The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

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.

Effect of Wound Irrigation with Povidone Iodine Versus Normal Saline on Superficial Incisional Surgical Site Infection Following Laparotomy for Peritonitis

Background

Peritonitis is a surgical emergency arising mostly from the perforation or rupture of an abdominal hollow viscus. Surgical operations for peritonitis are often attended by high morbidity and sometimes mortality in severe cases. Surgical site infection (SSI) is perhaps the most common post-operative morbidity following laparotomy for peritonitis.

Objective

To compare the rate of SSI in abdominal operations for peritonitis following wound irrigation with povidone iodine versus normal saline at a tertiary health institution in Nigeria.

Materials and Methods

This was a prospective, comparative hospital-based study over a year. Consecutive consenting adult patients were randomised into two groups in this study. The first group (A) used 500 mL of 1% povidone iodine for subcutaneous wound irrigation, while the second group (B) used 500 mL of normal saline for subcutaneous wound irrigation. Wound irrigation was done after an appropriate surgical procedure had been carried out based on the pathology. Wounds were assessed for SSI for up to 30 days after operation using the definition criteria by the Centre for Disease Control and Prevention (CDC). SSI rates were compared between the two groups.

Result

Fifty-eight consecutive patients with generalised peritonitis over a one-year period were enrolled in this study, but 53 patients who completed the study were analysed. Thirty patients were males and 23 were females, and their mean age was 40.83 ± 17.96 years. Overall, 15 (28.3%) patients had incisional SSI. There were nine (34.6%) cases in the povidone group, while there were six (22.2%) in the saline group. This difference was not statistically significant (P = 0.32). Klebsiella species were the dominant organisms isolated from the infected wounds.

Conclusion

Wound irrigation with povidone iodine after laparotomy for peritonitis did not reduce the rate and severity of surgical site infection more when compared to normal saline. We suggest further studies with a large number of patients in a multi-centre study to explore further the effect of povidone iodine versus normal saline wound irrigation on SSI following laparotomy for peritonitis.

A retrospective study comparing the effectiveness of carbapenems and tazobactam/piperacillin as an empirical treatment for patients infected with Bacteroides fragilis

BACKGROUND

Bacteroides fragilis is one of the most frequently isolated pathogenic anaerobic bacteria. Infections caused by B. fragilis are commonly treated with carbapenems or tazobactam/piperacillin. However, there is no evidence for the optimal antibiotic choice against infections caused by B. fragilis as an empirical therapy owing to its varied antibiotic resistance mechanisms. Hence, we compared the effectiveness of carbapenems and tazobactam/piperacillin as an antibiotic therapy in patients infected with B. fragilis.

METHODS

We investigated mortality, clinical and antimicrobial efficacy, and the percentage of patients who switched to broad-spectrum antibiotics, such as carbapenems or tazobactam/piperacillin, due to the aggravated symptoms of infection in patients receiving carbapenems or tazobactam/piperacillin from 2019 to 2024.

RESULTS

A total of 60 patients were included in the study; 24 patients received carbapenems and 36 received tazobactam-piperacillin as an empirical treatment against B. fragilis infections. None of the patients in either group died. Compared to carbapenem treatment, tazobactam/piperacillin treatment significantly improved inflammatory markers, including body temperature and C-reactive protein (45.8 % vs. 72.2 %, p = 0.039 and 37.5 % vs. 63.4 %, p = 0.045, respectively; carbapenem vs. tazobactam/piperacillin). The percentage of patients switching from carbapenems to tazobactam/piperacillin or vice versa was significantly lower in the tazobactam/piperacillin group than in the carbapenem group (41.7 % vs. 11.1 %, p < 0.001).

CONCLUSIONS

Our findings suggest that tazobactam/piperacillin can be used as the first-line empirical treatment for patients infected with B. fragilis.

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.

Sex-specific activation of platelet purinergic signaling is key in local cytokine release and phagocytosis in the peritoneal cavity in intra-abdominal sepsis

Intra-abdominal sepsis is a life-threatening complex syndrome caused by microbes in the gut microbiota invading the peritoneal cavity. It is one of the major complications of intra-abdominal surgery. To date, only supportive therapies are available. No studies have investigated the progression of intra-abdominal sepsis in the peritoneal cavity. Our group has shown that platelets play an essential role during sepsis, and blocking purinergic signaling in platelets through P2Y1 and P2Y12 antagonism significantly lowered inflammatory levels and improved survival in a murine model of sepsis. Here, we tested whether antagonizing purinergic signaling in platelets in the peritoneal cavity can reduce the local release of cytokines and modulate platelet interaction with the immune system. We used cecal ligation and puncture (CLP) to induce sepsis followed by intraperitoneal administration of MRS2279 (P2Y1 antagonist) or ticagrelor (P2Y12 antagonist) in male and female mice. The peritoneal cavity fluid (PCF) was collected 4 or 24 h post-CLP and analyzed for cell recruitment, platelet markers, cytokines, and platelet immune cell interactions. Platelet markers were increased 24 h after CLP, although the total platelet count in the peritoneal cavity was lower than the blood. Blocking P2Y12 or P2Y1 improved bacterial clearance in the PCF in a sex-dependent manner. The influx of immune cells in the peritoneal cavity was altered by blocking P2Y12 or P2Y1 sex-dependently. Blocking P2Y1 and P2Y12 receptors can enhance the phagocytic activity in the peritoneal cavity in a sex- and time-related manner, and platelets significantly contribute to the development and progression of sepsis in the peritoneal cavity.NEW & NOTEWORTHY Intra-abdominal sepsis is a challenging complication postabdominal surgery caused by perforations of the gastrointestinal tract where microbes invade the peritoneal cavity. This leads to local cytokine release and immune cell dysfunction. Our data identify platelets as key players in mediating inflammation in intra-abdominal sepsis. We have shown that blocking purinergic signaling in the peritoneal cavity reduced cytokine release and cell-cell interactions differently in males and females, hence a sex-specific strategy to improve intra-abdominal sepsis.

Challenges in Diagnosing and Managing Acute Cholecystitis in Cirrhosis

A 64-year-old male with cirrhosis and mild ascites secondary to metabolic-associated steatotic liver disease (MASLD) presented with right upper quadrant (RUQ) abdominal pain. Initial investigations, including an abdominal ultrasound and hepatobiliary iminodiacetic acid (HIDA) scan, did not show any evidence of acute cholecystitis. However, the patient's persistent symptoms and a positive sonographic Murphy's sign raised clinical suspicion for the condition. Subsequently, a computed tomography (CT) scan confirmed the diagnosis of acute cholecystitis. Blood cultures revealed Enterococcus faecalis and Klebsiella pneumoniae, prompting targeted antibiotic therapy. Given the high operative risk associated with cirrhosis, ascites, and extensive varices, the patient was treated conservatively with intravenous antibiotics followed by oral antibiotics. He was discharged with plans for an elective laparoscopic cholecystectomy versus endoscopic ultrasound-guided cholecystostomy (EUS-GBD) after further optimization for potential liver transplantation at an advanced center. This case underscores the complexities of diagnosing acute cholecystitis in cirrhotic patients, highlights the need for vigilant re-evaluation when imaging and clinical findings diverge, and addresses the challenges of managing high-risk surgical patients.

Efficacy and safety of ceftazidime-avibactam in combination with metronidazole in Japanese patients with complicated intra-abdominal infection: A phase 3, multicentre, open-label study

BACKGROUND

This phase 3 open-label study evaluated the efficacy and safety of ceftazidime-avibactam in Japanese patients with complicated intra-abdominal infections (cIAIs).

METHODS

Hospitalised adults with cIAI received ceftazidime-avibactam + metronidazole for 5-14 days. The primary efficacy endpoint was clinical cure at the test-of-cure (TOC) visit in the clinically evaluable (CE) analysis set. Efficacy was evaluated against a pre-defined point estimate criterion of ≥78 %. Microbiological responses, safety and pharmacokinetics were assessed as secondary objectives.

RESULTS

Sixty patients were enrolled at 27 Japanese study sites; 59 (mean age 57 years, 42 % female) were included in the modified intent-to-treat (MITT) analysis set. The most common baseline pathogens (microbiological MITT analysis set; n = 42) were Escherichia coli (n = 31; 74 %), Pseudomonas aeruginosa (n = 6; 14 %) and Klebsiella pneumoniae (n = 5; 12 %); all were susceptible to ceftazidime-avibactam. In the CE analysis set (n = 40), 36 patients (90.0 %; 95 % confidence interval: 76.3, 97.2) achieved clinical cure at TOC. Favourable per-pathogen microbiological responses at TOC were >90 % for common Gram-negative pathogens, including E. coli, K. pneumoniae, and P. aeruginosa. Adverse events were generally mild; the most common were constipation (12 %), diarrhoea (12 %), and insomnia (10 %). Pharmacokinetic observations of ceftazidime and avibactam were consistent with previous reports.

CONCLUSION

The proportion of patients with clinical cure at TOC was greater than the pre-defined threshold of 78.0 %. These findings in Japanese patients are consistent with multi-regional phase 3 non-inferiority trials demonstrating the efficacy and safety of ceftazidime-avibactam in patients with cIAIs.

CLINICALTRIALS GOV IDENTIFIER

NCT04927312.

Clinical outcomes of a twice-daily metronidazole dosing strategy for Bacteroides spp. bloodstream infections

OBJECTIVE

The optimal dose of metronidazole for the treatment of Bacteroides spp. bacteraemia has not been well defined.

METHODS

This study was a multi-centre, retrospective chart review of adult patients with bacteraemia secondary to Bacteroides spp. between October 2010 and March 2024. Clinical outcomes of patients who received metronidazole 500 mg twice daily were compared with those who received metronidazole 500 mg thrice daily. Clinical failure was defined as a composite of 30-day recurrent infection due to Bacteroides spp. or all-cause mortality.

RESULTS

Of the 242 patients who met the inclusion criteria, 76 received metronidazole twice daily and 166 received metronidazole thrice daily. Patients who received metronidazole twice daily did not have significantly different rates of clinical failure (15% vs 18%; P=0.561) or 30-day mortality (15% vs 17%; P=0.638) compared with those who received metronidazole thrice daily. After applying full-cohort matching, patients who received metronidazole twice daily were not at increased risk of clinical failure [odds ratio (OR)=0.859, 95% confidence interval (CI) 0.283-2.606; P=0.801] or 30-day mortality (OR=0.897, 95% CI 0.292-2.752; P=0.8573) compared with those who received metronidazole thrice daily.

CONCLUSIONS

In the largest study to date of patients with Bacteroides spp. bacteraemia treated with metronidazole, twice-daily dosing strategies were not associated with worse outcomes compared with thrice-daily dosing strategies.

In vitro activity of ceftolozane/tazobactam against ESBL-producing enterobacterales in China: SMART 2016-2019

OBJECTIVES

To evaluate the in vitro susceptibility of ESBL-producing Enterobacterales isolates to ceftolozane/tazobactam (C/T), a combination of tazobactam (a ß-lactamase inhibitor) and a new antipseudomonal cephalosporin.

METHODS

From 2016 to 2019, susceptibilities of 10,545 Enterobacterales isolated from intra-abdominal, urinary tract, respiratory tract and bloodstream infections to C/T and 11 other antimicrobial agents were analyzed. Non-ESBL-producing isolates were included for comparative analysis to provide a comprehensive susceptibility profile.

RESULTS

Among 10,545 isolated Enterobacterales, 54.6% were ESBL producers. The ESBL-positive rates for E. coli (4984/10,545, 47.3%) and K. pneumoniae (3606/10,545, 34.2%) were 59.8% and 51.1%, respectively. The susceptibility rate to C/T for all Enterobacterales was 79.5%. For E. coli and K. pneumoniae, the C/T susceptibilities were 89.3% and 68.0%, respectively. For non-ESBL-producing Enterobacterales, susceptibility to C/T was 99.5%. The susceptibility of non-carbapenem-resistant (CR) ESBL-producing Enterobacterales to C/T was 81.0%. The isolation rates of ESBL-positive and carbapenem-resistant Enterobacterales (CRE), CR-E. coli, and CR-K. pneumoniae were 14.3%, 5.6% and 26.8%, respectively. The susceptibility of ESBL-positive CREs to C/T was <20% for most antimicrobials except amikacin (50.4%). The susceptibility of ESBL-positive CR-E. coli to C/T was 28.2. For ESBL-producing CR-K. pneumoniae, susceptibility to most antimicrobials was <10%, except for amikacin (37.4%).

CONCLUSIONS

The present research underscores the viability of C/T as an alternative to carbapenems for the treatment of ESBL-producing, carbapenem susceptible Enterobacterales. However, the susceptibilities of ESBL-positive CRE to C/T and other studied antimicrobials were consistently below 20%, emphasizing for new innovative treatment strategies.

Intraoperative Low-Dose Glucocorticoids in Surgical Patients With Abdominal Sepsis: A Multicenter Retrospective Cohort Study

Background and Aims

Abdominal sepsis refers to a severe and potentially life-threatening condition characterized by the presence of infection, inflammation, and tissue damage within the abdominal cavity. Glucocorticoids (GCs) play an important role in regulation of the host immune and inflammation responses involved in sepsis and surgery. This study aimed to investigate the potential impact of intraoperative GCs administration on the clinical outcome of surgical patients with abdominal sepsis.

Methods

This retrospective cohort study included a 1:1 propensity score-matched cohort of surgical patients afflicted with abdominal sepsis at two medical centers from January 2008 to December 2022. Patients were classified into low-GCs, high-GCs, and non-GCs groups according to the dosage of steroids used intraoperatively, and in-hospital mortality was designated as the primary outcome.

Results

This study included a total of 476 patients, with 217 in the non-GCs group, 213 in the low-GCs group, and 46 in the high-GCs group. The overall in-hospital mortality rate was 7.56%. After propensity score matching (PSM), there were 168 cases in both the low-GCs group and the non-GCs group, with no significant differences observed between the groups regarding mortality rate, length of hospital-stay, and duration of intensive care unit (ICU) stay. In patients with septic shock, the use of low-dose GCs increased the urine output and decreased the requirements for vasopressors on the first postoperative day, however, it had no impact on the in-hospital mortality or ICU stay. Moreover, prophylactic use of GCs during anesthesia induction did not decrease the incidence of intraoperative hypotension or necessity of vasopressors use.

Conclusion

Intraoperative administration of low-dose GCs demonstrates a transient improvement in hemodynamics of patients with septic shock, however, it did not lead to improved clinical outcomes. Further research remains necessary to elucidate the optimal perioperative dosing strategy.

ESR Essentials: image guided drainage of fluid collections-practice recommendations by the Cardiovascular and Interventional Radiological Society of Europe

This ESR Essentials article intends to provide detailed, step-by-step, information on the role of imaging in the diagnosis, procedural management, and follow-up of patients with fluid collections. Evidence-based medicine recommendations for the positioning of percutaneous drainages and/or for diagnostic/therapeutic aspiration of fluid collections are provided. Although medical history, clinical symptoms, physical examination, and laboratory tests can raise suspicions regarding a collection, an imaging assessment is usually necessary for the diagnosis. Radiologists can easily identify fluid collections that are clinically suspected by using a wide range of imaging modalities, such as ultrasound, CT, MRI, and cone-beam CT. Consequently, these imaging methods (either alone or combined), can be used to aspirate the collection or for the placement of a drainage catheter. The choice of imaging technique to be used is influenced by the location of the collection, operator preference, size, and content of the collection. In addition, it is of utmost importance to underline the role of the interventional radiologist in the management and follow-up of patients with percutaneous drains, in collaboration with surgeons, clinicians, and diagnostic radiologists. KEY POINTS: Indications for percutaneous imaging-guided drainage are supported by clinical findings, laboratory tests, and pre-procedural imaging. Deciding between aspiration or drain insertion should follow patient assessment and fluid collection characterization. The interventional radiologist should be part of the entire patient care process including follow-up.

Antibacterial and antifungal drug concentrations in intra-abdominal abscesses: a prospective clinical study

Secondary peritonitis with intra-abdominal abscesses (IAA) is difficult to treat because of the supposed low rate of penetration of antimicrobial drugs at the site of infection. However, clinical data about the actual bioavailability of antimicrobial drugs in IAA are scarce. This prospective observational study aimed at assessing the drug penetration in IAA of the antibiotics (piperacillin-tazobactam, carbapenems) and antifungals (fluconazole, echinocandins) that are usually recommended for the treatment of intra-abdominal infections. Patients with IAA who underwent a radiological or surgical drainage procedure were included. Antimicrobial drug concentrations were measured in IAA (CIAA) and in a simultaneous plasma sample (Cplasma) to assess the CIAA/Cplasma ratio. The pharmacodynamic target was defined as a CIAA equal or superior to the clinical breakpoints of susceptibility of the most relevant intra-abdominal pathogens. Clinical outcomes were assessed at hospital discharge. A total of 54 antimicrobial drug measurements were performed in 39 IAA samples originating from 36 patients. Despite important inter-individual variability, piperacillin-tazobactam exhibited the highest CIAA/Cplasma ratios (median 2). The rates of target achievement were 75%-80% for piperacillin-tazobactam and meropenem but 0% for imipenem and ertapenem. These results tended to correlate with clinical outcomes (96% success rate versus 73%, respectively, P = 0.07). Among antifungals, fluconazole exhibited higher CIAA/Cplasma ratios and rates of target achievement compared to echinocandins. However, no differences in clinical outcomes were observed. These results provide unique information about antimicrobial drug penetration in IAA in real clinical conditions and suggest that piperacillin-tazobactam and meropenem may have better efficacy compared to imipenem or ertapenem.

Clinical Presentations and Surgical Outcomes in Patients With Nontraumatic Acute Abdominal Pain: A Prospective Analysis

BACKGROUND

 Nontraumatic acute abdominal pain is a common presentation in emergency settings, often requiring surgical intervention. This study aimed to explore the clinical presentations, surgical management, and outcomes in patients with nontraumatic acute abdominal pain, providing insights for improving management strategies.

METHODS

This observational study was conducted at a tertiary care hospital in North India and included 433 patients who underwent elective and emergency abdominal surgeries from June 2021 to May 2023. Data were collected on patient demographics, comorbidities, duration of symptoms, initial presenting symptoms, and surgical procedures performed. Laboratory parameters were assessed preoperatively, and postoperative outcomes, including complications, recovery metrics, and length of hospital stay, were recorded. Statistical analyses, including logistic regression, were utilized to determine the adjusted odds ratios for significant predictors of complications.

RESULTS

 A total of 433 patients were included in the analysis, with a mean age of 42.3 ± 12.1 years. The study revealed that 5.5% of patients experienced complications, with wound infections (3.0%) and intra-abdominal abscesses (0.9%) being the most common. Recovery metrics indicated that the mean time to resume oral intake was 2.5 ± 1.2 days, the time to first bowel movement was 3.0 ± 1.5 days, and the duration of the postoperative hospital stay averaged 5.0 ± 2.0 days. Logistic regression analysis identified significant predictors of complications, including diabetes mellitus (adjusted OR, 2.02; p < 0.001), hypertension (adjusted OR, 1.44; p = 0.025), and intraoperative findings such as appendiceal perforation (adjusted OR, 2.14; p < 0.001).

CONCLUSION

 The study underscores the critical role of timely diagnosis and appropriate surgical management in patients with nontraumatic acute abdominal pain. Recognizing high-risk factors, such as diabetes and elevated American Society of Anesthesiologists scores, can enhance surgical decision-making and improve patient outcomes. These findings advocate for refined management protocols and a multidisciplinary approach to optimize care for patients presenting with acute abdominal pain.

Efficacy and safety of eravacycline versus tigecycline for complicated intra-abdominal infections in the ICU: a multicenter, single-blind, parallel randomized controlled trial study protocol

Background

Complicated intra-abdominal infections (cIAIs), often caused by multidrug-resistant bacteria such as carbapenem-resistant A. baumannii (CRAB) and carbapenem-resistant Enterobacteriaceae (CRE) are a critical challenge in ICUs. Owing to their high mortality and treatment failure rates, there is an urgent need for effective therapies. This trial will compare eravacycline to tigecycline for treating cIAIs in patients in the ICU, aiming to provide a superior treatment option.

Methods

This is a multicenter, single-blind, parallel randomized controlled trial. Adult patients in the ICU with complex abdominal infections who meet the eligibility criteria will be included. The main outcome is the all-cause 30-day mortality of patients in clinically evaluable and microbiologically evaluable populations. Secondary outcomes include the proportion of total responsive patients in the clinically evaluable population at the end of treatment and test of cure visits; the proportion of total responsive patients in the microbiologically evaluable population at the end of treatment and test of cure visits; and ICU hospitalization time and costs. Safety assessments include the incidence of various adverse events and changes in clinical laboratory test results. The subjects will be randomly assigned to receive treatment with either eravacycline or tigecycline at a 1:1 ratio. The all-cause mortality rates of patients treated with eravacycline and TGC were 17.7 and 18.7%, respectively, with an estimated actual mortality rate of 0.95. A total sample size of 262 subjects is required to reach 80% power with an α of 0.05. Considering a 10% loss rate, 292 patients will be enrolled and randomly assigned to the three groups in equal proportions.

Ethics and communication

This trial was approved by the Ethics Committee of Ansteel Group General Hospital. The communication plan includes presentations at scientific conferences, scientific publications, and presentations to the public through nonprofessional media.

Clinical trial registration

https://clinicaltrials.gov/, ChiCTR2300078646.

Clinical characteristics and antimicrobial susceptibility of Eggerthella lenta infection over a 5-year trend at a university hospital in Japan

Eggerthella lenta (E. lenta) is known to cause intra-abdominal and anaerobic bloodstream infections. However, clinical insights and information on antimicrobial susceptibility in E. lenta infections are limited. This study aimed to elucidate the clinical characteristics and antimicrobial susceptibility of E. lenta infections. Patients with E. lenta isolated from various specimens who presented at Aichi Medical University Hospital between January 2018 and December 2022 were included. Patient information was retrospectively collected from electronic medical records. Logistic regression analysis was conducted to identify risk factors for bloodstream infections. The antimicrobial susceptibility of various antimicrobial agents against isolated strains was investigated. During the study period, seventy cases were classified as infection cases. The median age of patients was 69 years (range: 15-100 years), and 48 (68.6%) were males. The most common site of infection was the lower digestive tract (54.3%). In 70.4% of cases, polymicrobial infections occurred. Community-acquired infection was a significant risk factor for bloodstream infection, with an odds ratio of 4.94 (95% confidence interval: 1.02-23.9). The 30-day mortality rate was 10.0%. Univariate analysis showed lower mortality in patients who underwent surgical intervention than in those who did not (42.9% vs 57.1%, p = 0.02). The proportion of minimal inhibitory concentrations (MICs) of ≥ 32 μg/mL for piperacillin-tazobactam was 6.3%. Additionally, the proportions of MICs of ≥ 8 μg/mL for imipenem and meropenem were 1.4% and 0%, respectively. E. lenta should be considered when blood cultures yield gram-positive rods in community-acquired intra-abdominal infections. Effective treatment involves both antimicrobial agents and surgical interventions.

2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Risk Assessment, Diagnostic Imaging, and Microbiological Evaluation in Adults, Children, and Pregnant People

As the first part of an update to the clinical practice guideline on the diagnosis and management of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America, the panel presents 21 updated recommendations. These recommendations span risk assessment, diagnostic imaging, and microbiological evaluation. The panel's recommendations are based on evidence derived from systematic literature reviews and adhere 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.

Nosocomial cluster of patients infected with imipenemase-1-producing Enterobacter ludwigii

Introduction. Imipenemase (IMI) enzymes are an uncommon class A carbapenemases that have been isolated from aquatic environments and, occasionally, from clinical isolates of Enterobacterales.Aim. We describe a cluster of three patients infected by IMI-1 carbapenemase-producing Enterobacter ludwigii (IMI-1-Elud) in a tertiary university hospital in Gran Canaria, Spain.Methodology. Antimicrobial susceptibility was determined using the Vitek2 AST-N355 card and antibiotic gradient strips. The modified carbapenem inactivation method (CIM) test was performed in cases where the ertapenem MIC value was higher than 0.125 mg l-1. The carbapenemase was identified by PCR and DNA microarray and later characterized by whole-genome next-generation sequencing (NGS) with Illumina.Results. Three patients presented thoracic or abdominal infections caused by IMI-1-Elud ST1677 from 14 June 2022 to 14 July 2022. All patients underwent at least one gastroscopy during their admission, and two of them were located in adjoining rooms. Isolates were resistant to carbapenems, colistin and fosfomycin but susceptible to ciprofloxacin. IMI/NMC-A carbapenemase was detected by PCR and hybridization test and confirmed by NGS as IMI-1. All patients underwent at least one gastroscopy, and two of them were in nearby rooms. Patients showed microbiological and clinical improvement following focus drainage and targeted antibiotic treatment with a fluoroquinolone.Conclusions. This study reports the first documented global outbreak of patients infected with IMI-1-Elud. The source appeared to be related to endoscopes. Contact transmission may also have played a role. A screening method such as the modified CIM test is crucial for detecting less common carbapenemases that might not be identified by rapid molecular or immunochromatographic tests, as these often do not include bla IMI genes, which could lead to the undetected dissemination of carbapenemase-producing Enterobacterales. Effective infection source control and targeted treatment are essential for achieving a favourable clinical outcome.

Aztreonam-avibactam for the treatment of intra-abdominal infections

INTRODUCTION

Intra-abdominal infections are becoming increasingly common and can lead to significant morbidity and mortality. The incidence of these infections due to resistant gram-negative organisms is also increasing. Given this resistance, new antibiotic combinations are being developed, often utilizing older antibiotics and newer β-lactamase inhibitors. Aztreonam/avibactam (ATM-AVI) is one of the combination antibiotics, which combines aztreonam, a monobactam, with avibactam, a broad-spectrum β-lactamase inhibitor for the treatment of complicated intra-abdominal infections in combination with metronidazole.

AREAS COVERED

In this drug evaluation manuscript, we provide an overview of intra-abdominal infections and an overview of currently available antimicrobial agents used to treat these infections. ATM-AVI is introduced, including chemistry, pharmacodynamics, pharmacokinetics and clinical studies of this compound.

EXPERT OPINION

There are limited treatment options for complicated intra-abdominal infections due to resistant gram-negative organisms, especially those with metallo-β-lactamases. One treatment option for these infections is ATM-AVI, which was recently approved in Europe, in addition to metronidazole. These bacteria are difficult to treat, and this new compound is a safe and effective option for empiric treatment in places with a high incidence of infections due to these bacteria, and also treatment for infections when these resistant bacteria are isolated in culture.

Students' beliefs, basic psychological needs, classroom participation, foreign language anxiety, and academic adjustment: A correlation study in Tashkent, Uzbekistan

This study aimed to explore the relationships between study variables that directly and indirectly affect students' beliefs and academic adaptation. A measurement tool model was used to assess participants' 'academic adjustment' (academic motivation, academic lifestyle, academic achievement), basic psychological needs factors (autonomy, competence, relatedness), beliefs about assessment factors (benefit for learning, fairness), classroom participation, and students' FLP anxiety. Explanatory factor analysis (EFA) and confirmatory factor analysis (CFA) were employed to validate the questionnaires. The study sample consisted of 319 university students aged 17-35 years. The findings revealed significant associations among students' classroom participation, autonomy, foreign language anxiety, and relatedness. A significant indirect association with classroom participation through autonomy was also observed. Additionally, classroom participation showed significant correlations with foreign language anxiety, academic motivation, academic achievement, and perceived fairness. Academic achievement was significantly associated with academic lifestyle. Furthermore, classroom involvement was strongly associated with relatedness via foreign language classroom anxiety, and academic motivation was linked to academic lifestyle via academic performance. Academic achievement was linked to fairness via an academic lifestyle. According to the findings, the full mediation model considers all variables directly and indirectly, providing a validated model to guide higher education leaders and staff in developing programs that foster positive associations among the variables. Based on the main findings, limitations and recommendations were provided.

Microbiological profiles and clinical outcomes of critically ill surgical patients with lower gastrointestinal perforation in Japan: a single-center retrospective observational study

BACKGROUND

Lower gastrointestinal perforation (LGP) is a surgical emergency disease that can result in secondary bacterial peritonitis. Microbiological studies on LGP are rare. The present study aimed to ascertain the microbiological profile of LGP in patients admitted to the intensive care unit (ICU) at our institute after surgery. In addition, we investigated whether initial empirical therapy with vancomycin was associated with in-hospital mortality, duration of ICU stay, and duration of ventilator support.

METHODS

This single-center, retrospective, observational study was conducted at Kobe City Medical Center General Hospital, Japan. The study population included all patients diagnosed with LGP who were admitted to the ICU after emergency surgery between 2017 and 2023. The primary outcome assessed was the microbiological profile of microorganisms isolated from ascites fluid and blood of the participants. The secondary end-points were in-hospital mortality, duration of ICU stay, and duration of ventilator support. We performed univariate and multivariate regression analyses to evaluate the end-points.

RESULTS

During the study period, 89 patients were included in the analysis. The most commonly identified pathogen from the ascites cultures was Escherichia coli (65.2%), followed by Enterococcus spp. (51.7%). E. faecium was identified in 16 (18.0%) ascites samples. The microbiological profile of critically ill patients with LGP admitted to the ICU after surgery was similar to that of previous studies on intra-abdominal infection (IAI). Therefore, the initial empirical therapy in the IAI guidelines is more appropriate for LGP. Multivariate regression analysis suggested that the combination of initial empirical therapy with vancomycin was not associated with in-hospital mortality (odds ratio [OR] = 0.96, 95% confidence interval [CI] 0.23-3.00, p = 0.955), duration of ICU stay (coefficient=-0.92, 95% CI -3.04-1.21, p = 0.393), or duration of ventilator-support (coefficient=-9.03, 95%CI -49.69-31.63, p = 0.659).

CONCLUSION

The microbiological profile of critically ill patients with LGP admitted to the ICU after surgery was similar to that of previous studies on IAI. However, the frequency of E. faecium in the present study was higher than that in previous studies. Initial empirical therapy with drugs such as meropenem in combination with vancomycin for E. faecium was not associated with in-hospital mortality, duration of ICU stay, and duration of ventilator support, after adjusting for confounding factors.

Effect of Blood Product Resuscitation on Cefazolin Pharmacokinetics in Trauma Patients

Background: Antibiotics are frequently administered prophylactically to trauma patients with various injury patterns to prevent infectious complications. Trauma patients may also require large volume resuscitation with blood products. Limited data are available to support antibiotic dosing recommendations in this population. We hypothesized that we would be able to develop a population pharmacokinetic model of cefazolin, a frequently used antibiotic in the trauma scenario, from remnant blood samples by pharmacokinetic analysis of trauma patients. Methods: Remnant plasma from standard of care chemistry/hematology assessments was retrieved within 48 h of collection and assayed to determine cefazolin concentrations. Population pharmacokinetic analyses were conducted in Pmetrics using R. Linear regression was conducted to assess the effect of blood product resuscitation volume on cefazolin pharmacokinetic parameters. Results: Cefazolin concentrations best fitted a two-compartment model (Akaike information criterion: 443.9). The mean ± standard deviation parameters were total body clearance (4.3 ± 1.9L), volume of the central compartment (Vc: 7.7 ± 6.9L), and intercompartment transfer constants (k12: 1.3 ± 0.98 h-1, k21: 0.6 ± 0.45 h-1). No statistical relationships were observed between blood products, volume of blood products, and cefazolin clearance or Vc (R2: 0.0004-0.21, p = 0.08-0.95). Using a 5,000-patient Monte Carlo simulation, 2 g with repeated dosing every 2 h until end of surgery was required to achieve 93.2% probability of 100% free time above the minimum inhibitory concentration (MIC) (fT > MIC) at the ECOFF value for Staphylococcus aureus (2 mg/L). Conclusions: In these 15 trauma patients receiving blood transfusion, no relationship with blood volume resuscitation and cefazolin pharmacokinetics was observed. On the basis of this pharmacokinetic model, frequent cefazolin doses are required to maintain 100% fT > MIC.

[Early source control of infection in patients seen in the emergency department: a systematic review]

OBJECTIVE

The term source (or focus) control encompasses all those physical measures that can be used to reduce the inoculum and modify those factors in the infectious medium that promote microbial growth or foreign antimicrobial defenses of the host. The main objective of this systematic review (SR) is to know and compare whether early detection and control of the focus (in less than 6 hours) in adult patients treated in the ED for severe infection or sepsis, compared to not controlling the focus or delayed focus control (more than 12 hours) is more effective and safer (improves clinical evolution, mortality, complications, hospital stay or need for ICU admission).

METHODS

A systematic review is carried out following the PRISMA regulations in the databases of PubMed, Web of Science, EMBASE, Lilacs, Cochrane, Epistemonikos, Tripdatabase and ClinicalTrials.gov from January 2000 to December 31, 2023 without language restrictions and using a combination of MESH terms: "Source Control", "Early" "Infection OR Bacterial Infection OR Sepsis", "Emergencies OR Emergency OR Emergency Department" and "Adults". Observational cohort studies were included. No meta-analysis techniques were performed, but results were compared narratively.

RESULTS

A total of 1,658 articles were identified, of which 2 that met the inclusion criteria and were classified as high quality were finally analyzed. The included studies represent a total of 2,404 patients with 678 cases in which an intervention was performed to control the focus (28.20%). In the first study, 28-day mortality was lower in patients who underwent an intervention to control the focus (12.3% vs. 22.5%; P <0.001), with an adjusted HR of 0.538 (95% CI: 0.389-0.744; P<0.001). In the second, it was demonstrated that the time elapsed from when the patient was evaluated for the first time and was hemodynamically stabilized, until the start of surgery was associated with his survival at 60 days with an OR of 0.31 (95% CI: 0.19-0.45; P <0.0001). In fact, for each hour of delay an adjusted OR of 0.29 (95% CI: 0.16-0.47; P<0.0001) is established. So if the intervention is performed before 2 hours at 60 days, 98% of the patients are still alive, if it is performed between 2-4 hours it is reduced to 78%, if it is between 4-6 hours it drops to 55%, but if it is done for more than 6 hours there will be no survivors at 60 days.

CONCLUSIONS

This review shows that source control carried out after the evaluation of patients attending the ED reduces short-term mortality (30-60 days) and that it would be advisable to implement any required source control intervention as soon as possible, ideally early (within 6 hours).

Predicting surgical outcomes of acute diffuse peritonitis: Updated risk models based on real-world clinical data

Aim

The existing predictive risk models for the surgical outcome of acute diffused peritonitis (ADP) need renovation by adding relevant variables such as ADP's definition or causative etiology to pursue outstanding data collection reflecting the real world. We aimed to revise the risk models predicting mortality and morbidities of ADP using the latest Japanese Nationwide Clinical Database (NCD) variable set.

Methods

Clinical dataset of ADP patients who underwent surgery, and registered in the NCD between 2016 and 2019, were used to develop a risk model for surgical outcomes. The primary outcome was perioperative mortality.

Results

After data cleanup, 45 379 surgical cases for ADP were derived for analysis. The perioperative and 30-day mortality were 10.6% and 7.2%, respectively. The prediction models have been created for the mortality and 10 morbidities associated with the mortality. The top five relevant predictors for perioperative mortality were age >80, advanced cancer with multiple metastases, platelet count of <50 000/mL, serum albumin of <2.0 g/dL, and unknown ADP site. The C-indices of perioperative and 30-day mortality were 0.859 and 0.857, respectively. The predicted value calculated with the risk models for mortality was highly fitted with the actual probability from the lower to the higher risk groups.

Conclusions

Risk models for postoperative mortality and morbidities with good predictive performance and reliability were revised and validated using the recent real-world clinical dataset. These models help to predict ADP surgical outcomes accurately and are available for clinical settings.

Effectiveness of novel β-lactams for Pseudomonas aeruginosa infection: A systematic review and meta-analysis

BACKGROUND

Novel β-lactams have in vitro activity against Pseudomonas aeruginosa (PA), but their clinical performances and the selection criteria for practical use are still not clear. We aimed to evaluate the efficacy of novel β-lactams for PA infection in various sites and to compare the efficacy of each agent.

METHODS

We searched PubMed, Embase, Cochrane Library, and Web of Science for randomized controlled trials that used novel β-lactams to treat PA infection. The primary outcomes were clinical cure and favorable microbiological response. Subgroup analyses were performed based on drug type, drug resistance of pathogens, and site of infection. Network meta-analysis was carried out within a Bayesian framework.

RESULTS

In all studies combined (16 randomized controlled trials), novel β-lactams indicated comparable performance to other treatment regimens in both outcome measures (relative risk = 1.04; 95% confidence interval 0.94-1.15; P = .43) (relative risk = 0.97; 95% confidence interval 0.81-1.17; P = .76). Subgroup analyses showed that the efficacy of ceftolozane-tazobactam (TOL-TAZ), ceftazidime-avibactam (CAZ-AVI), imipenem-cilastatin-relebactam, and cefiderocol had no apparent differences compared to control groups among different infection sites, drug types and drug resistance of PA. In network meta-analysis, the results showed no statistically significant differences between TOL-TAZ, CAZ-AVI, and cefiderocol.

CONCLUSIONS

TOL-TAZ, CAZ-AVI, imipenem-cilastatin-relebactam, and cefiderocol are not inferior to other agents in the treatment of PA infection. Their efficacy is also comparable between TOL-TAZ, CAZ-AVI, and cefiderocol.

Should Empiric Anti-Fungals Be Administered Routinely for All Patients with Perforated Peptic Ulcers? A Critical Review of the Existing Literature

A perforated peptic ulcer (PPU) is a surgical emergency with a high mortality rate. PPUs cause secondary peritonitis due to bacterial and fungal peritoneal contamination. Surgery is the main treatment modality and patient's comorbidites impacts perioperative morbidity and surgical outcomes. Even after surgery, resuscitation efforts should continue. While empiric antibiotics are recommended, the role of empiric anti-fungal treatment is unclear due to a lack of scientific evidence. This literature review demonstrated a paucity of studies evaluating the role of empiric anti-fungals in PPUs, and with conflicting results. Studies were heterogeneous in terms of patient demographics and underlying surgical pathology (PPUs vs. any gastrointestinal perforation), type of anti-fungal agent, timing of administration and duration of use. Other considerations include the need to differentiate between fungal colonization vs. invasive fungal infection. Despite positive fungal isolates from fluid culture, it is important for clinical judgement to identify the right group of patients for anti-fungal administration. Biochemistry investigations including new fungal biomarkers may help to guide management. Multidisciplinary discussions may help in decision making for this conundrum. Moving forward, further research may be conducted to select the right group of patients who may benefit from empiric anti-fungal use.

Empirical antifungal therapy for health care-associated intra-abdominal infection: a retrospective, multicentre and comparative study

BACKGROUND

Current guidelines recommend using antifungals for selected patients with health care-associated intra-abdominal infection (HC-IAI), but this recommendation is based on a weak evidence. This study aimed to assess the association between early empirical use of antifungals and outcomes in intensive care unit (ICU) adult patients requiring re-intervention after abdominal surgery.

METHODS

A retrospective, multicentre cohort study with overlap propensity score weighting was conducted in three ICUs located in three medical institutions in France. Patients treated with early empirical antifungals for HC-IAI after abdominal surgery were compared with controls who did not receive such antifungals. The primary endpoint was the death rate at 90 days, and the secondary endpoints were the death rate at 1 year and composite criteria evaluated at 30 days following the HC-IAI diagnosis, including the need for re-intervention, inappropriate antimicrobial therapy and death, whichever occurred first.

RESULTS

At 90 days, the death rate was significantly decreased in the patients treated with empirical antifungals compared with the control group (11.4% and 20.7%, respectively, p = 0.02). No differences were reported for the secondary outcomes.

CONCLUSION

The use of early empirical antifungal therapy was associated with a decreased death rate at 90 days, with no effect on the death rate at 1 year, the death rate at 30 days, the rate of re-intervention, the need for drainage, and empirical antibiotic and antifungal therapy failure at 30 days.

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.

Surgical Site Infections in Gastrointestinal Surgeries: Estimation of Prevalence, Risk Factors and Bacteriological Profile

INTRODUCTION

Surgical site infections (SSIs) are one of the leading causes of operation-related adverse effects. To create an effective hospital infection program, information about a local pattern is essential. The ever-changing pattern of infections and inappropriate use of antibiotics has predisposed to the development of drug-resistant strains and has made the management of SSIs arduous.

AIMS AND OBJECTIVES

The purpose of this study is to estimate prevalence and identify risk factors and commonest organisms associated with SSIs.

METHODOLOGY

In this analytical cross-sectional study, the relationship between various risk factors and the development of SSIs was evaluated in patients undergoing elective surgery and staying at least seven days postoperatively in the Department of Surgical Gastroenterology and Liver transplant for a study duration of two months. Diagnosis of SSIs was based on modified CDC criteria. Wound pus was followed by blood collection in suspected secondary septicemia. MacConkey and blood agar were used to culture pus; brain heart infusion broth was used for blood samples. Antimicrobial susceptibility testing was carried out using Mueller-Hinton agar by the Kirby-Bauer method.

RESULTS

 Twelve out of 50 had developed postsurgical wound infections where Gram-negative organisms prevailed over Gram-positive ones. The associated risk factors identified in this study are age, BMI, wound class, American Society of Anesthesiologists (ASA) score, preprocedural WBC count >10,000, and the duration of surgery. Escherichia coli is the causative microbe for the majority of infections (35.7%). Gram-negative bacteria isolated in this study were extended-spectrum β-lactamase (ESBL) producers. Multidrug-resistant organisms were predominant.  Conclusion: The present study identified an SSI rate of 24% in gastrointestinal surgeries. The sensitivity and resistance pattern of the organisms isolated will help in measures to be taken to devise a proper and effective current hospital antibiotic prophylaxis policy.

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.

Utility of paired plasma and drainage fluid mNGS in diagnosing acute intra-abdominal infections with sepsis

BACKGROUND

Metagenomic next-generation sequencing (mNGS) has been increasingly applied in sepsis. We aimed to evaluate the diagnostic and therapeutic utility of mNGS of paired plasma and peritoneal drainage (PD) fluid samples in comparison to culture-based microbiological tests (CMTs) among critically ill patients with suspected acute intra-abdominal infections (IAIs).

METHODS

We conducted a prospective study from October 2021 to December 2022 enrolling septic patients with suspected IAIs (n = 111). Pairwise CMTs and mNGS of plasma and PD fluid were sent for pathogen detection. The mNGS group underwent therapeutic regimen adjustment based on mNGS results for better treatment. The microbial community structure, clinical features, antibiotic use and prognoses of the patients were analyzed.

RESULTS

Higher positivity rates were observed with mNGS versus CMTs for both PD fluid (90.0% vs. 48.3%, p < 0.005) and plasma (76.7% vs. 1.6%, p < 0.005). 90% of enrolled patients had clues of suspected pathogens combining mNGS and CMT methods. Gram-negative pathogens consist of most intra-abdominal pathogens, including a great variety of anaerobes represented by Bacteroides and Clostridium. Patients with matched plasma- and PD-mNGS results had higher mortality and sepsis severity. Reduced usage of carbapenem (30.0% vs. 49.4%, p < 0.05) and duration of anti-MRSA treatment (5.1 ± 3.3 vs. 7.0 ± 8.4 days, p < 0.05) was shown in the mNGS group in our study.

CONCLUSIONS

Pairwise plasma and PD fluid mNGS improves microbiological diagnosis compared to CMTs for acute IAI. Combining plasma and PD mNGS could predict poor prognosis. mNGS may enable optimize empirical antibiotic use.

Next-generation microbiological testing in intraabdominal infections with PCR technology

PURPOSE

Intraabdominal infections (IAI) are increasing worldwide and are a major contributor to morbidity and mortality. Among IAI, the number of multi-drug resistant organisms (MDRO) is increasing globally. We tested the Unyvero A50® for intraabdominal infections, compared the detected microorganisms and antibiotic resistance, and compared the results with those of routine microbiology.

METHODS

We prospectively compared samples obtained from surgical patients using PCR-based Unyvero IAI cartridges against routine microbiology for the detection of microorganisms. Additionally, we identified clinical parameters that correlated with the microbiological findings. Data were analyzed using the t-test and Mann-Whitney U test.

RESULTS

Sixty-two samples were analyzed. The PCR system identified more microorganisms, mostly Bacteroides species, Escherichia coli, and Enterococcus spp. For bacterial resistance, the PCR system results were fully concordant with those of routine microbiology, resulting in a sensitivity, specificity, and positive and negative predictive value (PPV, NPV) of 100%. The sensitivity, specificity, PPV, and NPV for the detection of microorganisms were 74%, 58%, 60%, and 72%, respectively. CRP levels were significantly higher in patients with detectable microorganisms. We identified more microorganisms and bacterial resistance in hospital-acquired intra-abdominal infections by using the PCR system.

DISCUSSION

IAI warrants early identification of the microorganisms involved and their resistance to allow for adequate antibiotic therapy. PCR systems enable physicians to rapidly adjust their antibiotic treatment. Conventional microbiological culture and testing remain essential for determining the minimal growth inhibition concentrations for antibiotic therapy.

Predictive Role of Acute Physiology and Chronic Health Evaluation II (APACHE II) in Patients With Peritonitis at the National Hospital Abuja

BACKGROUND

A validated tool may facilitate assessing the severity of peritonitis among surgical patients. This study evaluates the predictive role of Acute Physiology and Chronic Health Evaluation II (APACHE II) in the surgical outcomes of patients managed for peritonitis in Abuja.

METHOD

This is a prospective study of consecutive adult patients managed for peritonitis by the general surgery unit of National Hospital Abuja (NHA) over a 19-month period (September 2020 through March 2022). Patient characteristics and treatment outcomes were recorded in a structured proforma and analyzed using SPSS Statistics version 25 (IBM Corp., Released 2017; IBM SPSS Statistics for Windows, Version 25.0; Armonk, NY: IBM Corp.). The accuracy, sensitivity, specificity, and threshold of APACHE II were derived from the receiver operating characteristic (ROC) curve analysis and its coordinates.

RESULTS

There were 54 patients with peritonitis during the study period, with a male-to-female ratio of 2.6:1. This study's mortality and morbidity rates were 13.0% and 63.0%, respectively. The APACHE II score at admission was positively correlated with the likelihood of postoperative mortality, morbidity, number of postoperative complications, ICU admission, and length of hospital admission. The average APACHE II score of patients in this study was 7.1±5.2. APACHE II best-predicted mortality by the ROC curve at a threshold point of 9 (sensitivity of 85.7%, specificity of 70.2%, the accuracy of 86.8%, P-value 0.002). At a threshold score of 6, APACHE II was significantly associated with the occurrence of postoperative morbidity (sensitivity of 74.3%, specificity of 73.7%, accuracy of 75.2%, P-value = 0.043).

CONCLUSIONS

This study confirms that the APACHE II score at admission can predict the outcome of surgery within the first 30 days post-surgery among adult patients who had peritonitis at NHA.

Comparative Analysis of Demographic and Clinical Findings in Spontaneous, Peritoneal Dialysis-Related, and Secondary Bacterial Peritonitis

Background This study aims to contribute to peritonitis management strategies by comparing the demographic, clinical, and laboratory characteristics of patients diagnosed with spontaneous bacterial peritonitis (SBP), peritoneal dialysis-related peritonitis (PDrP), and secondary peritonitis. Methods This study included 86 patients diagnosed with peritonitis between 2016 and 2022. Patients were categorized and compared as SBP, PDrP, and secondary peritonitis. Results SBP was diagnosed in 36% of patients, secondary peritonitis in 36% and PDrP in 28%. The mean age of patients with PDrP is 43.71 ± 14.74, which is significantly lower compared to those with SBP and secondary peritonitis (p<0.001). Patients with hypertension (HT), chronic kidney disease (CKD), and those undergoing dialysis most commonly have PDrP whereas those without HT, without CKD, and not undergoing dialysis are most often diagnosed with secondary peritonitis (p=0.002, p<0.001, p<0.001). In peritoneal fluid cultures, the growth of Gram-positive bacteria was most commonly identified in patients with PDrP, while the growth of Gram-negative bacteria was most frequently seen in patients with secondary peritonitis (p=0.018). CRP levels and sedimentation rates were found to be higher in patients with secondary peritonitis (p<0.001, p=0.003). Conclusion The distinct characteristics observed across different types of peritonitis underscore the importance of tailored approaches to diagnosis and treatment. Parameters such as CRP levels, sedimentation rates, and patient age could serve as valuable indicators in discerning between various types of peritonitis. When selecting empirical antibiotic therapy, it's crucial to consider coverage for Gram-positive pathogens in cases of PDrP and Gram-negative pathogens in secondary peritonitis.

Better chance of survival is associated with higher neutrophil CD16 expression in patients with complicated intra-abdominal infections

Aim

The ability of neutrophil CD16 (nCD16) expression to predict outcome in complicated intra-abdominal infections (cIAIs) has not yet been studied; therefore we aimed to evaluate its potential prognostic value in such patients.

Methods

Between November 2018 and August 2021 a single-center prospective study was performed in the Department of Surgical Diseases at a University Hospital Stara Zagora. A flow cytometry was used to measure the levels of nCD16 before surgery and on the 3rd postoperative day (POD) in 62 patients with cIAIs.

Results

We observed a mortality rate of 14.5% during hospitalization. Survivors had significantly higher perioperative expression of nCD16 than non-survivors (P = 0.02 preoperatively and P = 0.006 postoperatively). As predictor of favorable outcome we found a good predictive performance of preoperative nCD16 (AUROC = 0.745) and a very good predictive performance of postoperative levels (AUROC = 0.846). An optimal preoperative threshold nCD16 = 34.75 MFI permitted prediction of survival with sensitivity and specificity of 66.7% and 77.8%, respectively. A better sensitivity of 72.5% and specificity of 85.7% were observed for threshold = 54.8 MFI on the 3rd POD.

Conclusion

Perioperative neutrophil CD16 expression shows a great potential as a predictor of favorable outcome in patients with cIAIs.

Complication analysis in acute appendicitis, results from an international multicenter study

PURPOSE

Acute appendicitis (AA) is frequent, its diagnosis is challenging, and the surgical intervention is not risk free. An accurate diagnosis will reduce unnecessary surgeries and associated risks. This study aimed to analyze the rate of appendectomies' postoperative complications.

METHODS

Multicenter, prospective, observational study conducted at three large hospitals (Pisa University Hospital, Italy; Henri Mondor University Hospital, Paris, France; and Valencia University Hospital, Spain).

RESULTS

A total of 3070 patients with a median age of 28 years (IQR 20-43) were enrolled. 1403 (45.7%) were females. Eight hundred ninety patients (29%) did not undergo preoperative imaging. Ultrasound and CT scans were performed in 1465 (47.7%) and 715 (23.3%) patients. Patients requiring CT scan were older [median 38 (IQR 26-53) vs. no imaging median 24 (IQR 16-35), Ultrasound median 28 (IQR 20-41); p < 0.0001]. Laparoscopic appendectomy was performed in 58.6%. Complications developed in 1279 (41.7%) patients: Clavien-Dindo grades I-II in 1126 (33.9%); Clavien-Dindo grades III-IV in 146 (5.2%). Overall mortality was 0.2%. Following resection of a normal appendix, 15% experienced major complications (Clavien-Dindo grades IIIb and above). Multivariable analysis revealed that age, Charlson comorbidity index, histopathology, and Alvarado score over 7 were associated with a higher risk of Clavien-Dindo complication grades IIIa and higher.

CONCLUSION

Appendectomy may be associated with serious postoperative complications. Complications were associated with older age, Charlson comorbidity index, histopathology, and high Alvarado scores. The definition of accurate diagnostic and therapeutic pathways may improve results. The association between clinical scores and radiology is recommended.

Sepsis Stewardship: The Puzzle of Antibiotic Therapy in the Context of Individualization of Decision Making

The main recent change observed in the field of critical patient infection has been universal awareness of the need to make better use of antimicrobials, especially for the most serious cases, beyond the application of simple and effective formulas or rigid protocols. The increase in resistant microorganisms, the quantitative increase in major surgeries and interventional procedures in the highest risk patients, and the appearance of a significant number of new antibiotics in recent years (some very specifically directed against certain mechanisms of resistance and others with a broader spectrum of applications) have led us to shift our questions from "what to deal with" to "how to treat". There has been controversy about how best to approach antibiotic treatment of complex cases of sepsis. The individualized and adjusted dosage, the moment of its administration, the objective, and the selection of the regimen are pointed out as factors of special relevance in a critically ill patient where the frequency of resistant microorganisms, especially among the Enterobacterales group, and the emergence of multiple and diverse antibiotic treatment alternatives have made the appropriate choice of antibiotic treatment more complex, requiring a constant updating of knowledge and the creation of multidisciplinary teams to confront new infections that are difficult to treat. In this article, we have reviewed the phenomenon of the emergence of resistance to antibacterials and we have tried to share some of the ideas, such as stewardship, sparing carbapenems, and organizational, microbiological, pharmacological, and knowledge tools, that we have considered most useful and effective for individualized decision making that takes into account the current context of multidrug resistance. The greatest challenge, therefore, of decision making in this context lies in determining an effective, optimal, and balanced empirical antibiotic treatment.

Prediction of injury localization in preoperative patients with gastrointestinal perforation: a multiomics model analysis

BACKGROUND

The location of gastrointestinal perforation is essential for severity evaluation and optimizing the treatment approach. We aimed to retrospectively analyze the clinical characteristics, laboratory parameters, and imaging features of patients with gastrointestinal perforation and construct a predictive model to distinguish the location of upper and lower gastrointestinal perforation.

METHODS

A total of 367 patients with gastrointestinal perforation admitted to the department of emergency surgery in Fujian Medical University Union Hospital between March 2014 and December 2020 were collected. Patients were randomly divided into training set and test set in a ratio of 7:3 to establish and verify the prediction model by logistic regression. The receiver operating characteristic curve, calibration map, and clinical decision curve were used to evaluate the discrimination, calibration, and clinical applicability of the prediction model, respectively. The multiomics model was validated by stratification analysis in the prediction of severity and prognosis of patients with gastrointestinal perforation.

RESULTS

The following variables were identified as independent predictors in lower gastrointestinal perforation: monocyte absolute value, mean platelet volume, albumin, fibrinogen, pain duration, rebound tenderness, free air in peritoneal cavity by univariate logistic regression analysis and stepwise regression analysis. The area under the receiver operating characteristic curve of the prediction model was 0.886 (95% confidence interval, 0.840-0.933). The calibration curve shows that the prediction accuracy and the calibration ability of the prediction model are effective. Meanwhile, the decision curve results show that the net benefits of the training and test sets are greater than those of the two extreme models as the threshold probability is 20-100%. The multiomics model score can be calculated via nomogram. The higher the stratification of risk score array, the higher the number of transferred patients who were admitted to the intensive care unit (P < 0.001).

CONCLUSION

The developed multiomics model including monocyte absolute value, mean platelet volume, albumin, fibrinogen, pain duration, rebound tenderness, and free air in the peritoneal cavity has good discrimination and calibration. This model can assist surgeons in distinguishing between upper and lower gastrointestinal perforation and to assess the severity of the condition.

[Vacuum-assisted laparostomy for advanced peritonitisis]

OBJECTIVE

To evaluate the efficacy of negative pressure therapy in patients with peritonitis.

MATERIAL AND METHODS

The study included 127 patients with advanced secondary peritonitis between 2019 and 2022. All patients were divided into 2 groups. All ones underwent staged sanitation of the abdominal cavity. In the first group (n=76), re-laparotomies were accompanied by skin suture only and passive abdominal drainage. The second group included patients (n=51) with open abdominal cavity strategy and negative pressure therapy (vacuum-assisted laparostomy). We analyzed the number of surgeries, postoperative complications, duration of hospital-stay and mortality.

RESULTS

In the second group, there were significantly lower morbidity, mean number of surgeries and hospital-stay. In addition, incidence of fascial closure of abdominal cavity was higher and mortality rate was lower in the same group.

CONCLUSION

Vacuum-assisted laparostomy in patients with advanced peritonitis can reduce the number of secondary purulent complications and mortality, as well as increase the incidence of fascial closure of abdominal cavity. This approach reduces the number of surgical interventions and duration of in-hospital 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.

Associated Factors of Leaked Repair Following Omentopexy for Perforated Peptic Ulcer Disease; a Cross-sectional Study

Introduction

Previous studies have reported numerous clinico-pathologic risk factors associated with increased risk of leaked repair following omental patch for perforated peptic ulcer disease (PPUD). This study aimed to analyze the risk factors associated with leaked repair of omental patch and document the management and outcome of established cases of leaked repair in a resource-poor setting.

Methods

This is a multicenter cross-sectional study of leaked repair after omental patch of PPUD between January 2016 to December 2022. Following primary repair of PPUD with omental pedicle reinforcement, associated factors of leaked repair were evaluated using univariate and multivariate analyses.

Results

Overall, 360 cases were evaluated (62.8% male). Leaked repair rate was 11.7% (42 cases). Those without immunosuppression were 3 times less likely to have leaked repair (aOR= 0.34; 95% CI: 0.16 - 0.72; p = 0.003) while those with sepsis were 4 times more likely to have leaked repair (aOR=4.16; 95% CI: 1.06 - 12.36; p = 0.018). Patients with delayed presentation (>48 hours) were 2.5 times more likely to have leaked repair than those who presented in 0 - 24 hours (aOR=2.51; 95% CI: 3.62 - 10.57; p = 0.044). Those with Perforation diameter 2.1-3.0 cm were 8 times (aOR=7.98; 95% CI: 2.63-24.21; p<0.0001), and those with perforation diameter > 3.0cm were 33 times (aOR=33.04; 95% CI: 10.98-100.25; p<0.0001) more likely to have leaked repair than those with perforation diameter of 0-1.0 cm. Similarly, in those with no perioperative shock, leaked repair was 4 times less likely to develop than those with perioperative shock (aOR= 0.42; 95% CI: 0.41-0.92; p = 0.041). There was significant statistical difference in morbidity (p = 0.003) and mortality (p < 0.0001) rates for cases of leaked repairs and successful repairs.

Conclusion

Leaked repair following omentopexy for peptic ulcer perforation was significantly associated with large perforation diameter, delayed presentation, sepsis, immunosuppressive therapy, and perioperative shock.

Emergency laparotomy for peritonitis in the elderly: A Multicentre observational study of outcomes in Sub-Saharan Africa

Background

Globally, interest in surgical diseases in the elderly was rekindled recently mainly due to a surge in the aging population and their increased susceptibility to infections. In sub-Saharan Africa, infective diseases are major causes of high morbidity and mortality especially in elderly cohorts, hence this study was set to evaluate current status of this scourge in the elderly in our environment.

Aim

To document the aetiologic factors and analyze the impact of selected clinical and perioperative indices on mortality and morbidity rates of peritonitis in the elderly.

Methods

This was a multicenter prospective study involving elderly patients aged 65years and above managed between October 2015 and September 2021 in Southeast Nigeria.

Results

Of the 236 elderly patients examined, approximately two-third (150, 63.6%) were aged 65-74years. The rest were aged ≥ 75years. There were 142(60.2%) males and 94(39.8%) females. Perforated peptic ulcer (89,37.7%) was the most common cause of peritonitis followed by ruptured appendix (59, 25.0%), then typhoid perforation (44,18.6%). However, typhoid perforation was the deadliest with a crude mortality rate of 40.9%. Overall, morbidity and mortality rates were 33.8% and 28.5% respectively. The main independent predictors of mortality were peritonitis arising from typhoid perforation (p = 0.036), late presentation (p = 0.004), district location of hospital (p = 0.011) and intestinal resection (p = 0.003).

Conclusion

Generalized peritonitis is a cause of significant morbidity and mortality in the elderly patients in our environment. Perforated peptic ulcer was the most common cause, but typhoid perforation remains the deadliest. Late presentation, district hospital setting and bowel resection were associated with elevated mortality.

Clinical Efficacy and Safety Evaluation of Ceftazidime-Avibactam in the Treatment of Klebsiella pneumoniae Infection: A Retrospective Analysis from a Hospital in China

Background

Ceftazidime-avibactam (CAZ-AVI) is a new cephalosporin/β-lactamase inhibitor combination that received clinical approval in China in 2019. This study aims to investigate the efficacy and safety of CAZ-AVI in the treatment of Klebsiella pneumoniae (KP) infection in a hospital, and differences in efficacy among various infection sites and between monotherapy and combination therapy, providing valuable insights for its further application.

Methods

Patients who used CAZ-AVI between January 2019 and April 2023 were identified through the hospital information system. Demographic information, details of the infection site, KP strain's drug sensitivity report, treatment duration, combination therapies, adverse drug reactions (ADR), and 28-day survival were recorded. Clinical and microbiological efficacies were analyzed using SPSS 23.0 software to compare different infection sites and combination therapies.

Results

The overall effective clinical response (CR) rate of CAZ-AVI against KP infection was 62.13%, with a favorable microbial response (MR) rate was 65.68% and a 28-day survival rate was 63.91%. No significant difference occurred in effective CR and 28-day survival rate among different infection sites (P = 0.709 and 0.862, respectively). The favorable MR rate for abdominal infections was slightly lower than that for other sites of infection (P = 0.021). No significant differences in effective CR, favorable MR, and 28-day survival between monotherapy and combination therapy were present (P values were 0.649, 0.123, and 0.280, respectively). The incidence of ADR was 1.78%, including increased creatinine, elevated transaminase, hematuria, and thrombocytopenia.

Conclusion

CAZ-AVI demonstrates good clinical efficacy and safety in the treatment of KP infections. The clinical efficacy of CAZ-AVI was similar across different infection sites, and combination therapy did not show an advantage over monotherapy. Further studies are warranted. It should be noted that CAZ-AVI may induce thrombocytopenia and hematuria.

Efficacy and safety of ceftazidime/avibactam in patients with infections caused by β-lactamase-producing Gram-negative pathogens: a pooled analysis from the Phase 3 clinical trial programme

OBJECTIVES

This post hoc pooled analysis evaluated clinical and microbiological outcomes and safety in patients with infections caused by β-lactamase-producing Gram-negative pathogens across five Phase 3, randomized, controlled, multicentre trials of ceftazidime/avibactam in adults with complicated intra-abdominal infection (cIAI), complicated urinary tract infection (cUTI)/pyelonephritis and nosocomial pneumonia (NP), including ventilator-associated pneumonia (VAP).

METHODS

In each trial, RECLAIM/RECLAIM 3 (cIAI), REPRISE (cIAI/cUTI), RECAPTURE (cUTI) and REPROVE (NP, including VAP) patients were randomized 1:1 to IV ceftazidime/avibactam (plus metronidazole for patients with cIAI) or comparators (carbapenems in >97% patients) for 5-21 days. Clinical and microbiological responses at the test-of-cure visit were assessed for patients with ESBLs, and/or plasmidic and/or overexpression of chromosomal AmpC, and/or serine carbapenemases without MBLs identified in baseline Gram-negative isolates by phenotypic screening and molecular characterization in the pooled microbiological modified ITT (mMITT) population.

RESULTS

In total, 813 patients (ceftazidime/avibactam, n = 389; comparator, n = 424) had ≥1 β-lactamase-producing baseline pathogen identified, amongst whom 792 patients (ceftazidime/avibactam, n = 379; comparator, n = 413) had no MBLs. The most frequent β-lactamase-producing pathogens across treatment groups were Escherichia coli (n = 381), Klebsiella pneumoniae (n = 261) and Pseudomonas aeruginosa (n = 53). Clinical cure rates in the pooled non-MBL β-lactamase-producing mMITT population were 88.1% (334/379) for ceftazidime/avibactam and 88.1% (364/413) for comparators; favourable microbiological response rates were 76.5% (290/379) and 68.8% (284/413), respectively. The safety profile of ceftazidime/avibactam was consistent with previous observations.

CONCLUSIONS

This analysis provides supportive evidence of the efficacy and safety of ceftazidime/avibactam in patients with infections caused by ESBLs, AmpC and serine carbapenemase-producing Gram-negative pathogens.

TRIAL REGISTRATION

NCT01499290; NCT01726023; NCT01644643; NCT01595438/NCT01599806; NCT01808092.

Timing of surgical operation for patients with intra-abdominal infection: A systematic review and meta-analysis

BACKGROUND

Intra-abdominal infections (IAIs) is the most common type of surgical infection, with high associated morbidity and mortality rates. In recent years, due to the use of antibiotics, various drug-resistant bacteria have emerged, making the treatment of abdominal infections more challenging. Early surgical exploration can reduce the mortality of patients with abdominal infection and the occurrence of complications. However, available evidence regarding the optimal timing of IAI surgery is still weak. In study, we compared the effects of operation time on patients with abdominal cavity infection and tried to confirm the best timing of surgery.

AIM

To assess the efficacy of early vs delayed surgical exploration in the treatment of IAI, in terms of overall mortality.

METHODS

A systematic literature search was performed using PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Ovid, and ScienceDirect. The systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses method. Based on the timing of the surgical operation, we divided the literature into two groups: Early surgery and delayed surgery. For the early and delayed surgery groups, the intervention was performed with and after 12 h of the initial surgical intervention, respectively. The main outcome measure was the mortality rate. The literature search was performed from May 5 to 20, 2021. We also searched the World Health Organization International Clinical Trials Registry Platform search portal and ClinicalTrials.gov on May 20, 2021, for ongoing trials. This study was registered with the International Prospective Register of Systematic Reviews.

RESULTS

We identified nine eligible trial comparisons. Early surgical exploration of patients with IAIs (performed within 12 h) has significantly reduced the mortality and complications of patients, improved the survival rate, and shortened the hospital stay.

CONCLUSION

Early surgical exploration within 12 h may be more effective for the treatment of IAIs relative to a delayed operation.

Andrographolide Attenuates Inflammation Due to Intra-Abdominal Sepsis by Enhancing Bacterial Clearance in Mice

Purpose

Intra-abdominal infection is a complex pathophysiological process involving multiple systems and organs of the body. Abdominal infections complicated by severe sepsis or septic shock have a high mortality rate of 30-50%. Therefore, novel strategies to treat sepsis are urgently needed.

Methods

Andrographolide (AD), the main active ingredient of Andrographis paniculata, reportedly exerts beneficial effects on mice with sepsis. However, its exact mechanism of action in attenuating inflammation due to intra-abdominal sepsis remains unclear to date. Hence, this study aimed to examine the therapeutic effects of AD on cecal ligation and puncture (CLP)-induced sepsis and elucidate the underlying mechanisms.

Results

Results showed that AD therapy could significantly improve the 7-day survival rate and alleviate pathological organ injury in mice with CLP. In addition, AD treatment decreased the levels of proinflammatory factors, such as tumor necrosis factor-α and interleukin (IL)-6 in the peritoneal cavity fluid and blood and increased the level of anti-inflammatory factor IL-10 in the peritoneal cavity fluid of mice with CLP. Moreover, bacterial counts in the blood and peritoneal lavage fluid were lower in the mice treated with AD than in those untreated. Mechanistically, AD treatment increased the percentage and phagocytic activity of macrophages in the peritoneal cavity.

Conclusion

These data showed that AD can improve the survival of mice with intra-abdominal sepsis by enhancing bacterial clearance, as evidenced by the increased percentages and phagocytic activity of macrophages in the peritoneal cavity. This study is the first to demonstrate the protective effects of AD against intra-abdominal sepsis.