Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: a prospective multicentre study (WISS Study)

Open abdomen versus primary closure in the management of severe abdominal sepsis: What is the right way? Results of the last 5 years of a reference center

PURPOSE

WSES guidelines allow open abdomen (OA) for critically ill patients due to secondary peritonitis in the case of inadequate source control, but this option results quite vague and with a low grade of evidence (Grade 2 C). Moreover, the emerging increasing in literature of complications, makes the use of OA in secondary peritonitis more debated. The aim of our study is to analyze the postoperative outcomes of patients undergoing OA versus primary closure (PC) in secondary peritonitis.

METHODS

We collected data from Tertiary Trauma Center from 2019 to 2024. The study included patients who underwent urgent laparotomy for severe secondary peritonitis, divided into two groups based on the strategy chosen in the index laparotomy: PC or OA. We retrospectively analyzed the data, considering as primary outcome post-operative mortality, while as secondary outcomes short terms complications and LOS.

RESULTS

283 patients fit the research for the diagnosis of peritonitis but only 176 were included as with a WSES-SSS > = 7. 128 patients (72,7%) were in the PC group, while 48 (27,3%) were managed with an OA strategy. There were no statistical differences in terms of mortality (p = 0.371), between the two groups. Complications were higher in the OA group (p = 0.001). From the logistic regression only MPI resulted an independent factor of mortality (p = 0.016; OR 1.080).

CONCLUSION

The study shows that OA in severe secondary peritonitis does not improve mortality and is associated with higher short-term complications and incisional hernias. However, RCT are necessary to better investigate the role of OA in the management of abdominal sepsis.

Risk factors for in-hospital mortality in surgical patients with abdominal sepsis in China: a nested case-control study

OBJECTIVES

To delineate the clinical characteristics and investigate the determinants that may affect the prognosis of surgical patients with abdominal sepsis.

DESIGN

A case-control study was nested in a cohort of surgical patients with abdominal sepsis between 2008 and 2022. We extracted patient' medical records to execute descriptive statistical analyses. Multiple logistic regression models and subgroup analysis were employed to elucidate the risk factors of in-hospital mortality.

SETTING

Two tertiary hospitals in China.

PARTICIPANTS

476 surgical patients diagnosed with abdominal sepsis between 2008 and 2022 were analysed.

INTERVENTIONS

None.

OUTCOME MEASURES

Descriptive statistics were used to examine pertinent patient information, including demographic details, laboratory findings, surgical interventions and anaesthetic records. Multivariate logistic regression was used to identify independent risk factors for in-hospital mortality. Subgroup analyses were conducted to explore the impact of specific clinical characteristics on outcomes.

RESULTS

476 patients diagnosed with abdominal sepsis were analysed, exhibiting an in-hospital mortality rate of 7.56%. Advanced age (OR 6.77, 95% CI 2.46 to 18.66, p<0.001), the presence of diabetes (OR 2.61, 95% CI 1.04 to 6.56, p=0.041) and higher preoperative Sequential Organ Failure Assessment (SOFA) score (OR 3.48, 95% CI 1.16 to 10.43, p=0.026) were identified as significant predictors of increased in-hospital mortality risk through a multinomial logistic regression model. Conversely, individuals afflicted with biliary diseases (OR 0.15, 95% CI 0.04 to 0.64, p=0.010) demonstrated a reduced risk of in-hospital mortality. Subgroup analysis revealed that low serum albumin levels emerged as a risk factor for in-hospital mortality in the patients with gastrointestinal diseases (OR 20.23, 95% CI 2.21 to 184.84, p=0.008) or advanced age (OR 10.52, 95% CI 2.29 to 48.31, p=0.002) through multinomial logistic regression analysis.

CONCLUSION

In this retrospective analysis, we delineated the clinical characteristics of surgical patients with abdominal sepsis and pinpointed risk factors associated with in-hospital mortality. These findings underscore the necessity for more tailored perioperative management strategies for patients with sepsis characterised by advanced age, diabetes, higher preoperative SOFA score and reduced preoperative albumin levels. Clinicians should prioritise early recognition and aggressive management of these high-risk individuals, including timely surgical intervention, optimisation of nutritional status and vigilant monitoring of organ function. These insights underscore the critical role of individualised care in enhancing the prognosis of surgical patients with abdominal sepsis.

TRIAL REGISTRATION NUMBER

ChiCTR2400081823.

Epidemiological analysis of intra-abdominal infections in Italy from the Italian register of complicated intra-abdominal infections-the IRIS study: a prospective observational nationwide study

BACKGROUND

Intra-abdominal infections (IAIs) are common and severe surgical emergencies associated with high morbidity and mortality. In recent years, there has been a worldwide increase in antimicrobial resistance associated with intra-abdominal infections, responsible for a significant increase in mortality rates. To improve the quality of treatment, it is crucial to understand the underlying local epidemiology, clinical implications, and proper management of antimicrobial resistance, for both community- and hospital-acquired infections. The IRIS study (Italian Register of Complicated Intra-abdominal InfectionS) aims to investigate the epidemiology and initial management of complicated IAIs (cIAIs) in Italy.

MATERIAL AND METHOD

This is a prospective, observational, nationwide (Italy), multicentre study. approved by the coordinating centre ethic committee (Local Research Ethics Committee of Pisa (Prot n 56478//2019). All consecutively hospitalized patients (older than 16 years of age) with diagnosis of cIAIs undergoing surgery, interventional drainage or conservative treatment have been included.

RESULTS

4530 patients included from 23 different Italian hospitals. Community Acquired infection represented the 70.9% of all the cases. Among appendicitis, we found that 98.2% of the cases were community acquired (CA) and 1.8% Healthcare-associated (HA) infections. We observed that CA represented the 94.2% and HA 5.8% of Gastro Duodenal perforation cases. The majority of HA infections were represented by colonic perforation and diverticulitis (28.3%) followed by small bowel occlusion (19%) and intestinal ischemia (18%). 27.8% of patients presented in septic shock. Microbiological Samples were collected from 3208 (70.8%) patients. Among 3041 intrabdominal sample 48.8% resulted positive. The major pathogens involved in intra-abdominal infections were found to be E.coli (45.6%). During hospital stay, empiric antimicrobial therapy was administered in 78.4% of patients. Amoxicillin/clavulanate was the most common antibiotic used (in 30.1% appendicitis, 30% bowel occlusion, 30.5% of cholecystitis, 51% complicated abdominal wall hernia, 55% small bowel perforation) followed by piperacillin/tazobactam (13.3% colonic perforation and diverticulitis, 22.6% cholecystitis, 24.2% intestinal ischemia, 28.6% pancreatitis). Empiric antifungal therapy was administered in 2.6% of patients with no sign of sepsis, 3.1% of patients with clinical sign of sepsis and 4.1% of patients with septic shock. Azoles was administered in 49.2% of patients that received empiric antifungal therapy. The overall mortality rate was 5.13% (235/4350). 16.5% of patients required ICU (748/4350). In accordance with mortality, it is important to highlight that 35.7% of small bowel perforation, 27.6% of colonic perforation and diverticulitis, 25.6% of intestinal ischemia and 24.6% of gastroduodenal complications required ICU.

CONCLUSION

Antibiotic stewardship programs and correct antimicrobial and antimycotic prescription campaigns are necessary to ulteriorly improve the adequacy of drug usage and reduce the resistances burden. This will help in improving the care and the cure of the next generations.

COVID-19 infection is a significant risk factor for death in patients presenting with acute cholecystitis: a secondary analysis of the ChoCO-W cohort study

BACKGROUND

During the coronavirus disease (COVID-19) pandemic, there has been a surge in cases of acute cholecystitis. The ChoCO-W global prospective study reported a higher incidence of gangrenous cholecystitis and adverse outcomes in COVID-19 patients. Through this secondary analysis of the ChoCO-W study data, we aim to identify significant risk factors for mortality in patients with acute cholecystitis during the COVID-19 pandemic, emphasizing the role of COVID-19 infection in patient outcomes and treatment efficacy."

METHODS

The ChoCO-W global prospective study reported data from 2546 patients collected at 218 centers from 42 countries admitted with acute cholecystitis during the COVID-19 pandemic, from October 1, 2020, to October 31, 2021. Sixty-four of them died. Nonparametric statistical univariate analysis was performed to compare patients who died and patients who survived. Significant factors were then entered into a logistic regression model to define factors predicting mortality.

RESULTS

The significant independent factors that predicted death in the logistic regression model with were COVID-19 infection (p < 0.001), postoperative complications (p < 0.001), and type (open/laparoscopic) of surgical intervention (p = 0.003). The odds of death increased 5 times with the COVID-19 infection, 6 times in the presence of complications, and it was reduced by 86% with adequate source control. Survivors predominantly underwent urgent laparoscopic cholecystectomy (52.3% vs. 23.4%).

CONCLUSIONS

COVID-19 was an independent risk factor for death in patients with acute cholecystitis. Early laparoscopic cholecystectomy has emerged as the cornerstone of treatment for hemodynamically stable patients.

Distribution and Antimicrobial Resistance of Complicated Intraabdominal Infection Pathogens in Two Tertiary Hospitals in Egypt

Background: Management of complicated intraabdominal infections (cIAIs) requires containment of the source and appropriate initial antimicrobial therapy. Identifying the local data is important to guide the empirical selection of antimicrobial therapy. In this study, we aimed to describe the pathogen distribution and antimicrobial resistance of cIAI. Methods: In two major tertiary care hospitals in Egypt, we enrolled patients who met the case definition of cIAI from October 2022 to September 2023. Blood cultures were performed using the BACTAlert system (BioMerieux, Marcy l'Etoile, France). A culture of aspirated fluid, resected material, or debridement of the infection site was performed. Identification of pathogens and antimicrobial susceptibility testing were conducted by the VITEK-2 system (BioMerieux, Marcy l'Etoile, France). Gram-negative resistance genes were identified by PCR and confirmed by whole bacterial genome sequencing using the Nextera XT DNA Library Preparation Kit and sequencing with the MiSeq Reagent Kit 600 v3 (Illumina, USA) on the Illumina MiSeq. Results: We enrolled 423 patients, 275 (65.01%) males. The median age was 61.35 (range 25-72 years). We studied 452 recovered bacterial isolates. Gram-negative bacteria were the vast majority, dominated by E. coli, followed by Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, and Proteus mirabilis (33.6%, 30.5%, 13.7%, 13%, and 5.4%, respectively). High rates of resistance were detected to third- and fourth-generation cephalosporins and fluoroquinolones. No resistance was detected to colistin. Resistance to amikacin and tigecycline was low among all isolates. Resistance to meropenem and ceftazidime/avibactam was moderate. ESBL genes were common in E. coli and K. pneumoniae. CTX-M15 gene was the most frequent. Among Enterobacterales, blaOXA-48 and blaNDM were the most prevalent carbapenemase genes. Pseudomonas aeruginosa isolates harbored a wide variety of carbapenemase genes (OXA, NDM, VIM, SIM, GIM, SPM, IMP, AIM), dominated by metallo-beta-lactamases. In 20.6% of isolates, we identified two or more resistance genes. Conclusion: High resistance rates were detected to third- and fourth-generation cephalosporins and fluoroquinolones. Amikacin and tigecyclines were the most active antimicrobials. Our data call for urgent implementation of antimicrobial stewardship programs and reinforcement of infection control.

2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Risk Assessment in Adults and Children

This paper is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America. In this paper, the panel provides a recommendation for risk stratification according to severity of illness score. The panel's recommendation is based on evidence derived from systematic literature reviews and adheres to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.

Source Control and Antibiotics in Intra-Abdominal Infections

Intra-abdominal infections (IAIs) account for a major cause of morbidity and mortality, representing the second most common sepsis-related death with a hospital mortality of 23-38%. Prompt identification of sepsis source, appropriate resuscitation, and early treatment with the shortest delay possible are the cornerstones of management of IAIs and are associated with a more favorable clinical outcome. The aim of source control is to reduce microbial load by removing the infection source and it is achievable by using a wide range of procedures, such as definitive surgical removal of anatomic infectious foci, percutaneous drainage and toilette of infected collections, decompression, and debridement of infected and necrotic tissue or device removal, providing for the restoration of anatomy and function. Damage control surgery may be an option in selected septic patients. Intra-abdominal infections can be classified as uncomplicated or complicated causing localized or diffuse peritonitis. Early clinical evaluation is mandatory in order to optimize diagnostic testing and establish a therapeutic plan. Prognostic scores could serve as helpful tools in medical settings for evaluating both the seriousness and future outlook of a condition. The patient's conditions and the potential progression of the disease determine when to initiate source control. Patients can be classified into three groups based on disease severity, the origin of infection, and the patient's overall physical health, as well as any existing comorbidities. In recent decades, antibiotic resistance has become a global health threat caused by inappropriate antibiotic regimens, inadequate control measures, and infection prevention. The sepsis prevention and infection control protocols combined with optimizing antibiotic administration are crucial to improve outcome and should be encouraged in surgical departments. Antibiotic and antifungal regimens in patients with IAIs should be based on the resistance epidemiology, clinical conditions, and risk for multidrug resistance (MDR) and Candida spp. infections. Several challenges still exist regarding the effectiveness, timing, and patient stratification, as well as the procedures for source control. Antibiotic choice, optimal dosing, and duration of therapy are essential to achieve the best treatment. Promoting standard of care in the management of IAIs improves clinical outcomes worldwide. Further trials and stronger evidence are required to achieve optimal management with the least morbidity in the clinical care of critically ill patients with intra-abdominal sepsis.

Management of intra-abdominal infections: recommendations by the Italian council for the optimization of antimicrobial use

Intra-abdominal infections (IAIs) are common surgical emergencies and are an important cause of morbidity and mortality in hospital settings, particularly if poorly managed. The cornerstones of effective IAIs management include early diagnosis, adequate source control, appropriate antimicrobial therapy, and early physiologic stabilization using intravenous fluids and vasopressor agents in critically ill patients. Adequate empiric antimicrobial therapy in patients with IAIs is of paramount importance because inappropriate antimicrobial therapy is associated with poor outcomes. Optimizing antimicrobial prescriptions improves treatment effectiveness, increases patients' safety, and minimizes the risk of opportunistic infections (such as Clostridioides difficile) and antimicrobial resistance selection. The growing emergence of multi-drug resistant organisms has caused an impending crisis with alarming implications, especially regarding Gram-negative bacteria. The Multidisciplinary and Intersociety Italian Council for the Optimization of Antimicrobial Use promoted a consensus conference on the antimicrobial management of IAIs, including emergency medicine specialists, radiologists, surgeons, intensivists, infectious disease specialists, clinical pharmacologists, hospital pharmacists, microbiologists and public health specialists. Relevant clinical questions were constructed by the Organizational Committee in order to investigate the topic. The expert panel produced recommendation statements based on the best scientific evidence from PubMed and EMBASE Library and experts' opinions. The statements were planned and graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence. On November 10, 2023, the experts met in Mestre (Italy) to debate the statements. After the approval of the statements, the expert panel met via email and virtual meetings to prepare and revise the definitive document. This document represents the executive summary of the consensus conference and comprises three sections. The first section focuses on the general principles of diagnosis and treatment of IAIs. The second section provides twenty-three evidence-based recommendations for the antimicrobial therapy of IAIs. The third section presents eight clinical diagnostic-therapeutic pathways for the most common IAIs. The document has been endorsed by the Italian Society of Surgery.

Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery

Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs.

Development and validation of a nomogram to predict postsurgical intra-abdominal infection in blunt abdominal trauma patients: A multicenter retrospective study

BACKGROUND

Intra-abdominal infection is a common complication of blunt abdominal trauma. Early detection and intervention can reduce the incidence of intra-abdominal infection and improve patients' prognoses. This study aims to construct a clinical model predicting postsurgical intra-abdominal infection after blunt abdominal trauma.

METHODS

This study is a retrospective analysis of 553 patients with blunt abdominal trauma from the Department of General Surgery of 7 medical centers (2011-2021). A 7:3 ratio was used to assign patients to the derivation and validation cohorts. Patients were divided into 2 groups based on whether intra-abdominal infection occurred after blunt abdominal trauma. Multivariate logistic regression and least absolute shrinkage and selection operator regression were used to select variables to establish a nomogram. The nomogram was evaluated, and the validity of the model was further evaluated by the validation cohort.

RESULTS

A total of 113 were diagnosed with intra-abdominal infection (20.4%). Age, prehospital time, C-reactive protein, injury severity score, operation duration, intestinal injury, neutrophils, and antibiotic use were independent risk factors for intra-abdominal infection in blunt abdominal trauma patients (P < .05). The area under the receiver operating curve (area under the curve) of derivation cohort and validation cohort was 0.852 (95% confidence interval, 0.784-0.912) and 0.814 (95% confidence interval, 0.751-0.902). The P value for the Hosmer-Lemeshow test was .135 and .891 in the 2 cohorts. The calibration curve demonstrated that the nomogram had a high consistency between prediction and practical observation. The decision curve analysis also showed that the nomogram had a better potential for clinical application. To facilitate clinical application, we have developed an online at https://nomogramcgz.shinyapps.io/IAIrisk/.

CONCLUSION

The nomogram is helpful in predicting the risk of postoperative intra-abdominal infection in patients with blunt abdominal trauma and provides guidance for clinical decision-making and treatment.

[Laparoscopic surgery for advanced peritonitis]

OBJECTIVE

To determine the criteria for choosing surgical access in patients with advanced peritonitis considering its local and general manifestations.

MATERIAL AND METHODS

We analyzed treatment outcomes in 588 patients with advanced peritonitis. The most common causes of peritonitis were destructive forms of acute appendicitis (273 cases), perforated gastroduodenal ulcers (165 cases), acute cholecystitis (59 cases). To determine the criteria for choosing surgical access in advanced peritonitis, we analyzed treatment outcomes considering MPI, SPP and WSES SSS score.

RESULTS

The choice of surgical access in advanced peritonitis can only symbolically be standardized according to modern scoring systems (MPI, SPP, WSES SSS). Laparotomy is necessary for MPI score ≥30 and SPP score > 10 (WSES SSS score > 8). Regardless of MPI, SPP, WSES SSS scores, the absolute contraindications for laparoscopic surgery are dense non-removable fibrin deposits, interintestinal abscesses, purulent recesses, intra-abdominal pressure > 20 mm Hg or small intestine dilation> 3 cm, sepsis or septic shock (qSOFA score 2-3), previous open abdominal surgery, unstable hemodynamics, technical difficulties. Conversion should be used at any doubt.

CONCLUSION

Careful patient selection, surgical experience and training in laparoscopic technique are decisive factors for wider use of laparoscopic approach in patients undergoing emergency abdominal surgery.

Therapeutic effect of adipose-derived mesenchymal stem cells in a porcine model of abdominal sepsis

BACKGROUND

The term sepsis refers to a complex and heterogeneous syndrome. Although great progress has been made in improving the diagnosis and treatment of this condition, it continues to have a huge impact on morbidity and mortality worldwide. Mesenchymal stem cells are a population of multipotent cells that have immunomodulatory properties, anti-apoptotic effects, and antimicrobial activity. We studied these capacities in a porcine model of peritoneal sepsis.

METHODS

We infused human adipose-derived mesenchymal stem cells (ADSCs) into a porcine model of peritoneal sepsis. Twenty piglets were treated with antibiotics alone (control group) or antibiotics plus peritoneal infusion of ADSCs at a concentration of 2 × 106 cells/kg or 4 × 106 cells/kg (low- and high-dose experimental groups, respectively). The animals were evaluated at different time points to determine their clinical status, biochemical and hematologic parameters, presence of inflammatory cytokines and chemokines in blood and peritoneal fluid, and finally by histologic analysis of the organs of the peritoneal cavity.

RESULTS

One day after sepsis induction, all animals presented peritonitis with bacterial infection as well as elevated C-reactive protein, haptoglobin, IL-1Ra, IL-6, and IL-1b. Xenogeneic ADSC infusion did not elicit an immune response, and peritoneal administration of the treatment was safe and feasible. One day after infusion, the two experimental groups showed a superior physical condition (e.g., mobility, feeding) and a significant increase of IL-10 and TGF-β in blood and a decrease of IL-1Ra, IL-1b, and IL-6. After 7 days, all animals treated with ADSCs had better results concerning blood biomarkers, and histopathological analysis revealed a lower degree of inflammatory cell infiltration of the organs of the peritoneal cavity.

CONCLUSIONS

Intraperitoneal administration of ADSCs as an adjuvant therapy for sepsis improves the outcome and diminishes the effects of peritonitis and associated organ damage by regulating the immune system and reducing intra-abdominal adhesions in a clinically relevant porcine model of abdominal sepsis.

Surgical treatment of spondylodiscitis in critically ill septic patients

PURPOSE

Surgical procedures in critically ill patients with spondylodiscitis are challenging and there are several controversies. Here, we present our experience with offering surgical intervention early in critically ill septic patients with spondylodiscitis.

METHOD

After we introduced a new treatment paradigm offering early but limited surgery, eight patients with spondylodiscitis complicated by severe sepsis and multiple organ failure underwent urgent surgical treatment over a 10-year period. Outcome was assessed according to the Barthel index at 12-month follow-up and at the last available follow-up (mean 89 months).

RESULTS

There were 7 men and 1 woman, with a mean age of 62 years. The preoperative ASA score was 5 in 2 patients, and 4 in 6 patients. Six of them presented with high-grade paresis, and in all of them, spondylodiscitis with intraspinal and/or paravertebral abscesses was evident in MR imaging studies. All patients underwent early surgery (within 24 h after admission). The median time in intensive care was 21 days. Out of the eight patients, seven survived. One year after surgery, five patients had a good outcome (Barthel index: 100 (1); 80 (3); and 70 (1)). At the last follow-up (mean 89 months), 4 patients had a good functional outcome (Barthel index between 60 and 80).

CONCLUSION

Early surgical treatment in critically ill patients with spondylodiscitis and sepsis may result in rapid control of infection and can provide favorable long-term outcome. A general strategy of performing only limited surgery is a valid option in such patients who have a relatively high risk for surgery.

Damage Control Surgery and Transfer in Emergency General Surgery

Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.

The Significance of Preoperative Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), and Systemic Inflammatory Index (SII) in Predicting Severity and Adverse Outcomes in Acute Calculous Cholecystitis

The prediction of severity in acute calculous cholecystitis (AC) is important in therapeutic management to ensure an early recovery and prevent adverse postoperative events. We analyzed the value of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic inflammatory index (SII) to predict advanced inflammation, the risk for conversion, and postoperative complications in AC. Advanced AC was considered the cases with empyema, gangrene, perforation of the gallbladder, abscesses, or difficulties in achieving the critical view of safety. A 3-year retrospective was performed on 235 patients admitted in emergency care for AC. The NLR was superior to the PLR and SII in predicting advanced inflammation and risk for conversion. The best predictive value was found to be at an NLR "cut-off" value of >4.19, with a sensitivity of 85.5% and a specificity of 66.9% (AUC = 0.824). The NLR, SII, and TG 13/18 correlate well with postoperative complications of Clavien-Dindo grade IV (p < 0.001 for all variables) and sepsis. For predicting early postoperative sepsis, TG 13/18 grading >2 and NLR > 8.54 show the best predicting power (AUC = 0.931; AUC = 0.888, respectively), although not significantly higher than that of the PLR and SII. The NLR is a useful biomarker in assessing the severity of inflammation in AC. The SII and PLR may be useful in the prediction of systemic inflammatory response.

Typhoid Intestinal Perforation Prognostic Score in Poor-Resource Settings

Background

Mortality from peritonitis due to typhoid intestinal perforation (TIP) in sub-Saharan Africa is high.

Objectives

This study aimed to determine the predictive factors of mortality, propose a prognostic score, and determine the appropriate surgical treatment for TIP in low-resource settings.

Materials and Methods

This was a retrospective data collection of peritonitis due to TIP admitted at Zinder National Hospital from 2014 to 2021. To build a typhoid intestinal perforation prognostic score (TIPPS), patients were randomised into two groups: a score-building group and a validation group. Univariate and multivariate analyses were performed to identify risk factors of mortality. The value of P <0.05 was assigned significant for all analyses.

Results

TIP accounted for 52.4% (n = 1132) of all cases of peritonitis (n = 2159). The median age was 12 years. Rural provenance represented 72.2% (n = 817). Deaths accounted for 10.5% (n = 119). The factors influencing mortality were respiratory rate ≥24/min (odds ratio [OR] = 2.6, P = 0.000), systolic blood pressure <90 mmHg (OR = 0.31, P = 0.002), serum creatinine >20 mg/L (OR = 2.6, P ≤ 0.009), haemoglobin (OR = 2.1, P = 0.000), comorbidity (OR = 3.5, P = 0.001), the American Society of Anesthesiologists score IV&V (OR = 3.3, P = 0.000), admission and management delay > 72 h (OR = 3.2, P = 0.001), and a number of perforations (OR = 2.4, P = 0.0001). These factors were used to build a "TIPPS" score, which ranged from 8 to 20. The risk of mortality was associated with increased TIPPS. The performance of this score was good in the two groups (area under receiver operating characteristic > 0.83). According to the severity and mortality risk of TIP, we classified TIPS into four grades: grade I (low risk: 8-10), grade II (moderate risk: 11-13), grade III (high risk: 14-16) and grade IV (very high risk: 17-20).

Conclusion

The TIPPS is simple. It can describe the severity of the disease and can predict the risk of death. The study highlights the importance and impact of timely and adequate perioperative resuscitation in more complicated cases.

Prediction of outcome using CD14++CD16-, CD14++CD16+ and CD14+CD16++ monocyte subpopulations in patients with complicated intra-abdominal infections

There is still no study investigating the prognostic performance of CD14++CD16-, CD14++CD16+ and CD14+CD16++ monocyte subpopulations in complicated intra-abdominal infections (cIAIs); therefore, we aimed to evaluate the association between monocyte subtypes and outcome in such patients. A single-center prospective study was conducted at a University Hospital Stara Zagora between November 2018 and August 2021. Preoperatively and on the 3rd postoperative day (POD), we measured the levels of CD14++CD16-, CD14++CD16+ and CD14+CD16++ monocytes in peripheral blood using flow cytometry in 62 patients with cIAIs and 31 healthy controls. Nine of the 62 patients died during hospitalization. Survivors had higher pre-surgery percentages of CD14++CD16- classical monocytes and higher percentage of these cells predicted favorable outcome in ROC analysis (AUROC = 0.781, p = 0.008). The CD14++CD16+ intermediate monocyte percentages were higher in non-survivors both pre- and postoperatively but only the higher preoperative values predicted a lethal outcome (AUROC = 0.722, p = 0.035). For CD14+CD16++ non-classical monocytes, non-survivors had lower percentages on day 3 post-surgery and low percentage was predictive of lethal outcome (AUROC = 0.752, p = 0.046). Perioperative levels of monocyte subpopulations in peripheral blood show a great potential for prognostication of outcome in patients with cIAIs.

Source control in emergency general surgery: WSES, GAIS, SIS-E, SIS-A guidelines

Intra-abdominal infections (IAI) are among the most common global healthcare challenges and they are usually precipitated by disruption to the gastrointestinal (GI) tract. Their successful management typically requires intensive resource utilization, and despite the best therapies, morbidity and mortality remain high. One of the main issues required to appropriately treat IAI that differs from the other etiologies of sepsis is the frequent requirement to provide physical source control. Fortunately, dramatic advances have been made in this aspect of treatment. Historically, source control was left to surgeons only. With new technologies non-surgical less invasive interventional procedures have been introduced. Alternatively, in addition to formal surgery open abdomen techniques have long been proposed as aiding source control in severe intra-abdominal sepsis. It is ironic that while a lack or even delay regarding source control clearly associates with death, it is a concept that remains poorly described. For example, no conclusive definition of source control technique or even adequacy has been universally accepted. Practically, source control involves a complex definition encompassing several factors including the causative event, source of infection bacteria, local bacterial flora, patient condition, and his/her eventual comorbidities. With greater understanding of the systemic pathobiology of sepsis and the profound implications of the human microbiome, adequate source control is no longer only a surgical issue but one that requires a multidisciplinary, multimodality approach. Thus, while any breach in the GI tract must be controlled, source control should also attempt to control the generation and propagation of the systemic biomediators and dysbiotic influences on the microbiome that perpetuate multi-system organ failure and death. Given these increased complexities, the present paper represents the current opinions and recommendations for future research of the World Society of Emergency Surgery, of the Global Alliance for Infections in Surgery of Surgical Infection Society Europe and Surgical Infection Society America regarding the concepts and operational adequacy of source control in intra-abdominal infections.

The unrestricted global effort to complete the COOL trial

BACKGROUND

Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.

METHODS

The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.

DISCUSSION

OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.

TRIAL REGISTRATION

National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).

The unrestricted global effort to complete the COOL trial

BACKGROUND

Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.

METHODS

The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.

DISCUSSION

OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.

TRIAL REGISTRATION

National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).

Effectiveness of intraoperative peritoneal lavage with saline in patient with intra-abdominal infections: a systematic review and meta-analysis

Background

Intraoperative peritoneal lavage (IOPL) with saline has been widely used in surgical practice. However, the effectiveness of IOPL with saline in patients with intra-abdominal infections (IAIs) remains controversial. This study aims to systematically review randomized controlled trials (RCTs) evaluating the effectiveness of IOPL in patients with IAIs.

Methods

The databases of PubMed, Embase, Web of Science, Cochrane library, CNKI, WanFang, and CBM databases were searched from inception to December 31, 2022. Random-effects models were used to calculate the risk ratio (RR), mean difference, and standardized mean difference. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to rate the quality of the evidence.

Results

Ten RCTs with 1318 participants were included, of which eight studies on appendicitis and two studies on peritonitis. Moderate-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (0% vs. 1.1%; RR, 0.31 [95% CI, 0.02–6.39]), intra-abdominal abscess (12.3% vs. 11.8%; RR, 1.02 [95% CI, 0.70–1.48]; I2 = 24%), incisional surgical site infections (3.3% vs. 3.8%; RR, 0.72 [95% CI, 0.18–2.86]; I2 = 50%), postoperative complication (11.0% vs. 13.2%; RR, 0.74 [95% CI, 0.39–1.41]; I2 = 64%), reoperation (2.9% vs. 1.7%; RR,1.71 [95% CI, 0.74–3.93]; I2 = 0%) and readmission (5.2% vs. 6.6%; RR, 0.95 [95% CI, 0.48–1.87]; I2 = 7%) in patients with appendicitis when compared to non-IOPL. Low-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (22.7% vs. 23.3%; RR, 0.97 [95% CI, 0.45–2.09], I2 = 0%) and intra-abdominal abscess (5.1% vs. 5.0%; RR, 1.05 [95% CI, 0.16–6.98], I2 = 0%) in patients with peritonitis when compared to non-IOPL.

Conclusion

IOPL with saline use in patients with appendicitis was not associated with significantly decreased risk of mortality, intra-abdominal abscess, incisional surgical site infection, postoperative complication, reoperation, and readmission compared with non-IOPL. These findings do not support the routine use of IOPL with saline in patients with appendicitis. The benefits of IOPL for IAI caused by other types of abdominal infections need to be investigated.

Cost-effectiveness of ceftazidime/avibactam plus metronidazole versus meropenem as first-line empiric therapy for the treatment of complicated intra-abdominal infections: A study based on the in-vitro surveillance data in China

BACKGROUND

With the increase in drug resistance rates of pathogens isolated from complicated intra-abdominal infections (cIAIs), ceftazidime/avibactam (CAZ-AVI) is increasingly used clinically. However, given the high drug cost and the fact that not yet covered by the health insurance payment, this study evaluated the cost-effectiveness of CAZ-AVI plus metronidazole versus meropenem as a first-line empiric treatment for cIAIs from the perspective of the Chinese healthcare system.

METHODS

A decision analytic model with a one-year time horizon was constructed to assess the cost-effectiveness based on the entire disease course. Model inputs were mainly obtained from clinical studies, published literature, and publicly available databases. Primary outcomes were cost, quality-adjusted life years (QALYs), life years (Lys), and incremental cost-effectiveness ratio (ICER). One-way sensitivity analysis and probabilistic sensitivity analysis were also performed.

RESULTS

In the base cases, compared to meropenem, CAZ-AVI plus metronidazole had a shorter mean hospital length of stay (-0.77 days per patient) and longer life expectancy (+0.05 LYs and +0.06 QALYs). CAZ-AVI plus metronidazole had an ICER of $25517/QALY, which is well below the threshold of $31509 per QALY in China. The one-way sensitivity analysis showed that the change of the treatment duration of CAZ-AVI plus metronidazole was the parameter that most influenced the results of the ICER. In probabilistic sensitivity analysis, CAZ-AVI plus metronidazole was the optimal strategy in 75% of simulations at $31510/QALY threshold.

CONCLUSIONS

CAZ-AVI plus metronidazole could be considered as a cost-effective option for the empiric treatment of patients with cIAIs in China, and this benefit will be more evident when the price of CAZ-AVI decreases by 23.8%.

Association of the origin of contamination and species of microorganisms with short-term survival in dogs with septic peritonitis

OBJECTIVE

To assess the association between anatomical location of contamination and mortality in dogs with gastrointestinal and biliary origin of septic peritonitis.

METHODS

Medical records at two private referral hospitals between 2003 and 2020 were retrospectively reviewed. Cases were included if the origin of contamination was confirmed intraoperatively within the gastrointestinal or biliary tract. Cases were excluded if the dog died or was euthanized intraoperatively or where the data regarding the origin of contamination were not available. The association of anatomical origin with survival was assessed specifying the locations as stomach, small intestine, large intestine and biliary tract. The gastrointestinal tract origin was further subdivided into pylorus, nonpylorus, duodenum, jejunum, ileum, caecum and colon.

RESULTS

The overall survival rate was 75.9% (n = 44/58). There were no significant differences in survival among different anatomical origins of contaminations before or after subdivision (P = 0.349 and 0.832, respectively). Also, there was no association between isolated microorganism species in microbiological culture and the anatomical origin (P = 0.951) and the microorganism species was not associated with survival (P = 0.674).

CONCLUSIONS

There was no association between anatomical location of leakage, microorganism species and survival although further studies are warranted to analyse the relationships between anatomical leakage site and microorganism species as well as microorganism species and mortality.

[Choice of surgical approach and option for completing laparotomy in widespread peritonitis]

OBJECTIVE

To create a system for choosing surgical approach and completing laparotomy in advanced secondary peritonitis via combination of clinical, visual intra-abdominal criteria and systems for predicting the outcomes of peritonitis.

MATERIAL AND METHODS

The study included 686 patients with peritonitis between May 2015 and December 2022. Age of patients ranged from 16 to 95 years (mean 53.4±8.7). Male-to-female ratio was 1.2:11 (377:309). Destructive appendicitis was the cause of peritonitis in 274 (39.9%) patients, gastroduodenal ulcer perforation - 160 (23.3%) patients, colonic perforation - 188 (27.4%) patients, other causes - 64 (9.4%) patients. At baseline, 481 (70.1%) patients underwent diagnostic laparoscopy, and laparoscopic surgery was possible in 302 (62.8%) cases. Primary median laparotomy was performed in 205 (29.9%) patients. The closed method of completing laparotomy was used in 345 patients (77 - 22.3% died), staged elective surgeries - 28 (18 - 64.3% died), open abdomen technique was used in 11 patients (5 - 45.5% died). Redo laparotomy on demand was performed in 44 patients. Of these, 21 (47.7%) ones died. Overall mortality was 15.0% (n=103). The main causes of mortality were sepsis/septic shock (67 cases, 65.0%), acute cardiovascular and respiratory failure (15 patients, 14.6%).

RESULTS

The developed index of approach and completion of surgery in secondary peritonitis is valuable to make a decision on access and completion of surgery in patients with widespread peritonitis.

CONCLUSION

Integral systems for assessment of clinical status and choice of treatment strategy are effective in systematizing the results, evaluating treatment outcomes and conducting researches.

Outcomes of Patients With Sepsis and Septic Shock Requiring Source Control: A Prospective Observational Single-Center Study

Source control is important in management of septic shock. We studied differences in outcomes of patients with sepsis and septic shock who required source control intervention compared with those who did not need such intervention and the effect of the timing of source control on various clinical outcomes.

DESIGN

Prospective observational study from February 28, 2020, to March 31, 2021.

SETTING

Medical ICU of academic quaternary medical center.

PATIENTS

Two hundred five adult (≥18 yr) ICU patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were divided into a medical treatment group and a source control group. Patients requiring source control were further divided into early (intervention performed < 24 hr) and late (≥ 24 hr) source control groups. The primary outcomes were 30-day and ICU mortality. Secondary outcomes were ICU and hospital length of stay (LOS), days on mechanical ventilation, and need for renal replacement therapy. A total of 45.9% patients underwent source control. Of these, early source control was performed in 44.7% and late source control in 55.3% of patients. There was no significant difference in 30-day mortality or ICU mortality in the medical versus source control groups or in early versus late source control groups. Compared with the medical group, mean hospital LOS (11.5 vs 17.4 d; p < 0.01) and ICU LOS (5.2 vs 7.7 d; p < 0.01) were longer in the source control group. The hospital LOS (12.5 vs 21.4 d; p < 0.01) and ICU LOS (5.2 vs 9.7 d; p < 0.01) were also longer in patients who had delayed source control than in patients who had early source control. There were no significant differences in other outcomes.

CONCLUSIONS

Although mortality was similar, patients who had delayed source control had a longer ICU and hospital LOS. Early source control may improve health care utilization in septic shock patients.

Effectiveness of Five Antibiotic Regimens for the Treatment of Intra-Abdominal Infection in Bogotá

Background: Intra-abdominal infection (IAI) results in prolonged in-hospital length-of-stay, critical care unit requirements, and multiple surgical procedures. Several antimicrobial agents are available for treatment of IAI. In Colombia, there are no data on the comparative effectiveness of the different regimens used. Patients and Methods: A multicenter retrospective cohort study was completed in four third-level hospitals by comparing treatment effectiveness of five different antibiotic protocols (ampicillin-sulbactam, clindamycin-amikacin, piperacillin-tazobactam, amikacin-metronidazole, and cefuroxime-metronidazole) in patients with a diagnosis of IAI. Analysis was based on a composed outcome of therapeutic failure (change of antibiotic because of no clinical improvement, requirement of surgical re-intervention, post-operative infection, change of antibiotic because of antimicrobial resistance, and in-hospital mortality). Association of each antibiotic protocol to therapeutic failure was assessed through logistic regression analysis. Results: Five hundred ninety-three individuals were included. Two hundred twenty-nine were prescribed ampicillin-sulbactam; 170, clindamycin-amikacin; 77, amikacin-metronidazole; 83, piperacillin-tazobactam; and 34, cefuroxime-metronidazole. Therapeutic failure rate was 22%. Multivariable analysis showed none of the evaluated antibiotic protocols had an association with the primary outcome. Variables having an association for higher risk were age >70 years old (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.04-4.18); complicated IAI (OR, 3.36; 95% CI, 1.4-8.07); and World Society of Emergency Surgery (WSES) Sepsis Severity Score (OR, 1.31; 95% CI, 1.18-1.45). Adequate source control (OR, 0.16; 95% CI, 0.05-0.45) and hospitalization at Health Center 2 (OR, 0.30; 95% CI, 0.14-0.63) were identified as protective factors. Conclusions: There are no differences between the rate of therapeutic failure among the different antibiotic protocols evaluated. This outcome depends heavily on risk factors related to disease severity when surgical intervention occurs.

Sepsis Team Organizational Model to Decrease Mortality for Intra-Abdominal Infections: Is Antibiotic Stewardship Enough?

Introduction. Sepsis is an overwhelming reaction to infection with significant morbidity, requiring urgent interventions in order to improve outcomes. The 2016 Sepsis-3 guidelines modified the previous definitions of sepsis and septic shock, and proposed some specific diagnostic and therapeutic measures to define the use of fluid resuscitation and antibiotics. However, some open issues still exist. Methods. A literature research was performed on PubMed and Cochrane using the terms "sepsis" AND "intra-abdominal infections" AND ("antibiotic therapy" OR "antibiotic treatment"). The inclusion criteria were management of intra-abdominal infection (IAI) and effects of antibiotic stewardships programs (ASP) on the outcome of the patients. Discussion. Sepsis-3 definitions represent an added value in the understanding of sepsis mechanisms and in the management of the disease. However, some questions are still open, such as the need for an early identification of sepsis. Sepsis management in the context of IAI is particularly challenging and a prompt diagnosis is essential in order to perform a quick treatment (source control and antibiotic treatment). Antibiotic empirical therapy should be based on the kind of infection (community or hospital acquired), local resistances, and patient's characteristic and comorbidities, and should be adjusted or de-escalated as soon as microbiological information is available. Antibiotic Stewardship Programs (ASP) have demonstrated to improve antimicrobial utilization with reduction of infections, emergence of multi-drug resistant bacteria, and costs. Surgeons should not be alone in the management of IAI but ideally inserted in a sepsis team together with anaesthesiologists, medical physicians, pharmacists, and infectious diseases specialists, meeting periodically to reassess the response to the treatment. Conclusion. The cornerstones of sepsis management are accurate diagnosis, early resuscitation, effective source control, and timely initiation of appropriate antimicrobial therapy. Current evidence shows that optimizing antibiotic use across surgical specialities is imperative to improve outcomes. Ideally every hospital and every emergency surgery department should aim to provide a sepsis team in order to manage IAI.

A Proposal for a Classification Guiding the Selection of Appropriate Antibiotic Therapy for Intra-Abdominal Infections

Adequately controlling the source of infection and prescribing appropriately antibiotic therapy are the cornerstones of the management of patients with intra-abdominal infections (IAIs). Correctly classifying patients with IAIs is crucial to assessing the severity of their clinical condition and deciding the strategy of the treatment, including a correct empiric antibiotic therapy. Best practices in prescribing antibiotics may impact patient outcomes and the cost of treatment, as well as the risk of “opportunistic” infections such as Clostridioides difficile infection and the development and spread of antimicrobial resistance. This review aims to identify a correct classification of IAIs, guiding clinicians in the selection of the best antibiotic therapy in patients with IAIs.

Antimicrobial Challenge in Acute Care Surgery

The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients' morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.

Chi-square automatic interaction detector decision tree analysis model: Predicting cefmetazole response in intra-abdominal infection

BACKGROUND

Cefmetazole is used as the first-line treatment for intra-abdominal infections. However, only a few studies have investigated the risk factors for cefmetazole treatment failure.

AIMS

This study aimed to develop a decision tree-based predictive model to assess the effectiveness of cefmetazole in initial intra-abdominal infection treatment to improve the clinical treatment strategies.

METHODS

This retrospective cohort study included adult patients who were unexpectedly hospitalized due to intra-abdominal infections between 2003 and 2020 and initially treated with cefmetazole. The primary outcome was clinical intra-abdominal infection improvement. The chi-square automatic interaction detector decision tree analysis was used to create a predictive model for clinical improvement after cefmetazole treatment.

RESULTS

Among 2,194 patients, 1,807 (82.4%) showed clinical improvement post-treatment; their mean age was 48.7 (standard deviation: 18.8) years, and 1,213 (55.3%) patients were men. The intra-abdomせinal infections were appendicitis (n = 1,186, 54.1%), diverticulitis (n = 334, 15.2%), and pancreatitis (n = 285, 13.0%). The chi-square automatic interaction detector decision tree analysis identified the intra-abdominal infection type, C-reactive protein level, heart rate, and body temperature as predictive factors by categorizing patients into seven groups. The area under the receiver operating characteristic curve was 0.71 (95% confidence interval: 0.68-0.73).

CONCLUSION

This predictive model is easily understandable visually and may be applied in clinical practice.

Prophylactic onlay mesh at emergency laparotomy: promising early outcomes with long-acting synthetic resorbable mesh

Background

Careful surgical strategy is paramount in balancing the prevention of fascial dehiscence, incisional hernia (IH) and fear of additional mesh‐related wound complications post‐laparotomy. This study aims to review early outcomes of patients undergoing an emergency laparotomy with prophylactic TIGR® mesh, used to reduce early fascial dehiscence and potential subsequent IH.

Method

A retrospective, ethically approved review of 24 consecutive patients undergoing prophylactic TIGR® mesh placement during emergency laparotomies by a single surgeon between January 2017 and June 2021 at a University Hospital. A standardized approach included onlay positioning of the mesh, small‐bite fascial closure, and a wound bundle. We recorded patient demographics, operative indications, findings, degree of peritonitis, postoperative complications, and mortality.

Result

The study included 24 patients; 16/24 (66.6%) were female and median age was 72.5 (range 31–86); 14/24 patients were ASA grade III or greater; 4/24 patients (16.6%) developed six complications and 3/6 occurred in a single patient. Complications included subphrenic abscess, seroma, intrabdominal hematoma, enterocutaneous fistula leading to deep wound infection and small bowel perforation. Five (20.8%) patients died in hospital; central venous catheter sepsis (n = 1), fungal septicaemia (n = 1) and multiorgan failure (n = 3). Surgical site infection and seroma rates were low, occurring in 2/24 patients (4% each).

Conclusion

This study has identified that prophylactic onlay mesh in patients undergoing an emergency laparotomy is not associated with significant wound infection or seroma when used with an active wound bundle. The wider use of TIGR® to prevent fascial dehiscence and potential long‐term IH prevention should be considered.

Comparison of the PIPAS severity score tool and the QSOFA criteria for predicting in-hospital mortality of peritonitis in a tertiary hospital in Uganda: a prospective cohort study

BACKGROUND

The majority of the prognostic scoring tools for peritonitis are impractical in low resource settings because they are complex while others are quite costly. The quick Sepsis-related Organ Failure Assessment (qSOFA) score and the Physiologic Indicators for Prognosis in Abdominal Sepsis (PIPAS) severity score are two strictly bedside prognostic tools but their predictive ability for mortality of peritonitis is yet to be compared. We compared the predictive ability of the qSOFA criteria and the PIPAS severity score for in-hospital mortality of peritonitis.

METHOD

This was a prospective cohort study on consecutive peritonitis cases managed surgically in a tertiary hospital in Uganda between October 2020 to June 2021. PIPAS severity score and qSOFA score were assessed preoperatively for each case and all cases were then followed up intra- and postoperatively until discharge from the hospital, or up to 30 days if the in-hospital stay was prolonged; the outcome of interest was in-hospital mortality. We used Receiver Operating Characteristic curve analysis to assess and compare the predictive abilities of these two tools for peritonitis in-hospital mortality. All tests were 2 sided (p < 0.05) with 95% confidence intervals.

RESULTS

We evaluated 136 peritonitis cases. Their mean age was 34.4 years (standard deviation = 14.5). The male to female ratio was 3:1. The overall in-hospital mortality rate for peritonitis was 12.5%. The PIPAS severity score had a significantly better discriminative ability (AUC = 0.893, 95% CI 0.801-0.986) than the qSOFA score (AUC = 0.770, 95% CI 0.620-0.920) for peritonitis mortality (p = 0.0443). The best PIPAS severity cut-off score (a score of > = 2) had sensitivity and specificity of 76.5%, and 93.3% respectively, while the corresponding values for the qSOFA criteria (score > = 2), were 58.8% and 98.3% respectively.

CONCLUSIONS

The in-hospital mortality in this cohort of peritonitis cases was high. The PIPAS severity score tool has a superior predictive ability and higher sensitivity for peritonitis in-hospital mortality than the qSOFA score tool although the latter tool is more specific. We recommend the use of the PIPAS severity score as the initial prognostic tool for peritonitis cases in the emergency department.

Time to source control and outcome in community-acquired intra-abdominal infections: The multicentre observational PERICOM study

BACKGROUND

Optimal management of community-acquired intra-abdominal infections (IAI) requires timely surgical source control and adequate anti-infective treatment.

OBJECTIVE

To describe the initial management of community-acquired IAI admitted to the emergency department and assess the association between the length of time to either diagnosis or therapeutic procedures and patient outcomes.

DESIGN

A prospective, multicentre, observational study.

SETTING

Thirteen teaching hospitals in France between April 2018 and February 2019.

PATIENTS

Two hundred and five patients aged at least 18 years diagnosed with community-acquired IAI.

MAIN OUTCOME MEASURES

The primary outcome was hospital length of stay. The secondary outcome was hospital mortality.

RESULTS

Patients had a mean age of 56 (± 21) years and a median [interquartile] SAPS II of 26 [17 to 34]. Among the study cohort, 18% were postoperatively transferred to intensive care unit and 7% had died by day 28. Median [IQR] time to imaging, antibiotic therapy and surgery were 4 [2 to 6], 7.5 [4 to 12.5] and 9 [5.5 to 17] hours, respectively. The length of time to surgical source control [0.99, 95% confidence interval (CI), 0.98 to 0.99], SOFA greater than 2 [0.36 (95% CI, 0.26 to 0.651)], age greater than 60 years [0.65 (95% CI, 0.45 to 0.94)], generalized peritonitis [0.7 (95% CI, 0.56 to 0.89)] and laparotomy surgery [0.657 (95% CI, 0.42 to 0.78)] were associated with longer hospital length of stay. The duration of time to surgical source control [1.02 (95% CI, 1.01 to 1.04)], generalized peritonitis [2.41 (95% CI, 1.27 to 4.61)], and SOFA score greater than 2 [6.14 (95% CI, 1.40 to 26.88)] were identified as independent risk factors for 28-day mortality.

CONCLUSION

This multicentre observational study revealed that the time to surgical source control, patient severity and generalized peritonitis were identified as independent risk factors for increased hospital LOS and mortality in community-acquired IAI. Organisational strategies to reduce the time to surgical management of intra-abdominal infections should be further evaluated.

STUDY REGISTRATION

ClinicalTrials.gov on 1 April 2018, NCT03544203.

Diffuse Appendicular Peritonitis: Laparoscopic vs Open Access — Viewpoint From Aside

The perforative acute appendicitis with the development of diffuse peritonitis increases the incidence of postoperative complications to 47%, and mortality to 3%. Mortality in the case of the development of diffuse purulent peritonitis makes 4.5-58%, and it can exceed 70% in severe forms of diffuse peritonitis with the development of infectious-toxic shock and multiple organ failure. National Clinical Guidelines for acute appendicitis with diffuse peritonitis allow for appendectomy from both the median and laparoscopic access in the absence of general contraindications to the creation of pneumoperitoneum. However, despite the proven advantages of laparoscopic appendectomy, there are opponents of its use in diffuse forms of appendicular peritonitis. An increased number of postoperative abscesses with a minimally invasive approach has been reported in literature; however, recent randomized studies refute this fact. There is also evidence that the laparoscopic method for appendicular peritonitis often leads to a lengthening of the operation time and higher operating costs, but at the same time there is a decrease in postoperative pain syndrome, a reduction in the length of inpatient treatment and early social and labor rehabilitation, which leads to an overall decrease in hospital costs. Thus, to date, there is no generally accepted opinion about the advisability of laparoscopic access for appendicular peritonitis. At the moment, the presence of diffuse peritonitis is the most common intraoperative reason for refusing a minimally invasive surgical treatment. However, there is a tendency to trying to standardize indications and contraindications, which was the objective of our literature review.

[Safety and efficacy of laparoscopic approach for widespread appendicular peritonitis]

OBJECTIVE

To analyze treatment outcomes in patients with acute appendicitis complicated by widespread peritonitis.

MATERIAL AND METHODS

The study included 165 patients acute appendicitis complicated by widespread peritonitis. Inclusion criteria: acute appendicitis complicated by widespread peritonitis MIP grade 1-2 in reactive or toxic phase (grading system by Simonyan K.S.), abdominal cavity index ≤16. Exclusion criteria: MIP grade 3, terminal phase, abdominal cavity index ≥17.

RESULTS

Analysis of postoperative data revealed no correlation between surgical approach and incidence of postoperative intra-abdominal abscesses and infiltrates. In the main group, intra-abdominal abscesses occurred in 4.9% of patients (n=5), infiltrates - 12.8% (n=13). In the control group, these parameters were 4.6% (n=2) and 18.2% (n=8), respectively. We have developed and introduced into clinical practice a differentiated approach to surgical treatment of widespread appendicular peritonitis based on laparoscopic data. Abdominal cavity was intraoperatively assessed. The proposed method included 5 criteria with establishment of appropriate points (min 3, max 14). In case of total score 3-8, laparoscopic approach was preferred. Overall score 9-11 required laparoscopic surgery with subsequent elective repeated laparoscopy, ≥12 scores - intraoperative conversion and open surgery. Thus, subject to the rules of surgical intervention, the number of intra-abdominal complications between laparoscopic and open methods is equalized.

CONCLUSION

The developed differentiated surgical strategy for patients with appendicular peritonitis is effective and reduces the incidence of wound infection, extra-abdominal complications, and hospital-stay, as well as contributes to early rehabilitation of patients.

Acute appendicitis-advances and controversies

Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon's practice. With the recent advancements in AA's management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon's repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic's repercussions on patients and how surgeons' practices have evolved in the context of AA.

A New Score to Assess the Perioperative Period of the Cancer Patient Undergoing Non-Palliative Elective Surgery: A Retrospective Evaluation of a Case Report by PERIDIA Score

The complexity of cancer patients and the use of advanced and demolitive surgical techniques frequently need post-operatory ICU hospitalization. To increase safety and to select the best medical strategies for the patient, a multidisciplinary team has performed a new peri-operatory assessment, arising from evidence-based literature data. Verifying that most of the cancer patients, admitted to the intensive care unit, undergo major surgery with localizations in the supramesocolic thoraco-abdominal area, the team focused the attention on supramesocolic peridiaphragmatic cancer surgery. Some scores already in use in clinical practice were selected for the peri-operatory evaluation process. None of them evaluate parameters relating to the entire peri-operative period. In detail, only a few study models were found that concern the assessment of the intra-operative period. Therefore, we wanted to see if using a mix of validated scores, it was possible to build a single evaluation score (named PERIDIAphragmatic surgery score or PERIDIA-score) for the entire peri-operative period that could be obtained at the end of the patient's hospitalization period in post-operative ICU. The main property sought with the creation of the PERIDIA-score is the proportionality between the score and the incidence of injuries, deaths, and the length of stay in the ward. This property could organize a tailor-made therapeutic path for the patient based on pre-rehabilitation, physiotherapy, activation of social assistance services, targeted counseling, collaborations with the continuity of care network. Furthermore, if the pre-operative score is particularly high, it could suggest different or less invasive therapeutic options, and if the intra-operative score is particularly high, it could suggest a prolongation of hospitalization in ICU. The retrospective prospective study conducted on 83 patients is still ongoing. The first data would seem to prove an increase of clinical complications in patients who were assigned a one-third score with respect to the maximum (16/48) of PERIDIA-score. Moreover, patients with a 10/16 score within each phase of the evaluation (pre, peri, and post) more frequently develop injuries. In the light of these evidence, the 29-point score assigned to our patient can be considered as predictive for the subsequent critical and fatal complications the patient faced up.

Rate of stoma formation following damage-control surgery for severe intra-abdominal sepsis: a single-centre consecutive case series

BACKGROUND

Severe intra-abdominal sepsis (IAS) is associated with high mortality and stoma rates. A two-stage approach with initial damage-control surgery (DCS) and subsequent reconstruction might decrease stoma and mortality rates but requires standardization.

METHODS

A standardized two-stage damage-control algorithm for IAS was implemented in April 2016 and applied systematically.

RESULTS

Some 203 consecutive patients (median age 70 years, 62 per cent ASA score greater than 3) had DCS for severe IAS. Median operation time was 82 minutes, 60 per cent performed during night-time. Median intraoperative noradrenaline doses were 20 (i.q.r. 26) µg/min and blood gas analysis (ABG) was abnormal (metabolic acidosis) in 90 per cent of patients. The second-stage operation allowed definitive surgery in 76 per cent of patients, 24 per cent had up to four re-DCSs until definitive surgery. The in-hospital mortality rate was 26 per cent. At hospital discharge, 65 per cent of patients were stoma free. Risk factors for in-hospital death were noradrenaline (odds ratio 4.25 (95 per cent c.i. 1.72 to 12.83)), abnormal ABG (pH: odds ratio 2.72 (1.24 to 6.65); lactate: odds ratio 6.77 (3.20 to 15.78)), male gender (odds ratio 2.40 (1.24 to 4.85)), ASA score greater than 3 (odds ratio 5.75 (2.58 to 14.68)), mesenteric ischaemia (odds ratio 3.27 (1.71 to 6.46)) and type of resection (odds ratio 2.95 (1.24 to 8.21)). Risk factors for stoma at discharge were ASA score greater than 3 (odds ratio 2.76 (95 per cent c.i. 1.38 to 5.73)), type of resection (odds ratio 30.91 (6.29 to 559.3)) and longer operation time (odds ratio 2.441 (1.22 to 5.06)).

CONCLUSION

Initial DCS followed by secondary reconstruction of bowel continuity for IAS within 48 hours in a tertiary teaching hospital was feasible and safe, following a clear algorithm.

Peritoneal lavage with hydrogen-rich saline can be an effective and practical procedure for acute peritonitis

PURPOSE

Acute peritonitis has remained a fatal disease despite of recent advances in care and treatment, including antibiotic and anticoagulant treatments. The cause of death is mostly sepsis-induced multiple organ failure. Oxidative stress can play an important role in this situation, but antioxidant therapy to capture any excessive reactive oxygen species has not yet been fully established.

METHODS

Two experiments were performed. In the first experiment, we confirmed the effects of peritoneal lavage with hydrogen-rich saline (HRS) after a cecal ligation and puncture (CLP) operation in rats. In the second experiment, the changes in the hemodynamic state following this procedure were observed in a porcine model of abdominal sepsis to evaluate its safety and utility.

RESULTS

Peritoneal lavage with HRS significantly improved the survival after CLP in rats, and it ameliorated the levels of sepsis-induced organ failure. Moreover, it showed anti-inflammatory and anti-apoptosis as well as antioxidant effects. The second experiment demonstrated the potential safety and feasibility of this procedure in a large animal model.

CONCLUSION

This procedure can improve survival after sepsis through mitigating the sepsis-induced organ failure by inhibiting oxidative stress, apoptosis, and inflammatory pathways. Peritoneal lavage with HRS may therefore be an effective, safe, and practical therapy for patients with acute peritonitis.

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Advances in the pharmacological management of bacterial peritonitis

Introduction: Bacterial peritonitis is an infection with high mortality if not treated immediately. In the absence of an intraabdominal source of infection, bacterial peritonitis may arise in patients with liver cirrhosis, in patients on peritoneal dialysis (PD) for end-stage renal disease or in patients with tuberculosis. In patients with cirrhosis, bacterial peritonitis may trigger acute on chronic liver failure with substantial mortality despite optimal treatment. In patients on PD, peritonitis may make continuation of PD impossible, necessitating the switch to hemodialysis.Areas covered: Recovery from peritonitis and prevention of complications depend on timely pharmacological management. Challenges are the broad microbiological spectrum with growing rates of antimicrobial resistance, the underlying chronic liver or kidney failure and high rates of relapse. The authors provide a review of predisposing conditions, diagnosis, and prevention of bacterial peritonitis with a particular focus on the pharmacological management.Expert opinion: Diagnosis of the type of bacterial peritonitis is essential to pharmacological management. In patients with spontaneous bacterial peritonitis, broad-spectrum antibiotics should be given intravenously in conjunction with albumin. In patients on PD, antibiotic therapy should be preferably applied intraperitoneally with empirical coverage of gram-positive and gram-negative bacteria. Secondary peritonitis usually requires surgical or interventional treatment.

Computerized tomography scan in acute appendicitis with eventual negative appendectomy

Background and Aim:

Acute appendicitis (AA) is traditionally considered a clinical diagnosis and negative appendectomy (NA) rates vary across health-care systems. Computed tomography (CT) scans have been shown to aid in the reduction of NA rates. Our study aimed to determine the pre-operative imaging characteristics in patients undergoing appendectomy with eventual normal histology.

Materials and Methods:

An audit of all patients with a discharge diagnosis of AA was conducted from January 2011 to December 2015. Histology reports of all patients who underwent appendectomies were reviewed, and medical records of patients with NA were included in the study. To study the impact of CT scan reporting in NA patients, CT scan images of patients with NA were reviewed retrospectively by two blinded radiologists.

Results:

A total of 2603 patients underwent appendectomy for suspected AA, and NA rate was 3.34% (n=87). The mean age of patients with NA was 30.3 (14.8-69.8) years with no gender difference (51.7% male). Sixty-six (75.9%) patients had laparoscopic appendectomy with 3.5% open conversion rate. CT scans were done in 47 patients. Pre-operative CT scan report was more likely to report dilated appendix (n=26 [55.3%] vs. n=7 [14.9%], P=0.0001). Post-operative blinded radiology review was more like to report other pathology (n=27 [57.4%] vs. n=2 [4.3%], P=0.0001) and normal appendix (n=26 [55.3%] vs. n=5 (10.6%), P=0.0001).

Conclusion:

The NA rate is low. There needs to be standardized reporting for imaging features of prominent/dilated appendix.

Relevance for Patients:

Appendectomy must be avoided in patients with a normal CT scan and when another pathological diagnosis is established. Liberal imaging policy assists to reduce NA rates. Imaging features of prominent or dilated appendix can be subjective and international collaboration is needed to define thresholds for imaging diagnosis of AA.

The effect of glutathione as adjuvant therapy on levels of TNF-α and IL-10 in wistar rat peritonitis model

Background

Peritonitis is the second most common cause of severe sepsis that associated with a significant mortality rate. Due to a large gap of newer antibiotics innovation and antibiotic resistance emergence, the use of antioxidant has a possible alternative as adjuvant therapy in peritonitis management. It has been studied that glutathione as an alternative in the development of new anti-inflammatory effect. Thus, the aim of this study was to evaluate the levels of TNF-α and IL-10 after glutathione administration as adjuvant therapy in rat peritonitis model.

Materials and methods

Male wistar rats were divided into four groups (n = 6 per group), Group 1: control group (C), Group 2: peritonitis group (P), Group 3: peritonitis + Ceftriaxone group (P + Cef), Group 4: peritonitis + Ceftriaxone + Glutathione group (P + Cef + Glu). Twenty-four hours after peritonitis induction, the blood samples were taken to evaluate TNF-α and IL-10 levels.

Results

There was a significantly increase of mean TNF-α level in group 2 (P) 473,86 ± 388,99 pg/ml (p value 0,00) and significantly decrease of mean TNF-α level after glutathione injection in group 4 (P + Cef + Glu) (p value 0,02). No significant changes in IL-10 levels in rats peritonitis model.

Conclusions

Glutathione supplementation is significantly decrease the mean level of TNF-α in rats induced peritonitis, however there is no difference compare to antibiotic only. Moreover, there no significant changes level of IL-10 in rats induced peritonitis after glutathione injection.

Development and internal validation of clinical prediction models for outcomes of complicated intra-abdominal infection

BACKGROUND

Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. The aim of this study was to describe the clinical characteristics of patients with cIAI in a multicentre study and to develop clinical prediction models (CPMs) to help identify patients at risk of mortality or relapse.

METHODS

A multicentre observational study was conducted from August 2016 to February 2017 in the UK. Adult patients diagnosed with cIAI were included. Multivariable logistic regression was performed to develop CPMs for mortality and cIAI relapse. The c-statistic was used to test model discrimination. Model calibration was tested using calibration slopes and calibration in the large (CITL). The CPMs were then presented as point scoring systems and validated further.

RESULTS

Overall, 417 patients from 31 surgical centres were included in the analysis. At 90 days after diagnosis, 17.3 per cent had a cIAI relapse and the mortality rate was 11.3 per cent. Predictors in the mortality model were age, cIAI aetiology, presence of a perforated viscus and source control procedure. Predictors of cIAI relapse included the presence of collections, outcome of initial management, and duration of antibiotic treatment. The c-statistic adjusted for model optimism was 0.79 (95 per cent c.i. 0.75 to 0.87) and 0.74 (0.73 to 0.85) for mortality and cIAI relapse CPMs. Adjusted calibration slopes were 0.88 (95 per cent c.i. 0.76 to 0.90) for the mortality model and 0.91 (0.88 to 0.94) for the relapse model; CITL was -0.19 (95 per cent c.i. -0.39 to -0.12) and - 0.01 (- 0.17 to -0.03) respectively.

CONCLUSION

Relapse of infection and death after complicated intra-abdominal infections are common. Clinical prediction models were developed to identify patients at increased risk of relapse or death after treatment, these now require external validation.

Novel Multiparametric Nomogram for Overall Survival Prediction in Complicated Intra-Abdominal Infection: A Multicenter Study in China

Background: Complicated intra-abdominal infections (cIAIs) in the abdominal cavity or within an abdominal organ are numerous and frequent dangerous entities in the treatment of critically ill patients. Early clinical evaluation is necessary.

Methods: This retrospective multicenter study included patients from 10 intensive care units (ICUs). Risk factors for the overall survival (OS) of patients with cIAI were selected using least absolute shrinkage and selection operator regression, and a nomogram was constructed subsequently. Calibration curve and receiver operating characteristic (ROC) curve were used to evaluate the calibration and discriminative ability.

Results: In total, 544 patients diagnosed with cIAI were enrolled and divided into the study (n = 276) and validation (n = 268) sets. Sex, acute gastrointestinal injury, acute kidney injury, rare bacterium infection, Charlson score, and APACHE II score were identified as independent risk factors and were constructed for the nomogram. The nomogram showed marked calibration capability with a concordance index (C-index) of 0.909 and 0.831 in the study and validation set, respectively. Compared with the common clinical prognostic scoring system, the nomogram achieved the highest discrimination ability with an area under the curve (AUC) value of 0.91 and 0.83 in the study set and validation set, respectively.

Conclusions: Our newly constructed nomogram provides a useful tool for risk stratification and prognosis evaluation of cIAI.

Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper

Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.

Importance of CT-scan predicting clinical outcomes in gastro-intestinal perforation

Background

Gastrointestinal (GI) perforations are an acute surgical dilemma, with diagnostic workup often requiring abdominal imaging. Post-operative care for these patients may vary and oftentimes includes ICU care for sepsis, but not always. We evaluated if free fluid and air on computed tomography (CT) could be associated with sepsis, septic shock and mortality in GI perforations. The aim of our study was a correlation between a new CT-scan scoring system and septic complications in GI perforations.

Methods

We conducted an observational retrospective study about patients who underwent emergency surgery for intestinal perforation between January 2014 and June 2017. Inclusion criteria were a CT-scan positive for free fluid and air, and an intestinal perforation confirmed intraoperatively. A CT-score was created to evaluate location and extent of free fluid and air related to clinical outcome and prognosis. Univariate analysis between the CT score and the various clinical outcomes was conducted with the non-parametric Mann-Whitney test for continuous variables and with the chi-square test for categorical variables.

Results

One-hundred and fifty-one patients were evaluated. The mortality was 23.18% and the complications were present in 45.95%. The median CT score for patients who developed complications was 3, compared with a value of 2 in the absence of complications (P=0.008). A CT score of 4 or greater had a sensitivity and specificity for predicting pre-operative sepsis of 73.33% and 64.42% respectively, and for pre-operative septic shock of 35.56% and 93.27%. Looking at post-operative sepsis, sensitivity and specificity were 57.45% and 70.19%, and for septic shock 36.17% and 85.85%. Spearman correlation analysis revealed that at higher scores at CT score corresponded higher scores at the P-POSSUM morbidity, P-POSSUM mortality and WSES Sepsis Severity Score.

Conclusions

Our CT score shows a significant correlation with validated predictive scoring systems with regards to predicting sepsis, septic shock and complications—and seems to be a useful outcome predictor in GI perforation.

Mobilisation and redistribution of multivesicular bodies to the endfeet of reactive astrocytes in acute endogenous toxic encephalopathies

Endogenous toxicity caused by systemic inflammation as well as by acute liver failure triggers a wide range of dysfunctional disorders in the brain ranging from delirium and acute psychosis to coma. Astrocytes, the main homeostatic cells of the central nervous system (CNS), play a key role in pathophysiology of neurotoxic insults. We examined the cecal ligation and puncture (CLP) and acetaminophen-induced liver failure (AILF) of Wistar rats, and analysed ultrastructure of astrocytes in the brain cortex and subcortical white matter of sensorimotor zone with transmission electron microscopy. Both models showed significant similarities in reactive changes of astroglial endosomal machinery. In survived animals (with relative prevalence in the CLP-model), at 24 h after intervention we found an increase in number of multivesicular bodies (MVBs) in astroglial perikarya and astroglial processes. In particular, the number of MVBs substantially (3 times of control values) increased in the perivascular astroglial endfeet. Increased number of MVBs in astrocytes was associated with the lesser degree of intracellular oedema and with signs of compensated oedematous tissue changes. In deceased animals, up to 24 h after intervention, single MVBs were localised mainly in astroglial perikarya, and their number was not significantly changed compared to control. Activation of astroglial endosomal-exosomal machinery in both models reflects the uniform pattern of reactive changes of astroglia in these two systemic conditions and may represent activation of astroglial defence in sepsis-associated encephalopathy (SAE) and acute hepatic encephalopathy (AHE). Our data highlight the special role of astroglial adaptive activity in the counterbalancing of an impaired brain homeostasis under action of endogenous toxins. Accumulation of MVBs in astrocytic processes indicates the activation of their intercellular and gliovascular interactions through endo- and exocytosis in SAE and AHE.

Open abdomen management for severe peritonitis in elderly. Results from the prospective International Register of Open Abdomen (IROA): Cohort study

BACKGROUND

Analyzing the data of the International Register of Open Abdomen (IROA), the feasibility of open abdomen treatment has been demonstrated at every age. This new analysis on the IROA database investigates the risk factors for mortality in elderly patients treated with open abdomen for intra-abdominal infection.

METHODS

Data were derived from the IROA, a prospective observational international cohort study that enrolled patients treated with open abdomen worldwide. A univariate analysis of potential risk factors was performed. Inclusion criteria were patients older than 65 years and treated with open abdomen for intra-abdominal infection. End point was overall mortality, calculated within 30 days after open abdomen management, after 1-month and 1-year follow-up.

RESULTS

A total of 116 patients was analyzed with mean age of 76 ± 7 years. Definitive closure was achieved in 93 patients (93/116, 80.2%) for a mean open abdomen duration of 5.0 ± 5.0 days. Complicated patients were 101 (101/116, 87.1%) for a total of 201 complications. Overall, 62 out of 116 patients (53.4%) died: 23 patients (23/62, 37.1%) during open abdomen management, 29 patients (46.8%) within 30 days after abdominal closure, 9 patients (14.5%) after 1-month follow-up, and 1 patient (1.6%) after 1-year follow-up. Age did not affect mortality (75 ± 6 years in alive patients versus 77 ± 7 years in dead patients, p = 0.773). Definitive abdominal closure was the most important factor to prevent mortality.

CONCLUSIONS

This study confirmed that age alone cannot be considered a determinant for death, even in elderly patients managed with open abdomen for severe intra-abdominal infection.