease, mostly characterized by plasma leakage with or without hemorrhage. Clinical manifestations After an incubation period of 3 to 7 days, the illness begins abruptly and is followed by three phases – a febrile phase, a critical phase, and a recovery phase. Febrile phase The febrile phase is characterized by high temperature (38.5ºC) accompanied by headache, vomiting, myalgia, joint pain, and a transient macular rash. High fever may cause neurologic disturbances and febrile seizures in young children. Hemorrhagic manifestations include a positive tourniquet test, easy bruising and bleeding at venipuncture sites, fine petechiae, epistaxis, gingival bleeding, and mild gastrointestinal bleeding (Figure 183.1, Panel A, B, and C). A palpable liver may be noted, especially in young infants and children. The full blood count examination reveals
Introduction Endophthalmitis is a vision-threatening inflammation of the inner eye fluids and tissues. Infectious endophthalmitis results from either exogenous or endogenous entry of microbes into the eye. In reported clinical series, exogenous endophthalmitis is much more common than endogenous (or metastatic) endophthalmitis. By far, the most common cause of exogenous infection is intraocular procedures. Until recently, cataract surgery was the most frequently performed type of intraocular procedure, accounting for the greatest number of exogenous endophthalmitis cases. Intravitreal injection has now surpassed cataract surgery as the most frequently performed intraocular procedure and consequently is a significant contributor to the total number of exogenous endophthalmitis cases reported. Exogenous endophthalmitis can also occur after other types of intraocular surgery, including secondary lens implantation, glaucoma filtering surgery, vitrectomy surgery, and corneal transplantation. Organisms may also enter the eye during penetrating trauma, intraocular injection of medication, and contiguous spread into the eye from an infected corneal ulcer. Gram-positive bacteria are the most common cause of exogenous endophthalmitis. Incidence Postoperative endophthalmitis cases from the University of Miami (Bascom Palmer Eye Institute) over an 8-year period (2002 to 2009) demonstrated the incidence of nosocomial endophthalmitis after cataract surgery to be 0.025%. Endophthalmitis occurs after open-globe injuries in 3% to 30% of patients depending on the nature of the injury. The rate of development of Candida endogenous endophthalmitis in patients with documented candidemia has been reported to range from 2.8% to 45%.
Background and epidemiology Acute appendicitis is one of the most common surgical emergencies, with a lifetime incidence of approximately 7%. It can occur in males and females of all ages, but is most common in older children and young adults. The diagnosis is often delayed in younger children and the elderly due to atypical presentations. Pathogenesis The pathophysiology of acute appendicitis begins with obstruction of the appendicular lumen. The obstruction is commonly caused by a fecalith (impacted stool) in adults and lymphoid hyperplasia in children, but can also result from foreign bodies (undigested seeds), infections (especially parasitic), and tumors (most commonly adenocarcinoma, followed by carcinoid tumors). Luminal obstruction leads to accumulation of distal secretions and increased intraluminal pressure, which results in impairment of venous outflow and, subsequently, arterial inflow. The resulting ischemia yields bacterial translocation, mucosal necrosis, and, eventually, perforation. The natural progression and types of acute appendicitis are described in Table 53.1 (simple acute, suppurative, gangrenous, perforated, associated with abscess). The organisms most typically associated with gangrenous or perforated appendicitis are Escherichia coli, Peptostreptococcus, Bacillus fragilis, and various species of Pseudomonas, with most cases being polymicrobial.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
A fully updated version of this popular, clinically oriented, user-friendly text on infectious disease, with even more helpful graphics, tables, algorithms and images. It is packed full of information on diagnosis, differential diagnosis and therapy. In addition to the traditional organization of organ-system and pathogen-related information, this text also includes clinically helpful sections on the susceptible host (with individual chapters, for example, on the diabetic, the elderly, the injection drug user and the neonate), infections related to travel, infections related to surgery and trauma, nosocomial infection and bioterrorism. Positioned between the available encyclopedic tomes and the smaller pocket guides, this is a convenient, comprehensive and highly practical reference for all those practising in infectious diseases as well as internal or general medicine.
Probiotics recently are defined as “live microorganisms which when administered in adequate amount confer a health benefit on the host” by the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO). Mechanism of action of probiotics Competitive exclusion of pathogenic bacteria. Probiotics may compete with pathogenic bacteria for epithelial binding sites and thus prevent gut colonization by bacterial species such as Clostridium difficile, Salmonella choleraesuis, Staphylococcus aureus, and others. Induction of defensin production. Cytoprotective and antimicrobial substances are produced by the intestinal epithelium to control the microenvironment of the gut. Defensins are antimicrobial peptides synthesized by Paneth cells located in the crypts to counteract bacterial adherence and invasion. Production of antibacterial substances. Many lactic acid-producing bacteria (LAB) produce antibacterial peptides called bacteriocins, such as lactacin B from Lactobacillus acidophilus, having a narrow activity spectrum acting only against closely related bacteria. Improved intestinal barrier function. Recent data indicate that probiotics may initiate repair of the barrier function after damage. Modulation of host immune functions. Probiotic bacteria may act through the stimulation of Toll-like receptors (TLRs) and it appears that certain effects exerted by some probiotic strains or preparations are mediated through interactions with distinct TLRs. It can be assumed that probiotic bacteria stimulate dendritic cells which in turn produce anti-inflammatory cytokines. An ideal probiotic preparation should harbor the characteristics mentioned in Table 209.1. For an adequate amount of health benefits, a dose of 5 billion colony-forming units (CFU) a day (5 × 10⁹CFU/day), for at least 5 days, has been recommended. Bacteria and yeasts may be used as probiotics either in the form of a single strain or combination of microorganisms or mixed with prebiotics (Table 209.2).
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 study assessed the incidence, etiology, and consequences of ventilator-associated pneumonia in 1,000 consecutive patients admitted in a medical-surgical intensive care unit (ICU). A total of 264 patients were submitted to mechanical ventilation (MV) for more than 48 hours. Fifty-eight (21.9 percent) patients developed a bacterial pneumonia after a mean of 7.9 days (range, 2 to 40 days) of MV. In addition, they were ten superinfections in nine patients, raising the mean incidence to 25.7 percent. Five patients developed secondary bacteremia, and another five had septic shock. Identification of the causative agent of pneumonia was possible in 47 episodes by means of highly specific techniques (telescoping plugged catheter, blood cultures, and/or necropsy). Thirteen (27.6 percent) of these cases were polymicrobial. The predominant pathogens isolated in the first episode of pneumonia were Gram-negative bacilli (62.6 percent), but a high incidence of Staphylococcus aureus infection (23.2 percent) was detected. Gram-negative bacilli represented 66.6 percent of the total organisms isolated in superinfections. The mortality rate in the pneumonia group was 42 percent; this percentage is similar to mortality rate among MV patients without pneumonia (37 percent). We conclude that nosocomial pneumonia is a frequent complication of MV in the medical-surgical ICU. Ventilator-associated pneumonia does not appear to increase fatality in critically ill patients with a high mortality rate (38 percent); however, it significantly prolongs the length of stay in the ICU for survivors.
(Chest 1991; 100:439-44)
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.
To define the influence of prior antibiotic use on the etiology and mortality of ventilator-associated pneumonia (VAP).
A university hospital medical-surgical ICU.
Prospective clinical study.
Over a 35-month period, we prospectively studied 129 consecutive episodes of VAP. Etiologic diagnosis was established using a protected specimen brush and quantitative culture techniques. We examined prognostic factors by univariate and multivariate analyses using a statistical software package (SPSS).
The rate of VAP caused by Gram-positive cocci or Haemophilus influenzae was statistically lower (p < 0.05) in the patients who had received antibiotics previously, while the rate of VAP caused by Pseudomonas aeruginosa was statistically higher (p < 0.01). Patients died of causes directly related to the infection in 18 (14.0 percent) episodes, P aeruginosa being isolated in 9 of these fatal cases. Indeed, we found that 27.7 percent (15/54) of patients who had received prior antimicrobial therapy before the onset of pneumonia died, compared with only 4.0 percent (3/75) of those who did not. In the univariate analysis, the variables significantly associated with attributable mortality were age older than 45 years, use of corticosteroids, presence of shock, hospital day of VAP over 9, antecedent COPD, and a prior antibiotic use. A step-forward logistic regression analysis defined only prior antibiotic use (p < 0.0001, OR = 9.2) as significantly influencing the risk of death from VAP. The same result was obtained when severity was included in the model. However, prior antibiotic use entirely dropped out as a significant risk factor when the etiologic agent was included in the regression equation.
Distribution of infecting microorganisms responsible for VAP differs in patients who received prior antimicrobial therapy, and this factor determines a higher mortality rate. We suggest a restrictive antibiotic policy in mechanically ventilated patients with the purpose of reducing the risk of death from VAP.
To determine the effect of reoperation for severe abdominal sepsis on the course of proinflammatory mediators and hemodynamic factors.
Inception cohort.
A university hospital and a secondary care hospital.
Fifteen patients suffering from severe peritonitis due to intestinal perforation or infected necrotizing pancreatitis were studied following 19 subsequent operations. Plasma samples were obtained immediately before and after reoperation, as well as at 1, 3, 6, 12, and 24 hours after operation to determine endotoxin, tumor necrosis factor alpha, and interleukin-6 levels. Clinical factors and therapeutic support were recorded at the corresponding times.
Postoperative hemodynamic instability as defined by changes of the mean arterial pressure, pulmonary capillary wedge pressure, and vasopressor support. Courses of proinflammatory mediators were correlated to the hemodynamic findings.
Mean arterial pressure decreased from 94 mm Hg postoperatively to 80 mm Hg at 3 hours (P = .006) and 81 mm Hg at 6 hours postoperatively (P = .005). Pulmonary capillary wedge pressure dropped from 14 mm Hg postoperatively to 12 mm Hg at 1 hour (P = .05). Vasopressor support significantly increased from 1 to 6 hours postoperatively (P = .02). Neither endotoxin nor tumor necrosis factor alpha levels showed significant changes in the postoperative course. Interleukin-6 levels continously increased from 586 pg/mL preoperatively to 910 pg/mL at 1 hour (P = .02) and 931 pg/mL at 3 hours postoperatively (P = .04). Overall interleukin-6 levels (R = -0.38, P = .003) and especially early postoperative interleukin-6 levels inversely correlated with postoperative mean arterial pressure.
Reoperation for abdominal sepsis frequently causes substantial hypotension, and is, thus, potentially harmful to the patient. Reoperative trauma may induce an early postoperative increase in interleukin-6 levels. Because this increase occurs before the development of hypotension, a relationship between the kinetics of this cytokine and the observed hemodynamic instability may be present.
Staphylococcus epidermidis is generally considered to be a blood culture contaminant. Over a 5-month period, 13 of 108 surgical intensive care unit (SICU) patients (12%) had positive S. epidermidis blood cultures. Sources of infection recognized were total parenteral nutrition (TPN) lines (38.5%), central venous pressure (CVP) lines (23.1%), intravenous (IV) lines (7.7%), and arteriovenous (AV) shunts (7.7%). Sources were not established in three patients (23.1%), but in two of these patients the septicemia was within 48 hours of death. In the remaining 11, all TPN, CVP, and IV lines were removed, and in two with persistant fever (longer than 12 hours), antibiotics were instituted. One of these patients died of uncontrolled S. epidermidis septicemia. In the preceeding 10 months, seven S. spidermidis septicemias were identified (3.7% of 244 Patients in SICU). There were two contaminants. The antibiograms of the organisms in these nine patients varied. In this study there are six patterns of antibiotic resistance in blood cultures of S. epidermidis. In the epidemic group, all were resistant to penicillin, oxacillin, erythromycin, tetracycline, chloromycetin, clindamycin, and streptomycin, and sensitive only to cephalosporins. This outbreak was controlled by a rigid approach to the technical features of patient care, particularly of central and peripheral lines and hand washing. There were no positive blood cultures of the epidemic S. epidermidis in the subsequent 5 months; the incidence continued at 3.8% of 144 SICU patients. The overall 26.9% mortality rate associated with S. epidermidis septicemia and the extensive antibiotic resistance pattern indicate that S. epidermidis is a significant pathogen in surgical patients.
Remote or local infection appears to be causally associated with major organ failure in some surgical patients. Experience with the patients described suggests that the converse relationship may be clinically useful: organ failure may indicate the presence of otherwise occult intra-abdominal infection in postoperative patients and trauma victims. Support of organ function without definitive correction of underlying infection is only pallative.
A report is presented on bacteriologically proved bacterial peritonitis in 25 patients aged 33 to 61 yr with liver cirrhosis and ascites observed during a 4 yr period (1970-1974). Data on clinical features of cirrhosis and peritonitis, laboratory tests, bacteriology, liver function tests, predisposing and precipitating factors (ascites, previous paracentesis, significant infections of other location, use of an intraarterial catheter, corticoid application etc.) and the treatment in the cases under study are given in detail. The findings are compared with those of an earlier study from the same hospital concerning 23 similar cases observed between 1958 and 1970. The etiology, pathogenesis and prophylaxis of bacterial peritonitis in patients with ascitic liver cirrhosis are discussed. (Nizze - Rostock).
Intra-abdominal infections are commonly closed space infections, and the primary mode of therapy is surgical drainage and removal of necrotic tissue. However, the importance of appropriate antimicrobial therapy is not to be underemphasized.
AND CONCLUSIONS
The critically ill surgical patient is at high risk for the development of ICU-acquired infection. Normal mucosal defenses are breached by surgical incisions or by intravascular devices, urinary catheters, and endotracheal tubes. The integrity of the gastrointestinal epithelium is compromised by the lack of enteral nutrition and episodes of hypoperfusion, resulting in translocation of normal or disturbed enteric flora. The indigenous microbial flora, an important component of normal host defenses against invasive infection, is disrupted through the use of broad-spectrum antibiotics or by poorly understood influences associated with critical illness. Systemic immunity is altered, and multiple abnormalities of specific and nonspecific immune function can be documented.
Infections acquired within the ICU are commonly caused by endogenous organisms of low intrinsic pathogenicity, and the contribution of these infections to ICU outcome is controversial. Diagnosis is established by directed investigations, focusing on surgical sites and invasive devices. Therapy is primarily physical (drainage of infected collections or removal of contaminated devices), and antimicrobial therapy should employ narrow-spectrum agents guided by the results of Gram stain and culture. The prevention of ICU-acquired infection is based on timely and definitive surgical therapy, judicious use of invasive devices and antibiotics, and early enteral feeding. Infection-control measures aimed at endogenous reservoirs show some preliminary promise for certain subsets of patients, but remain, at present, experimental.
This work was supported in part by a grant from the Physician's Services Incorporated Foundation, Ontario, Canada.
To study the effect of severe illness on the nature of peritonitis and intra-abdominal abscesses, the microbiology and clinical course of patients operated on over a 1-year period with culture-proven intra-abdominal infections whose preoperative Acute Physiology and Chronic Health Evaluation (APACHE) II scores were greater than or equal to 15 (predicted mortality at least 50%) were examined. Twenty-nine patients were enrolled, and overall mortality was 52 per cent, with increasing mortality correlating with higher APACHE II scores. The organism most commonly isolated from the peritoneum was Candida albicans, followed by Enterococcus species, Enterobacter species, and Staphylococcus epidermidis. An increase in the mean of the APACHE II scores on Days 3 and 7 compared to the preoperative score was associated with a 91 per cent mortality, while a decrease was associated with only a 22 per cent mortality. The authors conclude that the microbiology of intra-abdominal infections is inherently different in severely ill patients and that longitudinal clinical scoring may be more useful than a single scoring in predicting outcome. These data suggest that trials to investigate the broadening of standard perioperative antimicrobial coverage in the ill and use of longitudinal clinical scoring to direct aggressive reintervention may be warranted.
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.
With the advances that are being made in many areas of medicine, the surgeon must be familiar with infectious diseases of the peritoneal cavity, which have increased in scope and complexity. In addition to the surgical management of secondary peritonitis resulting from perforation of the gastrointestinal tract, the practicing surgeon may be called on to manage patients with cirrhosis with infected ascitic fluid as well as patients undergoing peritoneal dialysis with infected dialysis fluid. In addition, there is increasing recognition of a group of patients with persistent intraabdominal sepsis or tertiary peritonitis in whom infection is associated with multiple systems organ failure and general depression of the immune system. This article endeavors to present an overview of the diagnostic and therapeutic approaches to these disease entities.
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.
The differential roles of infection as a microbial phenomenon and sepsis as a host response were studied in 210 critically ill surgical patients. Infections occurred in 41.4% of all cases and in 82% of nonsurviving patients. Both infection and the expression of a septic response, measured as a sepsis score, were associated with significantly increased intensive care unit morbidity and mortality. Nonsurviving patients with infection had significantly higher sepsis scores than did survivors. Nonsurvivors with sepsis, on the other hand, did not differ from survivors with respect to any variable reflecting infection but did have higher mean sepsis scores. Maximum sepsis scores and sepsis scores on the day of death were similar in patients dying without infection and those dying with uncontrolled infection. The magnitude of the host septic response, independent of the presence, bacteriologic characteristics, or control of infection, is an important determinant of outcome in critical surgical illness.
A clinical study was undertaken to evaluate the ability of the APACHE (acute physiology and chronic health care) II system to predict the development of multiple organ failure syndrome and subsequent mortality. The study was conducted in a university general surgery intensive care unit using the admission APACHE II score. Over a 1-year period, 92 patients qualified for the study, 24 of whom survived, 69 of whom suffered multiple organ failure syndrome, and 68 of whom died. The APACHE II score did not predict the development of multiple organ failure syndrome or mortality with clinical utility and significantly underestimated the potential for the development of multiple organ failure syndrome. Factors that did predict the development of multiple organ failure syndrome and mortality were the time-dependent changes in the PaO2-to-fraction of inspired oxygen ratio and serum lactate, creatinine, and bilirubin levels. Better markers of cell injury are needed for use in decision making and quality assurance analysis in surgical patients.
A total of 1,001 consecutive episodes of nosocomial pneumonia in 901 patients was identified by routine surveillance at the University of Virginia Medical Center between 1979 and 1983 (8.6 episodes/1,000 admissions). When only initial episodes were examined, 890 patients comprised the study sample. The overall case fatality rate was 30%. Stepwise logistic regression indicated that time from admission to pneumonia (p = 0.0006), age (p less than 0.0001), prior use of mechanical ventilation (p = 0.0032), and neoplastic disease (p = 0.0062) were associated with mortality. Multiple regression analysis indicated that the factors associated with increased length of hospitalization included posttracheostomy status (p = 0.0001), prior mechanical ventilation (p = 0.0001), immunosuppressive or leukopenic status (p = 0.0009), nasogastric intubation (p = 0.0003), and prior bacteremia (p = 0.0127). A sampled, individually matched cohort study (n = 74 pairs) was conducted to determine the proportion of mortality in cases that was attributable to infections (33%) and to determine excess hospital stay (seven days) among the patients with nosocomial pneumonia. Excess stay was statistically significant (p less than 0.0001), but proportional mortality was only marginally significant (p = 0.0892). Our findings suggest that nosocomial pneumonia accounts for approximately 33% of the crude mortality and contributes significantly to the economic burden associated with prolonged hospitalization.
To determine the attributable mortality and the excess length of hospital stay resulting from coagulase-negative staphylococcal bacteremia.
Matched historical cohort study.
Large university-based tertiary care center.
Of 171 patients with hospital-acquired coagulase-negative staphylococcal bacteremia identified by prospective surveillance of nosocomial infections from 1 July 1984 to 30 June 1987, 118 met criteria for the study and were matched to a control patient by age, sex, primary diagnoses, operative procedures, and date of admission.
Success was achieved in 621 of 650 (96%) variables used for matching. Staphylococcus epidermidis accounted for 92% of the bacteremias. Twenty cases (17%) had evidence of septic shock, and 10 had disseminated intravascular coagulation. The mortality rate in cases was 36 of 118 (30.5%) compared with 20 of 118 (16.9%) in controls. The attributable mortality was 13.6% (95% CI, 4.2 to 22.9) and the risk ratio for dying was 1.8 (95% CI, 1.2 to 2.7; P = 0.006). The median length of stay was 46 days for cases and 37.5 for controls (P = 0.0002).
Coagulase-negative staphylococci, the leading organisms causing hospital-acquired bacteremias, are associated with mortality in excess of that due to the underlying diseases alone. Moreover, they significantly prolong the length of hospital stay. These findings show the importance of coagulase-negative staphylococcal bacteremia in hospitalized patients.
Gastric alkalization of critically ill patients is associated with bacterial and fungal overgrowth in gastric contents. We studied the incidence of gastric colonization and its relation to other infections and antibiotic therapy in 25 critically ill ICU patients. All patients received 12-h NG Mylanta II and 15 received an H2-receptor antagonist. All patients had bacterial colonization of NG contents within 4 days of ICU admission and 10 had Candida colonization within 8 days. There were 70 NG isolates and the same isolates were found in tracheobronchial secretions (n = 46), blood (n = 4), urine (n = 4), and wounds (n = 8). Tracheobronchial colonization was preceded by NG colonization with the same organism in 12 instances (11 patients), was concurrent with NG colonization in 20 instances (14 patients), was followed by NG colonization in 14 instances (11 patients), and had no similar NG isolate in 18 instances (11 patients). NG culture of the same organism preceded four of eight positive blood cultures. In 35 of 70 NG isolates and five of 11 subsequent tracheobronchial isolates, colonization occurred despite concurrent appropriate antibiotics. We conclude that colonization of alkalinized NG contents is universal, is a common source of infection in other areas, and is not prevented by systemic antibiotic therapy. Local antibiotic therapy may be important in controlling this important source of infection.
The microbiology of infection acquired in the intensive care unit (ICU) was studied prospectively in 205 consecutive patients admitted to a surgical intensive care unit. A multiple organ failure (MOF) score was calculated for each admission. Susceptibility to ICU-acquired infection increased with increasing MOF scores. While Escherichia coli, Bacteroides fragilis, and enterococci were the most common isolates from infections present at the time of ICU admission, Staphylococcus epidermidis, Candida, and Pseudomonas dominated infections occurring in patients with high MOF scores. Mortality correlated highly with infection due to S epidermidis or Candida and only poorly with infection due to Pseudomonas or E coli; significant foci of invasive infection were frequently absent at autopsy. Quantitative cultures of proximal gastrointestinal fluid in 16 of these patients showed Candida, S epidermidis, and Pseudomonas to be the most common isolates, and all but one patient colonized with these organisms had invasive infection with the same organism. The proximal gastrointestinal tract appears to be an important occult reservoir of the predominant pathogens in MOF.
The charts of 25 patients who died in the intensive care unit of persistent peritonitis after abdominal operations were reviewed to determine the microbial flora and the efficacy of antibiotic treatment. All patients had undergone two or more surgical procedures for abdominal sepsis and 23 had at least three-system organ failure. The most common organisms cultured were: Staphylococcus epidermidis, 24 cultures from 16 patients, Candida albicans, 19 cultures from 10 patients, Pseudomonas aeruginosa, 16 cultures from 12 patients, Enterobacter, 16 cultures from 8 patients and enterococcus, 14 cultures from 8 patients. The classic isolates, Escherichia coli (11 cultures from six patients) and Bacteroides fragilis (4 cultures from three patients) were found infrequently. To determine the adequacy of antimicrobial therapy for this "new" flora, we examined the ability of appropriate agents to eradicate the micro-organism upon subsequent culture. Candida sp. were eradicated in 54% (6 of 11) of the assessable cases, while enterococcus and S. epidermidis were cleared in only 25% and 28% respectively. The spectrum of intra-abdominal organisms cultured from critically ill surgical patients in the intensive care unit differs from that seen in those with acute peritonitis. Despite administration of appropriate antimicrobial agents, these organisms tend to persist, probably reflecting impaired host defences with multiple-system organ failure rather than antimicrobial failure.
The records of 63 surgical patients with one or more positive blood cultures for Enterobacter organisms were reviewed to determine clinical, epidemiologic, and mortality risk factors. Enterobacter bacteremia occurred, on the average, on the twenty-third day of hospitalization, most frequently in male patients (47), after antibiotic therapy (48 patients), placement of central venous catheters (38 patients), gastrointestinal tract operations (36 patients), and respiratory failure (31 patients). Portals of entry were most commonly sputum (25 patients), open skin wounds (16 patients), and central venous lines (12 patients). Mortality risk (22 patients, 35%) was increased with Enterobacter bacteremia occurring after the fifteenth day of hospitalization (18 of 45 patients versus 4 of 28 patients, p less than 0.01), a preceding Enterobacter focus (13 of 22 patients versus 9 of 41 patients, p less than 0.05), preceding non-Enterobacter bacteremia (10 of 15 patients versus 12 of 48 patients, p less than 0.02), preceding total parenteral nutrition (11 of 21 patients versus 11 of 42 patients p less than 0.01), respiratory failure (19 of 36 patients versus 3 of 27 patients p less than 0.01), and renal failure (11 of 12 patients versus 11 of 51 patients p less than 0.01). The mortality risk was not diminished by specific antibiotic therapy. Enterobacter is emerging as an important pathogen in surgical patients. Prolonged antibiotic administration, particularly that of cephalosporins, may promote Enterobacter colonization of the tracheobronchial tree and skin with subsequent invasion enhanced by respiratory failure, open skin wounds, or central venous catheters traversing the skin. Mortality risk is determined primarily by factors associated with critical illness rather than effects of Enterobacter organisms and their specific treatment.(ABSTRACT TRUNCATED AT 250 WORDS)
Eighty-three patients with 117 episodes of candidemia were reviewed to examine the clinically significant variables and the results of treatment for this problem. Mortality was 52%. Patients who had bacteremia either synchronously or metachronously in association with Candida species had poorer survival rates. Staphylococcal and enterococcal species were the most frequently associated bacteria. Patients with Candida parapsilosis had better survival rates than patients with other species. Portals of entry for fungemia were catheters, wounds, the urinary tract, and the peritoneal cavity, but were undefined in 54% of patients. Antifungal chemotherapy could not be identified as affecting the outcome in these patients. It is suggested that candidemia in most patients represents a failure of host defense, and that septicemia of either bacteria or fungi may arise from the gastrointestinal tract in critically ill, immunocompromised patients.
Intraabdominal abscess induced multiple organ failure in 21 patients. Sepsis was most often due to perforation of the colon and was located with almost equal frequency in the upper and lower abdomen. Four patients died after single laparotomy for drainage. Seventeen were drained operatively more than once (average 3.4 operations) at mean intervals of 10 days. Sixteen of the 21 patients (76 percent) died with multiple organ failure despite drainage. Organ function improved temporarily in only one patient. Autopsy showed that pus had persisted or recurred in three patients. No significant predictors of survival were identified, although the advantage appears to lie with the younger patient in whom multiple organ failure develops relatively late after sepsis (mean 13 days) and who needs ventilatory assistance for less than 1 week. The location, size, and bacteriologic characteristics of abscesses do not appear to influence outcome. This study shows that early and repeated drainage of intraabdominal pus will not reverse multiple organ failure in the majority of patients.
Although enterococcus is well recognized as a pathogen in endocarditis, urinary tract infections, and biliary sepsis, its role in other forms of intraabdominal sepsis remains controversial. Antibiotics that lack activity against enterococcus can often be employed successfully in intraabdominal infections, even when enterococci are present as part of the polymicrobial flora. Furthermore, the enterococcus rarely emerges as a blood borne pathogen in such a setting. Breakthrough enterococcal septicemia may occur, however, in the immunodepressed host, particularly in the face of broad-spectrum antibiotic therapy not specific for enterococcus. Like infections with other opportunistic pathogens, enterococcal sepsis under these circumstances carries a high mortality. Specific antienterococcal drug therapy may be indicated as an adjunct to surgical management in selected patients with intraabdominal sepsis.
We studied 29 patients with multiple-organ failure (MOF) who underwent exploratory laparotomy because of suspected intra-abdominal sepsis. The purpose was to identify predictors of continuing abdominal sepsis and to assess outcome of operation in these severely ill patients. The strongest predictor of continuing intra-abdominal sepsis was development of unexplained single-organ failure, which occurred in 17 patients. Physical findings were not a totally reliable indicator of abdominal sepsis since only 15 of 29 patients had acute abdominal findings. The main clue to sepsis in patients without acute abdominal findings was worsening organ failure. Fifteen of 29 patients died of continuing MOF. Only one patient older than 50 years survived. We suggest that earlier operation is indicated in certain patients with organ failure. Particularly aggressive operative therapy seems justified in young patients with unexplained single-organ failure or worsening MOF.
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.
Generalized peritonitis was assessed in 176 patients, 67 (38%) of whom died. Cases were divided into causative groups: (1) appendicitis and perforated duodenal ulcer, (2) intraperitoneal origin other than appendix or duodenum, and (3) postoperative peritonitis. Mortalities were 10%, 50%, and 60%, respectively. Postoperative peritonitis was characterized by lack of influence of age on outcome, late operation, and more frequent organ failure. Delayed surgery carried a worse prognosis. Organ failure was a risk factor with 76% mortality, and was associated with late operation. Early surgery in organ failure improved survival. More sensitive indicators of early organ dysfunction might improve survival.
One hundred and six patients found at operation to have intra-abdominal sepsis were prospectively followed up to determine the incidence of organ malfunction and death. These outcomes were correlated with age, preexisting disease, underlying cause of sepsis, shock, nutritional status, and alcoholism. Organ malfunction occurred in 31 patients (29%), 19 (61%) of whom died. Two (3%) of 75 patients without organ malfunction died. Discriminant analysis revealed a significantly increased risk of death in patients with shock at any time, age greater than 65 years, alcoholism, bowel infarction, or malnutrition. A discriminant equation based only on preoperative variables correctly assigned the outcome of death or survival in 97 (92%) of the patients based on probabilities derived from this analysis. At present, this information is primarily of interest for researchers comparing outcomes in groups of patients, but with additional refinements it may become clinically useful for individual patients.
Thirteen episodes of Staphylococcus epidermidis sepsis occurred over a 20-month period in 11 patients receiving general surgical and medical care. These episodes were characterized by fever, toxicity, multiple positive blood cultures, and uniformly colonized intravascular catheters. An additional 16 patients had possible sepsis. Four associated deaths occurred; all three patients autopsied had multiple pulmonary abscesses in which gram-positive cocci were profusely present. In individual patients, prolonged episodes of septicemia were confirmed by multiple blood culture isolates of S. epidermidis, identical in antibiotic resistance pattern, phage type, and biotype. A prominent feature of the S. epidermidis isolates was resistance to many commonly used antimicrobial agents. Case-control studies and review of laboratory records indicated a significant association between multiply resistant S. epidermidis blood isolates and prolonged hospitalization and parenteral hyperalimentation. Most of these patients were hospitalized in the intensive care unit; nose and hand cultures taken from the personnel showed frequent carriage of multiply resistant S. epidermidis Staphylococcus epidermidis associated with intravascular devices may produce life-threatening bloodstream infections.
Various Candida species have been found increasingly in seriously ill surgical patients. This study, which evaluates the role of Candida in the pathogenesis of intraperitoneal infections, is a retrospective review of 56 episodes of intraperitoneal infection in which various Candida species were identified. All patients were on general surgical services; transplant patients were excluded. In all patients, intraperitoneal infections was confirmed at the time of operation. In 30 cases, peritonitis was the result of a spontaneous disease process - perforated viscus (25), intestinal necrosis (two), miscellaneous (three) - and in the other 26 cases, infection followed elective intraabdominal surgery. Infection was polymicrobial in 82% of the cases and the overall mortality rate was 70%. Uncontrolled sepsis was the predominant cause of death. Postmortem findings in 27 patients (of 40 deaths) showed nine cases of clinically unsuspected disseminated candidiasis, and persistent intraperitoneal Candida infection was present in eight more patients. None of the patients treated with amphotericin prior to death had residual foci of candidal infection. In 40 patients, intraperitoneal Candida was found before the onset of multiple organ failure syndromes, and survival was related to provision of systemic antifungal therapy before blood cultures became positive. Five of six patients treated prior to the development of positive blood cultures survived, whereas only nine of 27 untreated patients survived. If therapy was withheld until blood cultures became positive, only two out of six patients survived. Low-dose therapy consisting of 0.3 to 0.5 mg amphotericin B/kg daily for 7 days was equally effective as more prolonged treatment. We conclude that when Candida is identified as part of the intraperitoneal flora at operation for intraperitoneal infection, it should be treated with low-dose amphotericin B. Treatment should not be delayed until blood cultures become positive. Therapy should be monitored with repetitive cultures of multiple sites and with fundoscopy. No relapse occurred in patients so treated.
To develop an objective scale to measure the severity of the multiple organ dysfunction syndrome as an outcome in critical illness.
Systematic literature review; prospective cohort study.
Surgical intensive care unit (ICU) of a tertiary-level teaching hospital.
All patients (n = 692) admitted for > 24 hrs between May 1988 and March 1990.
None.
Computerized database review of MEDLINE identified clinical studies of multiple organ failure that were published between 1969 and 1993. Variables from these studies were evaluated for construct and content validity to identify optimal descriptors of organ dysfunction. Clinical and laboratory data were collected daily to evaluate the performance of these variables individually and in aggregate as an organ dysfunction score. Seven systems defined the multiple organ dysfunction syndrome in more than half of the 30 published reports reviewed. Descriptors meeting criteria for construct and content validity could be identified for five of these seven systems: a) the respiratory system (Po2/FIO2 ratio); b) the renal system (serum creatinine concentration); c) the hepatic system (serum bilirubin concentration); d) the hematologic system (platelet count); and e) the central nervous system (Glasgow Coma Scale). In the absence of an adequate descriptor of cardiovascular dysfunction, we developed a new variable, the pressure-adjusted heart rate, which is calculated as the product of the heart rate and the ratio of central venous pressure to mean arterial pressure. These candidate descriptors of organ dysfunction were then evaluated for criterion validity (ICU mortality rate) using the clinical database. From the first half of the database (the development set), intervals for the most abnormal value of each variable were constructed on a scale from 0 to 4 so that a value of 0 represented essentially normal function and was associated with an ICU mortality rate of < 5%, whereas a value of 4 represented marked functional derangement and an ICU mortality rate of > or = 50%. These intervals were then tested on the second half of the data set (the validation set). Maximal scores for each variable were summed to yield a Multiple Organ Dysfunction Score (maximum of 24). This score correlated in a graded fashion with the ICU mortality rate, both when applied on the first day of ICU admission as a prognostic indicator and when calculated over the ICU stay as an outcome measure. For the latter, ICU mortality was approximately 25% at 9 to 12 points, 50% at 13 to 16 points, 75% at 17 to 20 points, and 100% at levels of > 20 points. The score showed excellent discrimination, as reflected in areas under the receiver operating characteristic curve of 0.936 in the development set and 0.928 in the validation set. The incremental increase in scores over the course of the ICU stay (calculated as the difference between maximal scores and those scores obtained on the first day [i.e., the delta Multiple Organ Dysfunction Score]) also demonstrated a strong correlation with the ICU mortality rate. In a logistic regression model, this incremental increase in scores accounted for more of the explanatory power than admission severity indices.
This multiple organ dysfunction score, constructed using simple physiologic measures of dysfunction in six organ systems, mirrors organ dysfunction as the intensivist sees it and correlates strongly with the ultimate risk of ICU mortality and hospital mortality. The variable, delta Multiple Organ Dysfunction Score, reflects organ dysfunction developing during the ICU stay, which therefore is potentially amenable to therapeutic manipulation. (ABSTRACT TRUNCATED)
The fundamental principles of management of peritonitis include general supportive management, antibiotic therapy, and prompt surgical intervention. Several empiric antibiotic regimens have proven to be effective. All have in common activity against gram-negative bacilli and anaerobic bacteria. The choice of a particular regimen depends primarily on patient-specific factors. Surgical intervention includes source control, peritoneal toilet, and prevention of recurrent infection. Control of the source of contamination involves resecting, excluding, or patching the diseased viscus at laparotomy or, more recently, laparoscopic methods in selected cases. Attempts to prevent recurrent infection using intraoperative saline lavage and radical peritoneal débridement have shown no benefit in well-designed clinical trials. The roles for continuous postoperative peritoneal lavage, planned relaparotomy, and laparostomy in the current management of severe peritonitis remain to be established.
It is widely assumed that infections are the principal cause and primary outcome determinant of the syndrome of Multiple Organ Failure (MOF) in critically ill patients. Infections are frequent in these patients, but the prevention and treatment of infections may not influence the course of MOF. This study tested the hypothesis that infections play a decisive role in the outcome of MOF. Data were gathered concurrently on all adult patients admitted over an 18-month period to a non-cardiac surgical ICU at a university hospital and recorded in a computer database. Sepsis was defined as a state characterized by at least three of the following: fever, tachycardia, leukocytosis or leukopenia, increased cardiac index, reduced systemic vascular resistance, and hypercatabolism manifested by nitrogen-wasting. The presence of an infection was not required for the diagnosis of sepsis. Mild sepsis was defined as the presence of three or four parameters. Severe sepsis was defined as the presence of five or six parameters. MOF was defined as the development of dysfunction of at least two of the following major organ systems: cardiac, gut, pulmonary, renal, cerebral, and hepatic. Of 749 admissions, 73 patients developed MOF. Thirty four (47%) had a documented source of infection, 37 (51%) had positive blood cultures, and all had sepsis. Hospital mortality was 66 percent (48 of 73 patients). Death could not be predicted by bacteremia (P > 0.25), nor by the presence of an infectious source (P = 1.0), but was strongly associated with severe sepsis (P < 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)
To compare the outcome of abdominal infection in patients with or without previous systemic glucocorticoid therapy and to determine the effect of steroid administration on the relationship between APACHE II (Acute Physiology and Chronic Health Evaluation) scores and mortality.
Steroid therapy leads to greater mortality and relatively lower APACHE II scores.
Prospective cohort study.
University hospital.
Two hundred ninety-seven consecutive adult patients with abdominal infection treated by surgical or percutaneous drainage. Treatment was at the clinician's discretion. Seventy-one patients received systemic steroid therapy.
APACHE II score, clinical course, and death in hospital; relationship between APACHE II score and mortality in the steroid and no steroid groups.
Thirty-three patients receiving steroid therapy (46%) died vs 55 (24%) of 226 patients not receiving steroid therapy. The APACHE II score (P < .0001) and steroid administration (P = .04) were each independently associated with death. Steroid-treated patients had the same probability of dying as "nonsteroid" patients with an APACHE II score a mean of 3.7 points higher (95% confidence limits, 0.03 and 7.7). The confidence that 2, 3, or 4 extra APACHE II points is the appropriate correction for steroid-treated patients is 80%, 60%, or 40%, respectively.
Patients receiving steroid therapy appear to be at higher risk of dying of abdominal infection than predicted by APACHE II scores. The number of patients receiving cancer chemotherapy was too small to determine whether this was an additional risk factor. In the design of clinical trials stratified by APACHE II scores, steroid-treated patients should either be excluded or assigned two extra APACHE II points.
This study determined the association between proximal gastrointestinal (GI) colonization and the development of intensive care unit (ICU)-acquired infection and multiple organ failure (MOF) in a population of critically ill surgical patients.
ICU-acquired infection in association with progressive organ system dysfunction is an important cause of morbidity and mortality in critical surgical illness. Oropharyngeal and gastric colonization with the characteristic infecting species is common, but its association with ICU morbidity is poorly defined.
A prospective cohort study of 41 surgical ICU patients was undertaken. Specimens of gastric and upper small bowel fluid were obtained for quantitative culture; the severity of organ dysfunction was quantitated by a numeric score.
One or more episodes of ICU-acquired infection developed in 33 patients and involved at least one organism concomitantly cultured from the upper GI tract in all but 3. The most common organisms causing ICU-acquired infection--Candida, Streptococcus faecalis, Pseudomonas, and coagulase-negative Staphylococci--were also the most common species colonizing the proximal GI tract. Gut colonization correlated with the development of invasive infection within 1 week of culture for Pseudomonas (90% vs. 13% in noncolonized patients, p < 0.0001) or Staphylococcus epidermidis (80% vs. 6%, p < 0.0001); a weaker association was seen for colonization with Candida. Infections associated with GI colonization included pneumonia (16 patients), wound infection (12 patients), urinary tract infection (11 patients), recurrent (tertiary) peritonitis (11 patients), and bacteremia (10 patients). ICU mortality was greater for patients colonized with Pseudomonas (70% vs. 26%, p = 0.03); organ dysfunction was most marked in patients colonized with one or more of the following: Candida, Pseudomonas, or S. epidermidis.
The upper GI tract is an important reservoir of the organisms causing ICU-acquired infection. Pathologic GI colonization is associated with the development of MOF in the critically ill surgical patient.
by directly traversing the intact intestinal wall. In an animal Although primary peritonitis may occur in children without model, Escherichia coli passes from the bowel into the peritopredisposing disease, it is especially associated with post- neal cavity after the introduction of hypertonic solutions into necrotic cirrhosis and nephrotic syndrome. In adults, primary the peritoneum. The infrequent occurrence of bacteremia and peritonitis develops in up to 25% of patients with alcoholic the multiplicity of species in peritoneal fluid when anaerobic cirrhosis but has also been reported to occur in adults with bacteria are involved suggest that transmural migration of bacpostnecrotic cirrhosis, chronic active hepatitis, acute viral hepa- teria is the probable route of infection of ascitic fluid in most of these patients. In prepubertal girls, the pathogenesis of primary peritonitis is likely related to an ascending infection of genital origin, as
Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome Surgical infection stratification system for intra-abdominal infection: multicenter trial
- J C Marshall
- D J Cook
- N V Christou
- G R Bernard
- C L Sprung
- W J Sibbald
- E P Dellinger
- M J Wertz
- J L Meakins
- J S Solomkin
- M D Allo
- R J Howard
- R L Simmons
Marshall, J.C., Cook, D.J., Christou, N.V., Bernard, G.R., Sprung, C.L., Sibbald, W.J.: Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit. Care Med. 23:1638, 13. Dellinger, E.P., Wertz, M.J., Meakins, J.L., Solomkin, J.S., Allo, M.D., Howard, R.J., Simmons, R.L.: Surgical infection stratification system for intra-abdominal infection: multicenter trial. Arch. Surg. 120:21, 1985
Risk factors for hospital acquired Candidemia: a matched case control study Entero-coccal bacteremia in surgical patients Effects of gastric alkalization on bacterial colonization in critically ill patients
- S B Wey
- M Mori
- M A Pfaller
- R F Woolson
- R P Wenzel
- D T Barrall
- P R Kenney
- G J Slotman
- K W Burchard
Wey, S.B., Mori, M., Pfaller, M.A., Woolson, R.F., Wenzel, R.P.: Risk factors for hospital acquired Candidemia: a matched case control study. Arch. Intern. Med. 149:2349, 1989 40. Barrall, D.T., Kenney, P.R., Slotman, G.J., Burchard, K.W.: Entero-coccal bacteremia in surgical patients. Arch. Surg. 120:57, 1985 41. Garvey, B.M., McCambley, J.A., Tuxen, D.V.: Effects of gastric alkalization on bacterial colonization in critically ill patients. Crit. Care Med. 17:211, 1989